Cole Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Coudersport, Pennsylvania.
- Location
- 1001 East Second Street, Coudersport, Pennsylvania 16915
- CMS Provider Number
- 395228
- Inspections on file
- 14
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cole Place during CMS and state inspections, most recent first.
The facility failed to maintain proper infection control practices, as staff used non-leak-resistant mesh bags for soiled laundry, risking contamination. Additionally, a nurse aide returned to work prematurely after testing positive for COVID-19, without following CDC guidelines for testing and isolation. The facility lacked evidence of staffing shortages or mitigation measures to justify early return to work.
The facility failed to document that residents were offered influenza and pneumococcal immunizations and did not provide education on the benefits and side effects of these vaccines. This deficiency was identified in five residents, whose records lacked evidence of vaccine administration or education. The issue was discussed with the Nursing Home Administrator and the DON.
The facility failed to offer the COVID-19 vaccine and provide education to three residents, with missing documentation of vaccine administration or refusal. Additionally, the facility did not maintain proper records of a staff member's vaccination status, violating federal regulations.
Two residents were observed wearing hospital gowns due to delays in the return of their personal laundry, impacting their dignity. The facility sends laundry out to a contracted company without a specific return timeframe, and there is no protocol to ensure residents have enough clothing. The environmental services manager and operations manager confirmed these practices, and the Nursing Home Administrator and DON acknowledged the issue.
A facility failed to ensure consistent documentation of a resident's advance directives. The resident's POLST indicated a desire for CPR but refusal of intubation, while the electronic medical record instructed Full Code treatment without limitations. Interviews with RNs confirmed reliance on the EMR, which did not reflect the resident's refusal of intubation.
A resident with range of motion impairment did not consistently receive a physician-ordered splint for their right hand. Observations and staff interviews revealed the splint was not applied as scheduled, and it was in poor condition due to the resident chewing on it. Recommendations to use a tubi-grip sock were not followed, and staff documented the splint's application even when it was not in use.
A resident with severe cognitive impairment did not receive necessary routine dental services, despite having significant dental issues such as decay and heavy plaque buildup. The facility's documentation showed that the resident had previously refused treatment, but her cognitive status prevented effective participation in care planning. The facility failed to assist in making appointments or arranging transportation for dental services.
The facility failed to comply with the Act 52 Infection Control Plan by not providing evidence of infection control committee meetings and attendance. Despite repeated requests from the surveyor, the facility did not demonstrate adherence to the plan's requirements, which include having a multidisciplinary committee with representatives from various departments.
The facility failed to hold infection control committee meetings since February 2024 and did not document the disposition of a resident's personal belongings after their death. A resident admitted in early 2025 passed away, and their personal items, including glasses and a cell phone, were not accounted for, as confirmed by the Nursing Home Administrator and DON.
The facility did not comply with the required NA-to-resident ratios during the overnight shift on five occasions. For instance, with a census of 18 residents, only 1.00 NA was scheduled instead of the required 1.20 NAs. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility did not meet the required LPN-to-resident ratio during the overnight shift, as evidenced by a review of staffing hours. On a specific night, the facility had a census of 17 residents but no LPNs scheduled, failing to comply with the regulation of one LPN per 40 residents. This was confirmed by the Nursing Home Administrator and the DON.
The facility's laundry area was found to have a significant build-up of lint in the dryer vent and piping, with additional lint on the ground, posing a potential fire hazard. This was confirmed by the environmental services manager and supervisor during an inspection.
The facility failed to assess all required zones for bed rail entrapment risk for five residents, only evaluating zones two, three, and four. Despite high-risk assessments for two residents, enabler bars were used without complete documentation or informed consent, indicating a systemic issue in managing accident hazards.
The facility failed to implement enhanced barrier precautions for three residents, including one with a chronic wound and another with a Foley catheter, due to lack of signage and PPE. Additionally, the laundry area lacked gowns and handwashing facilities, increasing the risk of infection spread.
