Clarion Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarion, Pennsylvania.
- Location
- 999 Heidrick Street, Clarion, Pennsylvania 16214
- CMS Provider Number
- 395707
- Inspections on file
- 20
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Clarion Nursing And Rehab during CMS and state inspections, most recent first.
Surveyors found that medications were not administered according to prescriber orders and facility policy, which requires administration within one hour of the scheduled time. Over two evening shifts, many residents had medications scheduled for late afternoon and evening (including 4:30 p.m., 5:00 p.m., 6:30 p.m., 7:00 p.m., and 8:00 p.m.) that were actually given several hours late, in some cases close to or after midnight. These delays involved both single and multiple medications per resident, with some individuals receiving 10 or more medications well outside the required timeframe. The NHA confirmed that the medications identified in the records review were administered late.
A resident with impaired mobility and at risk for skin integrity issues was not repositioned every two hours as required by their care plan. Observations showed the resident remained on their back during multiple checks over two days, despite the care plan's directive. The DON confirmed the care plan was not followed.
A resident with a contracture did not receive the physician-ordered treatment of a washcloth or palm grip in the right hand to prevent further decline in range of motion. Observations on multiple occasions revealed the absence of the required device, and the DON confirmed the deficiency.
A resident with chronic systolic congestive heart failure was observed receiving supplemental oxygen throughout the day, contrary to the physician's order for administration only at night. This was confirmed by the DON, indicating a failure to follow the prescribed respiratory care plan.
The facility failed to properly label and dispose of medications, as observed in the C/B medication room and B-Wing medication cart. An opened vial of Tubersol PPD lacked an open date, and another was expired. An injector pen of Humalog insulin was also expired. These issues were confirmed by LPNs, indicating non-compliance with facility policies and manufacturer's guidelines.
A resident with a known allergy to Keflex was administered the medication due to failures by an RN and an LPN to verify allergies before medication administration. The RN did not check the resident's allergies before entering a new order, and the LPN administered the medication without reviewing the allergy information. This oversight was confirmed through staff interviews and an investigation by the DON.
An LPN failed to follow professional standards and facility policy for medication administration by not referencing the MAR before administering medications and not documenting immediately after. The LPN relied on familiarity with residents and shift reports, leading to a deficiency in nursing and pharmacy services.
The facility failed to honor a resident's right to self-determination and choice in significant aspects of their life. Despite the resident's documented preferences and cognitive ability, staff frequently left the resident in bed during meals and activities, contrary to their expressed wishes. Interviews and observations confirmed the resident's dissatisfaction and the staff's inappropriate actions.
The facility failed to maintain the privacy of confidential information during medication administration. An LPN left the medication cart unattended in the hallway with the computer screen unlocked and open, displaying resident information. This occurred while the LPN administered medication to multiple residents, leaving the computer screen accessible to anyone passing by.
A resident with multiple diagnoses, including multiple sclerosis and dementia, was neglected when a staff member transferred them using a mechanical lift without the required second staff member. This resulted in the resident being lowered to the floor after starting to slide off the bed.
The facility failed to maintain proper care of respiratory equipment for a resident who required oxygen therapy. Observations revealed that the filters on the resident's oxygen concentrator contained a gray dusty substance, indicating they had not been cleaned as required. A registered nurse confirmed the filters were dusty and should be cleaned weekly. The resident had diagnoses including Diabetes, High Blood Pressure, and Alzheimer's Disease.
The facility failed to ensure the accurate and safe disposition of controlled medications for a resident. The documentation lacked evidence that two licensed nurses were present and signed during the disposal of Morphine and Lorazepam, as required by facility policy. This deficiency was confirmed by the DON.
The facility failed to document attempts of non-pharmacological interventions before administering PRN psychotropic medications to two residents diagnosed with dementia, anxiety, and depression. The Director of Nursing confirmed the lack of documentation for both residents.
The facility failed to store food in accordance with safety standards, as two open containers of Imperial Butter Pecan 2.0 Cal Med Pass in the first-floor pantry refrigerator were found without open dates. A Registered Nurse confirmed that the containers should have been dated and discarded.
A resident with a history of unsteadiness on feet and other medical conditions required two-person assistance for transfers. However, a nursing assistant attempted to transfer the resident alone, resulting in a complete dislocation of the resident's left hip hemiarthroplasty. The facility's investigation confirmed the neglect, as the nursing assistant did not follow the care plan.
