Chambers Pointe Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 1425 Philadelphia Avenue, Chambersburg, Pennsylvania 17201
- CMS Provider Number
- 395944
- Inspections on file
- 22
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Chambers Pointe Health Care Center during CMS and state inspections, most recent first.
Surveyors found that a resident with dementia and depression received multiple PRN doses of Lorazepam for anxiety/agitation over several months without any documented evidence that non-pharmacological interventions were attempted beforehand, despite a facility policy requiring such measures for residents on psychotropic drugs. The Nursing Home Administrator confirmed that documentation of these interventions was absent and should have been present.
The facility failed to serve meals at appetizing and policy-compliant temperatures. A resident reported that hot foods were often not hot when received. For a lunch meal including salmon, stir-fried rice, green beans, pickled beets, and cheesecake, food temperatures taken before service were within or above the facility’s specified ranges, but temperatures taken after plating on a unit test tray showed hot items below the required minimum and a cold item above the allowed maximum. When the test tray was tasted, the hot items were lukewarm and the beets were not cold, and the staff member who prepared the tray acknowledged that the temperatures were not within the recommended ranges.
Surveyors found that the facility did not follow its own food storage policy requiring all products to be labeled and dated, including an open date for items once opened. During an observation of the Dogwood unit reach-in freezer, two open half-gallon containers of ice cream (Butter Pecan and Chocolate) were found without any indication of when they had been opened. A homemaker and the Nursing Home Administrator both confirmed that these ice cream containers should have been dated upon opening, demonstrating noncompliance with established dietary service standards.
Two residents using alternating air mattresses did not have documented air mattress safety assessments, despite care plans identifying skin integrity concerns and hospice involvement for one resident. MDS assessments showed that one resident was cognitively intact and required staff assistance, while the other was cognitively impaired, dependent for care, and on hospice. Observations confirmed both residents were using air mattresses, and the NHA acknowledged that required safety assessments had not been completed or documented.
A resident who required assistance for transfers fell and sustained a right shoulder fracture when a nurse aide failed to use a gait belt during ambulation, as required by the care plan and facility policy. The aide turned away to adjust bed linens, resulting in the resident losing balance and falling. The incident was substantiated as neglect due to noncompliance with safety protocols.
A facility failed to maintain a clean environment for a resident with cerebral palsy, as evidenced by a buildup of food and dust on the resident's power wheelchair. Observations confirmed the lack of a cleaning schedule for power wheelchairs, unlike regular wheelchairs.
The facility failed to accurately complete MDS assessments for two residents. One resident's assessment incorrectly indicated they had not received an anti-convulsant medication, despite records showing otherwise. Another resident's assessment inaccurately suggested a BIMS interview should be attempted, despite indications of communication difficulties. These errors were confirmed by the Nursing Home Administrator.
A resident receiving hospice services and opioid medication for pain management did not have timely follow-up documentation on the effectiveness of administered morphine sulfate. The facility's records showed delays in assessing pain relief, leading to additional doses being given without proper documentation of the initial dose's effectiveness.
A resident with dysphagia was not provided with the prescribed nectar thick liquids, receiving thin water during a luncheon and slightly thick Ensure Plus during a meal. The facility's policy requires thickened liquids as ordered, but staff interviews confirmed the oversight.
The facility failed to serve food items at proper temperatures. Initial food temperatures were within the required range, but the food was left uncovered in the steam table, causing it to become cold by the time it was served. Staff interviews confirmed that lids should have been closed when not plating food.
The facility failed to adhere to food service safety standards by not ensuring dietary staff wore proper hair coverings and by improperly storing food. Observations revealed uncovered hair on dietary staff and improperly stored, unlabeled, and undated food items in the freezer. These deficiencies were confirmed by the Executive Culinary Director.
The facility failed to resolve ongoing grievances related to cold food. Residents complained about cold, unappetizing meals, and grievances indicated that the issue persisted. Observations showed that while food temperatures were initially acceptable, a test tray revealed the food had become cold by the time it was served. The Nursing Home Administrator confirmed the ongoing concern.
The facility failed to respond timely to pharmacy recommendations for a resident with multiple diagnoses and medications. Despite the pharmacist's recommendations for periodic blood draws and laboratory testing, the physician did not review, respond to, or sign off on these recommendations, as confirmed by the DON.
The facility failed to notify a resident's representative in writing regarding the reason for hospitalization. Despite the resident being severely cognitively impaired and requiring assistance for daily care needs, there was no documented evidence that the resident's daughter, listed as the responsible party, was notified in writing about the hospitalizations.
The facility failed to update a resident's care plan to reflect their refusal of dinner trays, despite multiple documented instances and staff awareness. The resident, who was cognitively impaired and dependent on staff, had a care plan for inadequate oral intake and swallowing difficulty, but it did not include the refusals.