The facility did not adhere to its abuse prohibition policy by failing to investigate the employment history of two newly hired employees. The policy requires obtaining personal and/or professional references before employment, but records for an Activities Assistant and a Service Assistant showed no evidence of such attempts. This was confirmed by the NHA and HR.
A resident with multiple diagnoses, including cerebral palsy and major depressive disorder, was inaccurately assessed in the MDS as not requiring specialized services, despite a PASRR indicating otherwise. The Nursing Home Administrator confirmed the error in coding, highlighting a failure in accurate assessment and documentation.
The facility failed to prevent or treat UTIs for residents with indwelling catheters. A resident's catheter care policy was contradictory and not aligned with CDC guidelines, leading to improper catheter maintenance. Another resident experienced acute dysuria, but the facility failed to follow protocol, resulting in no urinalysis or antibiotic treatment. The facility's policies lacked professional standards, contributing to deficiencies in care.
The facility failed to properly store CPAP equipment for a resident with obstructive sleep apnea, leaving the mask unprotected from contaminants. Additionally, a resident using a flutter valve for a cough was not given clear instructions on usage frequency, and staff did not document follow-up to ensure proper use.
A facility's medication error rate exceeded the acceptable threshold, with errors involving two residents. An LPN failed to administer the correct number of tablets to one resident and did not follow timing instructions for another resident's medication. These errors were confirmed and discussed with facility leadership.
Infection Control and COVID-19 Work Exclusion Deficiencies
Penalty
Summary
The facility failed to ensure a safe environment free from the potential spread of infection related to the processing of resident personal laundry. Observations revealed that staff collected soiled personal laundry in mesh bags, which were not leak-resistant, potentially exposing staff to contamination during transport. The mesh bags were placed in a large, open bin in the nursing unit's soiled utility room, which lacked a lid, increasing the risk of contamination. Staff were instructed to rinse heavily soiled garments in the soiled utility hopper without the availability of isolation gowns, potentially contaminating the air, surfaces, and staff in the room. Additionally, the facility did not adhere to CDC guidelines for COVID-19 work exclusions. Employee 3, a nurse aide, returned to work five days after testing positive for COVID-19 on two separate occasions without undergoing subsequent testing to confirm a negative result. The facility's policy required adherence to CDC guidance, which stipulates a return to work after at least seven days with a negative test or ten days without testing. The facility did not provide evidence of any additional COVID-19 cases or staffing shortages that would justify early return to work under contingency or crisis staffing criteria. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the lack of evidence for additional COVID-19 cases or measures to mitigate staffing shortages. The facility did not progress through measures from conventional to contingent nurse staffing, nor did it communicate with local healthcare coalitions to identify additional healthcare personnel. This resulted in Employee 3 returning to work outside of CDC's conventional strategy parameters, potentially increasing the risk of COVID-19 transmission within the facility.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. No individual residents were identified as impacted. At the time of the finding, environmental staff was verbally reminded about the importance of keeping laundry in sealed bags and the use of PPE during laundry processing. 2. The Director of Nursing and/or designee will educate all environmental service staff and nursing assistants on the need to place resident personal laundry that is in a mesh bag in a plastic bag before removing it from the residents' room and the importance of using PPE when working in the soiled laundry area to prevent the potential spread of infection related to resident personal laundry processing. 3. The Administrator and/or designee will educate the Director of Nursing and Human Resources on the updates to the facility policy COVID-19 Testing and Exposure Management. Specifically, but not limited to the need to consider the continuum of options for addressing staffing shortages, and that contingency strategies followed by crisis strategies are provided to augment conventional strategies and are meant to be considered and implemented sequentially. As per the CDC, "when staffing shortages are anticipated, healthcare facilities and employers, in collaboration with human resources and occupational health services, should use capacity strategies to plan and prepare for mitigating this problem." The Director of Nursing will also be educated on the need to consider the PA DOH staffing Ratios and Hours Per Patient Day (HPPD) requirements while balancing strategies to mitigate staffing shortages, safe staffing to meet resident needs, and providing evidence of measures considered. 4. The Director of Nursing and/or designee will conduct 5 visual audits per week for 2 months to ensure the environmental service staff and/or nursing assistants place resident personal laundry that is in a mesh bag in a plastic bag for transport and storage and the importance of using PPE when working in the soiled laundry area to prevent the potential spread of infection related to resident personal laundry processing. The NHA and/or designee will conduct an audit on the return to work for any employee who is off due to COVID-19 and what was considered to support a return to work outside of the conventional strategies to mitigate staffing shortages. The audit will be completed for 2 months or until substantial compliance is achieved. Audit findings will be reviewed at the QAPI meeting.