Widespread Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-directed care and treatment consistent with physician orders and professional standards of practice for medication administration. Facility policy titled "Administering Medications" requires that medications be administered in accordance with prescriber orders, including required timeframes, and within one hour of the prescribed time unless otherwise specified. Review of medication administration records for two evening shifts showed that numerous scheduled medications were administered more than one hour late for 37 of 62 residents. On one evening, multiple residents had medications scheduled for 8:00 p.m. that were not administered until between approximately 10:05 p.m. and 11:12 p.m., and one resident had a 6:30 p.m. medication administered at 8:31 p.m. Another resident’s medications scheduled for 8:00 p.m. were not given until after midnight. On the subsequent evening shift, additional residents had medications significantly delayed beyond the one-hour window. Medications scheduled for 4:30 p.m., 5:00 p.m., 6:30 p.m., 7:00 p.m., and 8:00 p.m. were administered between approximately 7:21 p.m. and 10:44 p.m., with some 4:30 p.m. and 5:00 p.m. medications not given until after 8:30 p.m. and as late as 10:43 p.m. These delays affected residents receiving single medications as well as those receiving multiple medications at a time, including instances where residents had up to 11 or 12 medications scheduled for a specific time that were administered several hours late. During a phone interview, the Nursing Home Administrator confirmed that the listed medications were administered late. The cited deficiency is related to Pennsylvania regulations governing responsibility of the licensee, management, and nursing services.
Failure to Follow Repositioning Care Plan for Resident
Penalty
Summary
The facility failed to adhere to the care plan for a resident identified as R224, who was at risk for skin integrity issues due to impaired mobility. The care plan specified that the resident should be turned and repositioned every two hours to prevent skin breakdown. However, observations on two consecutive days revealed that the resident remained in the same position, lying on their back, during multiple checks throughout the day. The Director of Nursing confirmed that the care plan required repositioning every two hours, yet the resident was not repositioned as required. The resident's medical history included conditions such as hypertension, hypothyroidism, and chronic systolic congestive heart failure, which could contribute to their vulnerability to skin integrity issues. The failure to follow the care plan was a direct violation of the facility's policy and the resident's care needs.
Failure to Provide Physician-Ordered Contracture Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion due to a contracture. The resident, identified as R19, had a physician's order dated 10/23/24 to use a rolled-up washcloth in the right hand to manage the contracture until a palm grip could be ordered. This order included instructions to change the washcloth daily and ensure it was washed and dried thoroughly between changes. However, during observations on 3/25/25, 3/27/25, and 3/28/25, it was noted that the resident did not have the washcloth or palm grip in place as ordered. The Director of Nursing confirmed during an observation on 3/28/25 that the resident did not have the required washcloth or palm grip on the right hand, acknowledging that it should have been in place according to the physician's orders. This deficiency was identified as a failure to follow the facility's policy on the use of assistive devices and to provide the necessary treatment to prevent further decline in the resident's range of motion.
Failure to Adhere to Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide oxygen to a resident according to the physician's orders. The resident, identified as R224, had a physician's order dated 3/20/25 for oxygen to be administered at 1.5 liters per minute via nasal cannula only during hours of sleep. However, observations on multiple occasions revealed that the resident was receiving supplemental oxygen throughout the day, contrary to the specified order. This discrepancy was confirmed by the Director of Nursing during an interview. Resident R224 was admitted with diagnoses including hypertension, hypothyroidism, and chronic systolic congestive heart failure. Despite the clear physician's order and care plan intervention for oxygen administration only at night, the resident was observed receiving oxygen during the day while in bed and sitting in a wheelchair. This failure to adhere to the physician's order constitutes a deficiency in providing appropriate respiratory care as per the facility's policy and the resident's care plan.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of medications, as evidenced by observations and staff interviews. In the C/B medication room, an opened vial of Tubersol PPD was found without an open date, making it impossible for staff to determine the discard date. Additionally, another vial of Tubersol PPD was observed with an open date of 2/8/25, indicating that it was expired and should have been discarded. These findings were confirmed by an LPN, who acknowledged the lack of an open date on one vial and the expiration of the other. Similarly, in the B-Wing medication cart, an open injector pen of Humalog insulin was found with an open date of 2/17/25, indicating that it was expired. This was also confirmed by another LPN, who acknowledged that the Humalog insulin pen was expired and should have been discarded. The facility's policies on medication storage and labeling, as well as the manufacturer's guidelines for Tubersol PPD and Humalog insulin, were not adhered to, leading to these deficiencies.