The facility failed to ensure controlled medications were stored in a permanently-affixed compartment in the Main medication room and did not discard expired medical supplies in the Evergreen medication room. Observations revealed a non-affixed narcotic storage box with Ativan and expired intravenous catheters and syringes. Staff confirmed these deficiencies.
Lack of Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s psychotropic medication regimen was free from unnecessary medication use and that non-pharmacological interventions were implemented as required by facility policy. The facility’s policy on psychotropic medications, dated February 12, 2026, stated that residents using psychotropic drugs should also receive non-pharmacological interventions to facilitate reduction or discontinuation of these drugs. Resident 42’s quarterly MDS assessment dated March 12, 2026, documented that the resident was cognitively intact, required staff assistance for daily care needs, and had diagnoses including dementia and depression. Physician orders for Resident 42 between early January and mid-March 2026 directed administration of 0.50 mg Lorazepam every eight hours as needed for anxiety/agitation for 14-day periods. The MARs for January, February, and March 2026 showed multiple administrations of 0.50 mg Lorazepam on specific dates and times across those months. However, there was no documented evidence that non-pharmacological interventions were attempted prior to administering Lorazepam on any of those occasions. In an interview on March 25, 2026, the Nursing Home Administrator confirmed that there was no documentation of non-pharmacological interventions before the PRN Lorazepam doses and acknowledged that such documentation should have been present.
Failure to Serve Meals at Required Hot and Cold Holding Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at appetizing and policy-compliant temperatures. The facility’s policy dated February 12, 2026, required cold foods to be served between 33°F and 50°F and hot foods between 135°F and 155°F. A resident reported on March 23, 2026, that hot foods were often not hot when received. For the lunch meal on March 24, 2026, the planned menu included salmon fillet, stir-fried rice, green beans, pickled beets with onions, and cheesecake. Temperatures taken prior to meal service showed the salmon at 155°F, stir-fried rice at 168°F, green beans at 165°F, and pickled beets at 41°F, which were within or above the policy range at that point. During observation of the lunch meal service on the Dogwood unit on March 24, 2026, at 12:07 p.m., Homeworker 1 plated hot items directly from the steam table and cold items from containers on the counter for a test tray. When she took the temperatures of the foods once plated, the salmon measured 126°F, stir-fried rice 134°F, green beans 123.9°F, pickled beets 63.5°F, and cheesecake 50.3°F, showing that hot foods had fallen below the required minimum of 135°F and the pickled beets exceeded the maximum 50°F for cold foods. At 12:13 p.m., tasting of the test tray revealed the salmon and green beans were lukewarm and the pickled beets were not cold. Homeworker 1 acknowledged that the hot food temperatures were a little low and the beet temperature was a little high, and she referred to the tray line sheet for recommended temperatures.
Failure to Label and Date Opened Frozen Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards and its own policy by not properly labeling and dating opened frozen food items on the Dogwood unit. The facility’s food storage policy, dated February 12, 2026, required that all products be labeled and dated with the receiving date, and that all open items be labeled with the open date and resealed to prevent contamination. During an observation of the Dogwood unit reach-in freezer on March 23, 2026, surveyors found two half-gallon containers of ice cream (Butter Pecan and Chocolate) that were open and not labeled with the date they were opened. A homemaker interviewed at the time of the observation confirmed that the ice cream containers should have been dated when opened, and the Nursing Home Administrator later confirmed that the open containers should have been dated in accordance with policy.
Failure to Complete Air Mattress Safety Assessments
Penalty
Summary
The facility failed to complete required air mattress safety assessments for two residents who were using air mattresses. For one resident, a significant change MDS dated February 13, 2026, showed that the resident was cognitively intact and required staff assistance for daily care. The resident’s care plan, dated December 12, 2025, identified potential or actual impairment to skin integrity and included an intervention for use of an alternating air mattress to maintain intact skin. Observation on March 23, 2026, confirmed that this resident was using an air mattress on the bed. Review of the clinical record revealed no documented evidence that an air mattress safety assessment had been completed, and the Nursing Home Administrator confirmed that such an assessment should have been performed but was not. For the second resident, a quarterly MDS dated January 27, 2026, indicated that the resident was cognitively impaired, dependent on staff for daily care, and receiving hospice services. A care plan dated February 3, 2026, documented that the resident had an alternating air mattress provided by hospice. Observation on March 23, 2026, showed that this resident was in bed with an air mattress in use. Review of the clinical record revealed no documented evidence of an air mattress safety assessment for this resident. In an interview, the Nursing Home Administrator confirmed there was no documented air mattress safety assessment for this resident, despite the use of the equipment. These findings were cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Failure to Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and required assistance for transfers, experienced a fall resulting in a right proximal humerus fracture. The incident took place while the resident was being assisted from the bathroom to the bed by a nurse aide. The aide turned away to arrange bed linens, during which time the resident lost balance and fell backwards. Documentation and witness statements confirmed that a gait belt, which was required by the resident's care plan and facility policy for ambulation and transfers, was not used during this transfer. The nurse aide admitted to forgetting to use the gait belt, despite being aware of the policy. The facility's abuse and neglect policy mandates the use of appropriate safety measures to prevent harm, and defines neglect as the failure to provide necessary goods and services to avoid physical harm. The investigation substantiated that neglect occurred due to the failure to use a gait belt, directly leading to the resident's fall and subsequent injury. Clinical records indicated the resident required pain management and a sling for the shoulder fracture following the incident.
