Centre Care Rehabilitation And Wellness Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellefonte, Pennsylvania.
- Location
- 250 Persia Road, Bellefonte, Pennsylvania 16823
- CMS Provider Number
- 395779
- Inspections on file
- 32
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Centre Care Rehabilitation And Wellness Services during CMS and state inspections, most recent first.
The facility did not obtain informed consent for the use of side rails or enabler bars for two residents and failed to assess entrapment risk for two residents. One resident's family installed a side rail without facility assessment or consent, and another resident's record lacked documentation of informed consent for an enabler bar. Additionally, bed safety assessments for a third resident repeatedly omitted evaluation of a required entrapment zone.
A resident with a history of self-transferring and wandering was found with a large bruise on her right breast, and the facility's investigation was limited to only two staff statements, despite policy requiring broader staff interviews. The DON confirmed that no further investigation was conducted, resulting in a failure to thoroughly investigate the injury and rule out abuse.
A resident with a physician's order for Nuplazid, an antipsychotic used for hallucinations in Parkinson's disease, was not accurately coded as receiving an antipsychotic on two quarterly MDS assessments. This omission was confirmed by the DON and administrator after review of clinical records and staff interviews.
A resident with recent hospitalizations for pneumonia and appendectomy experienced a decline in functional status, but therapy services did not assess or intervene for over a week after a rehab referral was initiated. The resident and family reported increased difficulty with daily activities, and the family independently purchased a scooter to assist with mobility. The delay in therapy evaluation was confirmed by the DON, and the referral paperwork was not completed promptly.
A resident experienced significant weight loss over a one-month period, but staff did not obtain a reweight, notify the physician, or conduct an assessment as required by facility policy. No interventions were documented to address the resident's nutritional status, and the facility's registered dietitian was no longer employed at the time.
The facility's main kitchen had multiple sanitation and food storage deficiencies, including discarded items and expired food in the freezer, unlabeled and undated food items, and equipment with debris and stains. The dishwashing area had cleanliness issues and pest presence, with the dishwasher operating below required sanitization temperatures. Staff acknowledged the issues but failed to maintain professional standards.
A resident with cognitive impairment and a physician's order for a right hand splint to maintain range of motion did not have the splint consistently applied. Clinical records from September to October indicated repeated instances where the splint was unavailable or not found on the resident. Observations confirmed the absence of the splint, and staff interviews revealed difficulties in locating it, with the last laundering occurring about a week prior.
A facility failed to ensure a resident's participation in formulating an advance directive. Initially, the resident desired full resuscitation, but a later document indicated a DNR order based on verbal consent from the resident's daughter. The resident, assessed as cognitively intact, was not involved in this decision change, which was only addressed after surveyor questioning.
A facility failed to accurately assess a resident's mental health status. The resident's PASRR indicated a need for mental health services, but the admission MDS assessment incorrectly stated otherwise. This error was acknowledged by the Nursing Home Administrator and DON.
A facility failed to develop a care plan for a resident with a cardiac pacemaker, despite the resident's severe cognitive impairment and the presence of the device. The deficiency was identified during a clinical record review, which showed no care plan for monitoring or assessing the pacemaker, and was discussed with the facility's administration.
The facility failed to manage medical devices appropriately for three residents. A resident with a shoulder fracture lacked timely physician orders and therapy referrals for her sling. Another resident wore a back brace without documented justification or physician orders. Additionally, a resident with a cardiac pacemaker did not have his device needs incorporated into his care plan, and the facility failed to consult his cardiologist for proper monitoring. These deficiencies were confirmed by facility administration.
A resident at moderate risk for falls, requiring extensive assistance for bed mobility, fell and sustained injuries when a nurse aide attempted to reposition her alone. The care plan lacked specific instructions for the required assistance level, and the resident was using the wall for support, which was not a safe intervention.
The facility failed to ensure attending physicians addressed pharmacy recommendations for two residents. One resident's physician did not provide a rationale for not reducing medication doses, and another resident's attending physician was not consulted about psychotropic medications. The DON confirmed these communication and documentation lapses.
A facility failed to implement enhanced barrier precautions for a resident with a chronic wound and an indwelling medical device. Despite a care plan requiring gown and glove use during high-contact activities, an LPN did not wear a gown while performing wound care. The LPN believed a gown was unnecessary due to the absence of gowns on the resident's door, despite signage indicating otherwise.
The facility's main kitchen had a first aid kit with a significant dust build-up and expired items, including antiseptic towelettes, burn spray, and alcohol cleansing pads. The kit also contained empty packages and an open, expired burn treatment gel packet. These issues were discussed with the Nursing Home Administrator.