Deficiency in Immunization Documentation and Education
Penalty
Summary
The facility failed to comply with the regulatory requirements for influenza and pneumococcal immunizations as outlined in §483.80(d). The deficiency was identified through a review of facility policies, CDC guidelines, clinical records, and staff interviews. The facility did not document that residents were offered influenza and pneumococcal immunizations, nor did they provide education regarding the benefits and potential side effects of these immunizations. This failure was observed in five residents who were reviewed for immunization concerns. Resident 2's clinical record lacked documentation of a pneumococcal vaccine administration and did not show evidence that the resident or their representative received education about the vaccine's risks and benefits. Similarly, Resident 7's record showed previous vaccinations but no documentation of education or decision-making regarding newer vaccines as per current CDC guidelines. Resident 10's record included a refusal of consent for yearly immunizations but lacked evidence of education provided about the vaccines. Residents 12 and 14 also had no documented history of pneumococcal vaccine administration or evidence of education provided to them or their representatives. These findings were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to meet the regulatory requirements for immunization documentation and education.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The Pneumococcal immunization status for residents 2, 7, 10, 12, and 14 was reviewed. The influenza immunization status of resident 10 was reviewed. Residents' and/or resident representatives' 2, 7, 10, 12, and 14 were provided education regarding the benefits and potential side effects of the pneumonia vaccine. Resident/Responsible party 10 was provided education regarding the potential risks and benefits of the influenza vaccine and declination revisited. The clinical record has been updated to reflect the administration of the pneumococcal vaccine as indicated for residents 2, 7, 10, 12, and 14. 2. All current residents' pneumococcal and influenza immunization statuses will be reviewed. Residents/Resident representatives will be provided education on the potential risks and benefits of the pneumococcal and influenza vaccine. Residents/resident representatives will be offered the pneumococcal and influenza vaccines as indicated and the clinical record will be updated to reflect the administration of pneumococcal and influenza vaccines. 3. The pneumococcal and influenza immunization statuses will be reviewed for all new admissions. Residents/resident representatives will be provided education on the potential risks and benefits of the pneumococcal and influenza vaccines as part of the admission packet. Residents/residents representatives will be offered the pneumococcal and influenza vaccines as indicated and the clinical record will be updated to reflect the administration of pneumococcal and influenza vaccines. The Administrator will educate RNs, LPNs, and social worker on this system alteration. 4. The Director of Nursing and/or designee will audit the pneumococcal and influenza immunization clinical documentation for all new admissions for 3 months or until substantial compliance is achieved to ensure Residents/Resident representatives were provided education on the potential risks and benefits of the pneumococcal and influenza vaccines, to ensure Residents/residents representatives were offered the pneumococcal and influenza vaccines as indicated and that the clinical record was updated to reflect the administration of pneumococcal and influenza vaccines. Results will be reviewed at the QAPI meeting.