Failure to Maintain Cleanliness of Resident's Power Wheelchair
Penalty
Summary
The facility failed to ensure a clean environment for a resident, specifically regarding the cleanliness of a power wheelchair. A quarterly Minimum Data Set (MDS) assessment for a resident with cerebral palsy indicated that the resident was usually understood and could understand others. Observations on multiple occasions revealed a buildup of food and dust debris on the lower frames and an accumulation of dust on the black motor/battery cover of the resident's power wheelchair. An interview with the Director of Housekeeping confirmed these observations and revealed that while there is a regular cleaning schedule for standard wheelchairs, no such schedule exists for power wheelchairs.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents. For Resident 17, the deficiency involved the incorrect coding of Section N0415K, which should have indicated that the resident received an anti-convulsant medication, Gabapentin, during the assessment period. Despite physician's orders and the Medication Administration Record (MAR) confirming the administration of Gabapentin, the MDS assessment inaccurately reflected that the resident had not received the medication. This discrepancy was confirmed through an interview with the Nursing Home Administrator. For Resident 24, the deficiency was related to the incorrect coding of Section C0100, which pertains to the attempt to conduct a Brief Interview for Mental Status (BIMS). The quarterly MDS assessment inaccurately indicated that an interview should be attempted, despite Sections B0700 and B0800 showing that the resident was rarely or never understood and could rarely or never understand others. This inconsistency was also confirmed by the Nursing Home Administrator. These inaccuracies in the MDS assessments were identified through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews.
Failure in Pain Management Documentation
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident 17, who was receiving hospice services and required routine and as-needed pain medication. According to the facility's policy on pain management, they were to ensure pain management was consistent with professional standards, the comprehensive care plan, and the resident's goals and preferences. Resident 17's admission Minimum Data Set (MDS) assessment indicated that the resident was alert, oriented, and received opioid medication for pain management. Physician's orders specified that the resident was to receive morphine sulfate every two hours as needed for shortness of breath or pain. However, the Medication Administration Record for February 2025 showed that there was no documented follow-up on the effectiveness of the morphine sulfate administered on February 6 and 7, 2025. On both occasions, the effectiveness of the pain relief was not documented until several hours after administration, and it was noted as ineffective, leading to additional doses being administered. An interview with the Nursing Home Administrator confirmed the lack of follow-up regarding the effectiveness of the morphine sulfate after its administration on the specified dates.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was provided as ordered by the physician for a resident with dysphagia. The resident was prescribed a mechanically altered diet with nectar thick liquids due to swallowing difficulties. However, during a luncheon, the resident was given thin water instead of the prescribed thickened drink. Additionally, during a supper meal observation, the resident was provided with Ensure Plus, which was not thickened to the required nectar consistency, as confirmed by the dietitian and a registered nurse. The facility's policy on thickened liquids requires that they be provided only when ordered by a physician or delegated dietitian, and the resident's care plan specified the need for nectar thick liquids. Despite this, the resident received liquids that were not appropriately thickened, as the Ensure Plus was only slightly thick at room temperature, not meeting the required consistency. This oversight was confirmed through staff interviews, highlighting a failure to adhere to the prescribed dietary orders for the resident.