The facility failed to ensure self-determination for residents' wake time schedules, with staff waking residents as early as 5:30 AM without documented preferences or discussions with responsible parties. Observations and interviews confirmed that staff followed assignment sheets, disregarding individual resident choices.
The facility failed to properly store, secure, and label resident medications on two nursing units. A tube of Calmoseptine was found unsecured in a staff seating area, and another was found on top of a treatment cart. An unlabeled tube was also found on the wound treatment cart. Staff confirmed these medications should have been secured and labeled.
The facility failed to follow its infection control policies for handling contaminated linens and using PPE for a resident with an ESBL infection. Staff were observed not wearing gowns and improperly disposing of linens, despite clear signage and protocols. This lapse was confirmed through staff interviews, revealing confusion and lack of awareness about the resident's isolation status.
A resident with dementia and other cognitive impairments was taken to a medical appointment without notifying the responsible party, contrary to facility policy. The resident, who was totally dependent on staff, was out of the facility for six hours without any assistance from facility staff, and the transport company used does not provide attendants.
Failure to Obtain Informed Consent and Complete Bed Rail Safety Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails or enabler bars for two out of three residents reviewed, and did not assess entrapment risk for two out of three residents. For one resident with generalized muscle weakness and difficulty walking, a side rail was observed in use, but there was no documentation of informed consent or an entrapment risk assessment. The resident's family had brought and attached the side rail to the bed after admission, but the facility did not complete the required assessments or obtain consent. Interviews with facility leadership confirmed the absence of these documents. Another resident with generalized muscle weakness and mobility issues was observed using an enabler bar, but there was no evidence of informed consent in the clinical record, despite staff documentation indicating otherwise. For a third resident, enabler bars were present on both sides of the bed, and while bed safety assessments were performed periodically, the assessment for one entrapment zone (Zone 6) was consistently left incomplete. These findings were confirmed through interviews and record reviews, indicating lapses in both documentation and assessment procedures related to bed rail and enabler bar use.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a complete and thorough investigation of an injury of unknown origin for one resident. Clinical record review showed that the resident, who was known to transfer herself and wander with poor safety awareness, was observed with a 5 cm by 4 cm purple bruise on the top of her right breast. The resident was unable to explain how the bruise occurred. The facility's investigation included an assessment and measurement of the bruise, and an interdisciplinary team reviewed the incident, noting the resident's habit of carrying large pitchers of drinks on her chest, which was considered consistent with the injury. Abuse was ruled out based on this information. However, the investigation only included two staff witness statements: one from a nurse aide who observed the bruise and one from an LPN who was informed of the bruise by a registered nurse. The Director of Nursing confirmed that no further investigation was completed, despite facility policy requiring statements from all staff assigned to the resident and any staff with direct knowledge of the incident on the three shifts prior to discovery, unless a cause was identified. The lack of a comprehensive investigation into the injury of unknown origin constituted a deficiency.
Inaccurate MDS Assessment for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one resident. Clinical record review showed that the resident had a physician's order for Nuplazid, an antipsychotic medication, which was prescribed to be taken orally at bedtime. However, quarterly MDS assessments completed on two separate dates did not indicate that the resident was receiving an antipsychotic medication. This discrepancy was confirmed through interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged that the MDS assessments were not accurately coded to reflect the resident's medication regimen. The resident involved had a documented order for Nuplazid to treat hallucinations associated with Parkinson's disease, but this was not reflected in the required MDS documentation, resulting in an inaccurate assessment of the resident's care needs.
Delayed Therapy Assessment Following Resident Decline
Penalty
Summary
A deficiency was identified when a resident, previously independent in activities of daily living, experienced a decline in functional status following two recent hospitalizations for pneumonia and an appendectomy. Despite the resident and her family reporting increased difficulty with mobility and daily tasks, and the family independently purchasing a scooter to assist her, there was no evidence that therapy services had assessed or intervened in response to her decline. The resident stated she was not receiving therapy, and the family confirmed that the decision to purchase a scooter was made without input from therapy staff. Clinical record review showed that a rehabilitation referral was initiated due to the resident's change in condition, but the referral was not completed or acted upon for nine days. The therapy assessment was only performed after concerns were raised by the surveyor, revealing a significant decline from the resident's prior level of function. The Director of Nursing confirmed that the therapy evaluation was delayed, and the referral paperwork was not completed in a timely manner, resulting in a lack of appropriate assessment and intervention for the resident's change in condition.