Failure to Verify Allergies Leads to Medication Error
Penalty
Summary
The facility failed to adhere to nursing standards of practice for safe medication administration, specifically regarding the verification of medication allergies. A resident with a documented allergy to Keflex, an antibiotic, was administered the medication due to a series of oversights by the nursing staff. The resident, who had been admitted with conditions including chronic obstructive pulmonary disease, edema, and chronic atrial fibrillation, had Keflex listed as an allergy in their clinical record. Despite this, RN Employee E1 received a verbal order for Keflex from the physician and failed to verify the resident's allergies before entering the order into the facility's computer system and notifying LPN Employee E2. LPN Employee E2 subsequently administered the Keflex without reviewing the resident's allergy information. It was only after the medication was given that both RN Employee E1 and LPN Employee E2 realized the error. The Director of Nursing's investigation confirmed these lapses, and interviews with the involved staff corroborated the failure to check the resident's allergies prior to medication administration. This incident highlights a critical breakdown in the medication administration process, as outlined in the facility's policy and Pennsylvania Code Title 49.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for medication administration on Unit C. During an observation of medication administration, an LPN did not reference the Medication Administration Record (MAR) for three residents before administering their medications. The LPN administered medications to residents without verifying the right resident, right medication, right dosage, right time, and right method of administration as required by the facility's policy. Additionally, the LPN did not document the administration of medications immediately after giving them to each resident, as stipulated by the facility's policy and professional standards of practice. During an interview, the LPN admitted to not referencing the MAR before administering medications and not documenting the administration immediately after each resident. The LPN stated that they relied on their familiarity with the residents and received updates during shift reports. The LPN also mentioned that they were taught at a previous job to save time by administering all medications first and then documenting afterward. This practice led to the failure to adhere to the facility's policy and professional standards, resulting in a deficiency in nursing services and pharmacy services as per the relevant state codes.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor Resident R17's right to self-determination and choice in significant aspects of their life. Resident R17, who has intact cognitive status as indicated by a BIMS score of 15, expressed a desire to be out of bed for meals and activities, including attending bible study and resident council meetings. Despite these preferences being documented in the resident's care plan and MDS assessment, observations revealed that Resident R17 was frequently left in bed dressed in pajamas during times they wished to participate in activities or meals in the dining room. On multiple occasions, staff did not assist Resident R17 in getting out of bed in a timely manner, resulting in missed activities and meals in the dining room, contrary to the resident's expressed wishes and documented care plan interventions. Interviews with Resident R17 confirmed their dissatisfaction with not being assisted out of bed as per their preferences. The resident reported wanting to be up in their wheelchair for meals and activities but was often left in bed. This was corroborated by observations on several dates where the resident was found in bed during meal times and scheduled activities. The Nursing Home Administrator and the Director of Nursing acknowledged that residents have the right to be out of bed for meals and activities and confirmed that the staff's actions were inappropriate and did not align with the resident's wishes or the facility's policies on resident rights and self-determination.
Failure to Maintain Privacy of Confidential Information
Penalty
Summary
The facility failed to maintain the privacy of confidential information during medication administration on Unit C. The facility's policy on Confidentiality of Information and Personal Privacy, dated 1/2/24, mandates safeguarding the personal privacy and confidentiality of all resident personal and medical records. However, an observation on 4/9/24, between 3:50 p.m. and 4:20 p.m., revealed that an LPN left the medication cart unattended in the hallway with the computer screen unlocked and open, displaying resident information. This occurred while the LPN administered medication to multiple residents, leaving the computer screen accessible to anyone passing by. The LPN confirmed during an interview that the medication cart and computer screen were left unattended and out of view, with resident information accessible to passersby.