Failure to Serve Food at Proper Temperatures
Penalty
Summary
The facility failed to serve food items that were palatable and at proper temperatures. According to the facility's policy, hot foods should be served at 135-155 degrees Fahrenheit. On March 12, 2024, initial temperatures of the food items were within the required range when brought to the kitchenette. However, the food was left uncovered in the steam table throughout the lunch meal service. By the time lunch was served to the last resident, the temperatures of the food items had dropped below the required range, and the food was cold to taste. Interviews with a dietary aide and the nursing home administrator confirmed that the lids should have been closed when not plating food and that the food would be cold if lids were left open during service.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food service safety. Observations in the main kitchen revealed that the Assistant Dietary Director was wearing a hair restraint that did not completely cover her hair, leaving approximately three inches of her bangs uncovered. Additionally, in the Evergreen and Dogwood kitchenettes, dietary aides were observed either without hairnets or with hair restraints that did not fully cover their hair. These observations were confirmed by the Executive Culinary Director, who acknowledged that staff should have had all hair covered with hair restraints. Further deficiencies were noted in the storage of food. In the freezer, a tray containing 22 uncovered, unlabeled, and undated grey-colored, unidentifiable food patties was found. Additionally, 24 patties of pureed cranberry were uncovered, unlabeled, and undated, and a full box of an unspecified item was uncovered, undated, unlabeled, and open to the air. These findings were also confirmed by the Executive Culinary Director, who stated that the frozen patties and the box should have been covered and dated according to the facility's dietary policy on food storage.
Ongoing Grievances About Cold Food
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances related to cold food. A meeting with a group of residents revealed complaints about cold, unappetizing, and unpalatable food. Grievances filed on November 14, 2023, and February 7, 2024, indicated that residents continued to receive cold food. Observations of the lunch meal service on March 12, 2024, showed that while the food temperatures were initially within acceptable ranges, a test tray conducted after the last resident was served revealed that the food had become cold. An interview with the Nursing Home Administrator confirmed that cold food has been an ongoing concern and had not been resolved despite continued grievances and the cold test tray results.
Failure to Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to respond timely to pharmacy recommendations for a resident. The facility's policy, dated September 14, 2023, mandates that a licensed pharmacist collaborates with facility leadership to coordinate pharmaceutical services and resolve pharmaceutical concerns affecting resident care. However, for one resident, the facility did not adhere to this policy. The resident, who was cognitively impaired and had multiple diagnoses including atrial fibrillation, high blood pressure, high cholesterol, thyroid disorder, arthritis, and renal failure, had physician's orders for several medications including Meloxicam, potassium chloride, Losartan, Levothyroxine, Allopurinol, and Lasix. Despite the pharmacist's recommendations for periodic blood draws and laboratory testing to monitor the effects of these medications, the recommendations were not reviewed, responded to, or signed by the physician. Specifically, the pharmacy medication regime review (MRR) for the resident, dated September 27, 2023, and November 6, 2023, included recommendations for various blood tests to monitor the resident's condition and medication effects. These recommendations were not addressed by the physician, as confirmed by the Director of Nursing during an interview on March 13, 2024. This failure to act on the pharmacist's recommendations constitutes a deficiency in the facility's pharmaceutical services, as it did not comply with its own policies and procedures, potentially impacting the resident's care and medical outcomes.
Failure to Notify Resident's Representative of Hospitalization
Penalty
Summary
The facility failed to notify the resident's representative in writing regarding the reason for hospitalization for one of 30 residents reviewed. Resident 38, who was severely cognitively impaired and required assistance for daily care needs, was transferred to the hospital on multiple occasions. Despite the resident's daughter being listed as the responsible party and first emergency contact, there was no documented evidence that she was notified in writing about the hospitalizations in October and November 2023. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 12, 2024.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect the resident's specific care needs. Resident 21, who was cognitively impaired and dependent on staff for daily care, had a care plan indicating inadequate oral intake with swallowing difficulty and unintended weight loss. However, the care plan did not include information about the resident's refusal of dinner trays, despite multiple instances of refusal documented in nursing notes and dietary records. A speech therapy note indicated that Resident 21 could have a mechanically soft diet if alert, out of bed, and in the dining room. Despite this, the resident continued to refuse dinner trays on several occasions. Interviews with speech therapists and the nursing home administrator confirmed that the care plan needed to be updated to reflect these refusals, but this had not been done. This failure to update the care plan was a violation of the facility's policy and regulatory requirements.
Deficiencies in Medication Storage and Expired Medical Supplies
Penalty
Summary
The facility failed to ensure that controlled medications were stored in a separately-locked, permanently-affixed compartment in the Main medication room. During an observation, a narcotic storage box containing an unopened bottle of liquid Ativan was found in the refrigerator, but the box was not permanently affixed. This was confirmed by an interview with a registered nurse who acknowledged that the narcotic storage box should have been permanently affixed inside the refrigerator. Additionally, the facility failed to discard expired medical supplies in the Evergreen medication room. Observations revealed multiple intravenous catheters and syringes that had expired in various months of 2023. A registered nurse confirmed that these expired medical supplies should not have been in circulation. The Nursing Home Administrator also confirmed the absence of a policy regarding expired medical supplies and the permanent affixing of narcotic boxes in the medication refrigerator.
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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