Failure to Assess and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to provide timely assessments and implement interventions to maintain acceptable nutritional status for a resident who experienced significant weight loss. According to facility policy, residents with a weight change of five pounds or more in a month should be reweighed within 24 hours, and if the change is validated as significant, the registered dietitian must assess the resident, investigate the cause, and determine necessary interventions. The policy also requires notification of the physician, charge nurse, family, and registered nurse assessment coordinator in the event of significant weight changes. Clinical record review showed that a resident experienced a 15-pound (6.79%) weight loss in one month, which met the facility's criteria for significant weight loss. However, there was no evidence that staff obtained a reweight, notified the physician, or conducted an assessment of the weight loss. Additionally, no interventions were documented to address the resident's nutritional status. The Nursing Home Administrator confirmed these findings and stated that the registered dietitian was no longer employed by the facility at the time.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed during an initial tour. The walk-in freezer contained discarded items on the floor, including food pieces and a hair net, and had expired gluten-free rolls, with one package open to the air. The prep area had a drawer with debris and a stainless steel shelf with dust and stains. Equipment such as a commercial mixer and warmer units had dried stains and debris, and a soup kettle was improperly covered with a garbage lid and stained plastic. The oven had a build-up of debris, and cans on a cart were stained. Food items lacked proper labeling and dating, including garlic, salt and pepper, and a baking pan with an unlabeled food item. The walk-in cooler contained improperly stored sandwiches and other food items without proper labeling or dating. A roll of ham was dripping onto a box of pork tenderloin, and garden salad bags were past their best-by dates. The dishwashing area had multiple cleanliness issues, including dried stains on the dishwasher, a crusted substance on a shelf, and splash stains on the wall. There was a build-up of debris under the dishwasher, and a garbage receptacle had dried stains and debris. Winged insects and ants were observed in the dishwashing area and kitchen, indicating a pest control issue. The dishwasher's temperature gauges were inaccurate, with the rinse temperature consistently below the required level for sanitization. Employee 1, a cook, was observed using the dishwasher without recording temperatures, and the Director of Dining and maintenance staff acknowledged the issue, stating they had contacted a repair company. The report was reviewed with the Nursing Home Administrator, highlighting the facility's failure to adhere to professional standards for food storage, preparation, and equipment maintenance.
Failure to Implement Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to assess and implement physician-ordered treatment to maintain range of motion for a resident identified as having range of motion concerns. The resident, who had a cognitive impairment with a BIMS score of 6, had a physician's order dated August 10, 2023, for a right hand splint to be worn at all times except during care. The care plan also indicated the need for the splint due to the resident's self-care performance deficit related to their medical history, requiring staff assistance for daily activities. Despite these orders, the clinical record revealed multiple instances from September 7, 2024, to October 8, 2024, where the splint was not available or not found on the resident. Observations on October 6 and October 8, 2024, confirmed the absence of the splint on the resident's right hand. Interviews with staff, including a licensed practical nurse and laundry staff, indicated that the splint was sometimes removed by the resident and could not be located, with the last known laundering occurring approximately one week prior to the interview. This information was reviewed with the Director of Nursing on October 8, 2024.
Failure to Ensure Resident Participation in Advance Directive Decisions
Penalty
Summary
The facility failed to ensure that Resident 127 participated in formulating an advance directive, which is a violation of the resident's rights. The clinical record review revealed that Resident 127 had initially signed a Medical Treatment Guidelines document indicating her desire for full resuscitation. However, a subsequent document signed by two facility staff indicated that Resident 127's daughter gave verbal consent to withhold resuscitation efforts, resulting in a DNR order. This change in medical treatment was not documented as having involved Resident 127's participation, despite her being assessed as cognitively intact. During an interview with the Nursing Home Administrator and the Director of Nursing, it was confirmed that there was no evidence of Resident 127's involvement in the decision to change her advance directives. The facility only discussed the change with Resident 127 after the surveyor's questioning. This lack of documentation and failure to involve the resident in the decision-making process led to the deficiency noted in the report.
Inaccurate Assessment of Resident's Mental Health Status
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for one resident who was reviewed. The clinical record for this resident showed a Preadmission Screening and Resident Review (PASRR) completed on July 17, 2024, which indicated a positive screen for serious mental illness, necessitating a Level II PASRR. A subsequent letter from the Department of Human Services Office of Mental Health and Substance Abuse Services, dated July 25, 2024, confirmed the resident's eligibility for mental health services, requiring the facility to provide or arrange for these services. However, the admission Minimum Data Set (MDS) assessment dated August 1, 2024, inaccurately indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. This discrepancy was identified during an interview with the Nursing Home Administrator and Director of Nursing on October 6, 2024, who acknowledged the incorrect coding on the resident's admission MDS assessment regarding her PASRR determination.