Failure to Ensure Safe Transfer of Resident
Penalty
Summary
The facility failed to ensure that a resident was free of neglect during care. Resident R8, who has multiple diagnoses including multiple sclerosis, dementia, and chronic obstructive pulmonary disease, is dependent on staff for transfers from chair to bed. The resident's care plan, Kardex, and physician orders all specified that transfers should be conducted using a mechanical lift (Sara lift) with the assistance of two staff members. However, on the date of the incident, NA Employee E3 transferred Resident R8 using the Sara lift without the required second staff member. This resulted in Resident R8 being lowered to the floor after starting to slide off the bed while still attached to the lift. The facility's investigation confirmed that NA Employee E3 did not follow the protocol requiring two staff members for the transfer. The Nursing Home Administrator and Director of Nursing acknowledged that the mechanical lift should always be operated by two staff members when used with a resident. The incident was classified as neglect, as the facility failed to provide the necessary services to avoid physical harm, pain, mental anguish, or emotional distress to Resident R8.
Failure to Maintain Proper Care of Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment for a resident (R22) who required oxygen therapy. According to the facility's policy, filters from oxygen concentrators should be washed every seven days. However, observations revealed that the filters on Resident R22's oxygen concentrator contained a gray dusty substance, indicating they had not been cleaned as required. Resident R22 had a physician's order for oxygen at two liters per minute via nasal cannula for shortness of breath. During an interview, a registered nurse confirmed that the filters were dusty and should be cleaned weekly. Resident R22 had diagnoses including Diabetes, High Blood Pressure, and Alzheimer's Disease.
Failure to Ensure Proper Disposition of Controlled Medications
Penalty
Summary
The facility failed to implement procedures to ensure the accurate and safe disposition of controlled medication records for Resident CR68. According to the facility's policy, Schedule II-V medications remaining after a resident's discharge or order discontinuation must be disposed of by two licensed nurses or a licensed nurse and a licensed pharmacist. Resident CR68, who was admitted to the facility and ceased to breathe on 2/18/24, had 12.5 milliliters of Morphine and 29.75 milliliters of Lorazepam transferred to a Federally approved waste container. However, the documentation lacked evidence that two licensed nurses were present and signed during the disposal process. This deficiency was confirmed by the Director of Nursing during an interview on 4/12/24.
Failure to Attempt Non-Pharmacological Interventions Before Administering PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted prior to the administration of PRN psychotropic medications for two residents. Resident R39, diagnosed with dementia, anxiety, and depression, received Haldol and Lorazepam without documented attempts of non-pharmacological interventions. Specifically, Haldol was administered on one occasion, and Lorazepam was used twice in April 2024 without any evidence of alternative calming methods being tried first. Similarly, Resident R60, also diagnosed with dementia, anxiety, and depression, received Vistaril multiple times from October 2023 to March 2024 without documented attempts of non-pharmacological interventions. The MARs and clinical records for Resident R60 showed that Vistaril was administered numerous times across several months without any evidence of non-pharmacological approaches being attempted prior to medication administration. The Director of Nursing confirmed the lack of documentation for both residents.
Failure to Date and Discard Opened Food Containers
Penalty
Summary
The facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators reviewed. Specifically, during an observation of the first-floor pantry refrigerator, two open containers of Imperial Butter Pecan 2.0 Cal Med Pass were found without open dates. According to the facility's policy on Food Receiving and Storage, beverages must be dated when opened and discarded after twenty-four hours. This deficiency was confirmed during an interview with a Registered Nurse, who acknowledged that the containers should have been dated and discarded due to the lack of an open date.
Neglect During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect during care, resulting in actual harm. The resident, who had a history of hypomagnesemia, hyperlipidemia, hypertension, and unsteadiness on feet, required extensive assistance with two-person transfers. However, a nursing assistant attempted to transfer the resident alone, which led to the resident's left leg giving out and a complete dislocation of the left hip hemiarthroplasty. The nursing assistant's actions were contrary to the resident's care plan, which specified the need for two-person assistance during transfers. The incident occurred when the nursing assistant tried to lay the resident down by themselves, resulting in the resident falling and landing hard on the bed. The resident immediately reported pain in the left hip and was later found to have a completely dislocated left hip hemiarthroplasty. The facility's investigation confirmed that the nursing assistant did not follow the care plan and attempted the transfer without the required assistance, leading to the resident's injury. The facility's policies on identifying types of abuse and safe lifting and movement of residents were not adhered to in this case. The nursing assistant's failure to follow the care plan and the facility's procedures resulted in the resident experiencing significant pain and requiring hospital transfer for further treatment. The facility acknowledged the deficiency and took immediate action to address the issue, including suspending the nursing assistant and providing additional education to staff.
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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