Failure to Implement Care Plan for Resident with Pacemaker
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with a cardiac pacemaker. The clinical record review revealed that the resident, who had a biventricular pacemaker implanted in March 2020, was assessed with severe cognitive impairment. Despite this, there was no care plan developed related to the pacemaker or associated monitoring and assessment. This deficiency was identified during a review of the resident's clinical record, which lacked documentation of a care plan addressing the pacemaker, and was discussed with the Nursing Home Administrator and Director of Nursing.
Deficiencies in Medical Device Management for Residents
Penalty
Summary
The facility failed to provide the highest practicable care regarding the use of medical devices for three residents. Resident 155 was observed with a sling immobilizing her left arm and shoulder, following a fall that resulted in a shoulder fracture. Despite returning from the hospital with a discharge summary recommending the use of a sling and swath for immobilization, there was no documented evidence of physician orders or a therapy referral for her fracture until six days later. This delay in obtaining appropriate orders and care for Resident 155's fracture was confirmed by the facility's Administrator and Director of Nursing. Resident 167 was observed wearing a back brace without any documented evidence in her clinical record to justify its use. There were no physician orders, care plans, or therapy evaluations regarding the back brace, and it was later revealed that the brace was brought in by the resident's family for comfort. Additionally, Resident 66, who had an implanted cardiac pacemaker, did not have his pacemaker needs incorporated into his care plan. The facility failed to contact his cardiologist to determine the correct implementation of his pacemaker check machine, leaving the facility unaware of the necessary monitoring requirements. These deficiencies were confirmed through interviews with the facility's administration.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate interventions to prevent a fall for a resident identified as being at moderate risk for falls. The resident, who required extensive assistance from two staff members for bed mobility due to inadequate core strength and balance, experienced a fall when a nurse aide attempted to reposition her alone. During the incident, the resident rolled onto the floor, sustaining skin tears on both elbows and a closed hematoma above her left eyebrow. The care plan did not specify the number of staff required for safe repositioning, and the resident was accustomed to using the wall to stabilize herself, which was not a safe or approved intervention. Interviews and clinical record reviews revealed that the resident's care plan lacked clear instructions regarding the level of assistance needed for bed mobility. The Director of Nursing confirmed that there was no clinical evidence indicating the required assistance level at the time of the fall. The resident reported that she was instructed by aides to use the wall for support, which led to her foot slipping and the subsequent fall. The facility's investigation corroborated the resident's account, highlighting the absence of appropriate interventions to prevent the fall.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to ensure that the attending physicians addressed pharmacy recommendations for two residents. For Resident 195, the clinical record showed that the Interdisciplinary Team Evaluation recommended a gradual dose reduction of Buspar, Seroquel, and Trazodone. However, the physician's response did not address these specific medications and lacked a clinical rationale for not reducing the doses. Furthermore, a subsequent evaluation indicated that the physician had never met the resident and did not provide an order for dose reduction, with the Director of Nursing confirming that the recommendation was sent to the wrong physician. For Resident 84, the Interdisciplinary Team Evaluation noted the use of psychotropic medications Citalopram, Mirtazapine, and Risperdal, with a physician agreeing not to reduce the dosages. However, the physician consulted was not the resident's attending physician, and there was no evidence that the attending physician received a consultant pharmacist report or documented an evaluation of the medications. The Director of Nursing confirmed these findings, indicating a lack of proper communication and documentation regarding the resident's medication management.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling medical device and a chronic wound, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. The resident, identified as having a history of a multi-drug resistant organism, required the use of gown and gloves during high-contact care activities. Despite the facility's plan of care initiated on June 7, 2024, which included specific instructions for donning gown and gloves, an observation on October 6, 2024, revealed that a licensed practical nurse (Employee 3) did not wear a gown while performing wound care on the resident's right foot. Employee 3 admitted to not wearing a gown because she believed it was unnecessary due to the absence of gowns on the resident's door. This was despite the presence of an EBP sign instructing staff to use gown and gloves for wound treatments. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting a lapse in adherence to infection prevention and control protocols.
Deficiency in Kitchen First Aid Kit Maintenance
Penalty
Summary
The facility failed to maintain a safe and clean environment in the main kitchen area. During an observation, a first aid kit attached to the wall was found to have a significant build-up of dust on its exterior. Additionally, the kit contained expired antiseptic towelettes, an open triangular bandage box with no bandages, and burn spray with the plastic cap removed, which was also expired. Inside the first aid kit, there were multiple empty packages, expired alcohol cleansing pads, and a container of burn treatment gel with an open, expired gel packet placed back in the box. These findings were reviewed with the Nursing Home Administrator.
Failure to Ensure Resident Self-Determination in Wake Time Schedules
Penalty
Summary
The facility failed to ensure self-determination for residents' choices related to wake time schedules for 21 of 34 residents sampled. Observations and interviews revealed that residents were being woken up and dressed for the day as early as 5:30 AM without documentation that this was part of their normal routine or discussed with their responsible parties. This practice was confirmed by multiple staff members who indicated that they were expected to get certain residents up and ready for the day based on assignment sheets and lists provided by the administration. Clinical record reviews for the affected residents showed varying degrees of cognitive impairment, with many residents having severe or moderate cognitive impairments due to conditions such as dementia. For example, Resident 1 had a BIMS score of 7 indicating severe cognitive impairment, while Resident 18 had no cognitive impairment but expressed a preference not to be woken up before 7:00 AM. Despite these varying levels of cognitive function, there was no documentation in the clinical records to support that early wake times were part of the residents' normal routines or that these preferences were discussed with their responsible parties. The observations and interviews conducted on April 9, 2024, revealed that the facility's practice of waking residents early was not aligned with promoting and facilitating resident self-determination. Staff members confirmed that they followed lists and assignment sheets that dictated which residents to wake up early, without considering individual preferences or documented routines. This deficiency was reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to honor residents' rights to self-determination regarding their wake times.
Failure to Properly Store and Label Medications
Penalty
Summary
The facility failed to properly store, secure, and label resident medications and biologicals on two of five nursing units. On the [NAME] Nursing Unit, a tube of Calmoseptine labeled with Resident 8's name was found in an unsecured staff seating area, easily accessible to anyone passing by. Additionally, another tube of Calmoseptine labeled with Resident 6's name was found unsecured on top of a treatment cart in the hallway. A partially used, unlabeled tube of Calmoseptine was also found on the wound treatment cart. Interviews with staff confirmed that these medications should have been secured and properly labeled. The Director of Nursing acknowledged that the medications should be labeled and secured in the treatment carts.
Failure to Adhere to Infection Control Policies
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection regarding transmission-based precautions on one of its nursing units. Specifically, the facility did not adhere to its own policies for handling contaminated linens and the use of personal protective equipment (PPE) for a resident with an ESBL infection. The policy required that dirty linens be placed in a yellow laundry bag and tied, and that staff wear gowns and gloves when handling these linens. However, observations revealed that staff were not following these protocols. Employee 1 was seen handling contaminated linens without a gown and placing them in a blue bag instead of a yellow one. Employee 2 also entered the resident's room without a gown and was unclear about the resident's isolation status. The resident in question had a history of cognitive impairment and was frequently incontinent of urine. The resident's clinical records indicated that they were on contact precautions due to an ESBL infection in the urine. Despite clear signage on the resident's door indicating the need for contact precautions, staff failed to comply with the required PPE protocols. This lapse in protocol was confirmed through staff interviews, where it was evident that there was confusion and a lack of awareness about the resident's isolation status and the proper procedures to follow. The deficiency was reviewed with the Nursing Home Administrator and Director of Nursing, who acknowledged the failure to adhere to infection control policies. The facility's policies clearly outlined the steps to prevent the spread of infection, including the use of gowns and gloves and the proper disposal of contaminated linens. However, the observations and staff interviews indicated a significant gap in the implementation of these policies, leading to a potential risk of infection spread within the facility.
Failure to Involve Responsible Party in Resident's Medical Appointment
Penalty
Summary
The facility failed to provide the highest practicable care for a resident by not involving the responsible party in the resident's medical appointment. The facility's policy requires the responsible party to be involved whenever possible, and if the resident is competent, they may attend the appointment alone. However, the resident in question had a diagnosis of dementia, depression, cognitive communication deficit, mood disturbance, psychotic disturbance, and anxiety, and was assessed as not capable of making her own decisions and at high risk for falls. Despite this, the facility did not notify the responsible party of the resident's orthopedic appointment, which was a follow-up for a previous fall with a fracture. The responsible party confirmed that she was not informed of the appointment and would have attended if she had been aware of it. The resident was transported to the appointment by a company that does not provide attendants to accompany residents during their appointments. The resident, who was totally dependent on staff for care, was out of the facility for six hours without any assistance from facility staff. The facility does not have an agreement or contract with the transport company and simply calls the company and receives a bill. The Administrator and Director of Nursing acknowledged these findings, indicating a failure to adhere to the facility's policy and ensure the resident's safety and well-being during the appointment.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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