Deficiencies in COVID-19 Vaccine Offer and Documentation
Penalty
Summary
The facility failed to ensure that each resident was offered the COVID-19 vaccine and provided with education regarding its benefits and risks. Specifically, for three residents reviewed for immunization concerns, there were deficiencies in documentation and education. Resident 2 had a consent form signed for the 2024/2025 COVID-19 vaccine, but there was no evidence of the vaccine being administered. Resident 7's record showed a refusal of the vaccine in 2021, but there was no documentation of any subsequent offer or education about the 2024/2025 vaccine. Resident 10's record lacked any evidence of receiving or refusing the vaccine, as well as any education provided about it. The facility's policy required that residents and their representatives receive education about the COVID-19 vaccine and have the opportunity to accept or refuse it. However, the survey found that the facility did not adhere to these policies for the residents reviewed. The medical records did not include necessary documentation of education provided or the vaccine's administration or refusal, which is a requirement under the facility's policy and federal regulations. Additionally, the facility failed to maintain proper documentation of staff COVID-19 vaccination status as required. Specifically, there was no information provided regarding the vaccination status of Employee 3, a nurse aide, despite requests from the surveyor. This lack of documentation is a violation of the requirement to maintain records of staff vaccination status and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Residents 2, 7, and 10 were provided with education on the benefits and risks associated to the covid vaccine and offered vaccine if desired. The clinical record has been updated to reflect the administration of the COVID vaccine as indicated for residents 2, 7, and 10. Employee 3 was provided education on the benefits and risks associated with the covid vaccination and where she can get the vaccination if desired. 2. All residents' covid vaccine statuses for the 2024-2025 vaccine will be reviewed and vaccine offered with education on risks and benefits. All current employee files reviewed for vaccine education acknowledgement. 3. Covid vaccine review with new residents incorporated into admission process including education on risks and benefits. Covid vaccine education given to new staff upon hire with acknowledgement form. 4. DON or designee will complete audits for new resident covid vaccination education and offer and new hires for covid vaccine education weekly x4 then monthly x2 with results reported to QAPI.
Failure to Ensure Resident Dignity Due to Laundry Delays
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for two residents. Observations revealed that both residents were in bed wearing hospital gowns due to not having their personal clothes returned from the laundry service in a timely manner. Resident 3 reported not having any clothes to wear and stated that her laundry was sent out but not returned promptly. Observations of her closet confirmed the lack of clothing, with only one shirt present and no pants. Similarly, Resident 11 was observed in a hospital gown and reported frequently running out of clothes due to delays in the return of her laundered items. Her closet was also found to be empty. Interviews with the environmental services manager and operations manager confirmed that residents' personal laundry is sent out to a contracted company four times a week, but there is no specific timeframe for its return. They also acknowledged that there is no facility protocol to ensure residents have enough clothes, expecting residents to have 14 days' worth of clothing. The Nursing Home Administrator and Director of Nursing confirmed these findings.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 3's care plan reflects her preference to occasionally wear hospital gowns depending on her preference each day. Resident 3 and resident 11 had their clean laundry returned to them. 2. All residents using facility laundry services will have closets checked for clothing that allows for seven outfits or per resident's preference. 3. Social Worker and CNAs will be educated to report concerns with availability of clean clothes for residents. 4. Social Worker or designee will complete random audits on 5 residents per week to ensure the resident has the availability of resident's clean clothes. Audits will be completed weekly x4 then monthly x2 with results reported to QAPI.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to establish clear and consistent resident wishes regarding advance directives for a resident reviewed for advance directive concerns. The clinical record review of the resident's physical chart revealed a POLST signed by a physician and the resident, indicating the resident desired CPR but refused intubation. However, the active physician orders in the resident's electronic medical record instructed staff to implement Full Code treatment without any limitations. Interviews with two registered nurses revealed that they would refer to the electronic medical record, which did not indicate a DNR status, and would initiate CPR without limitations. The nurses confirmed that the electronic medical record did not reflect the resident's wish to refuse intubation as indicated in the POLST. The surveyor reviewed the omission with the Director of Nursing, highlighting the inconsistency between the resident's POLST and the electronic physician orders.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 118's physician order and banner notification were updated to reflect resident 118's desire for CPR and refusal of intubation (i.e. DNI). There was no harm to resident 118. 2. All current resident records will be reviewed to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 3. The DON or Designee will educate all RNs, LPNs, and Social Workers on the need to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 4. Social worker or designee will audit to ensure that the Banner Bar and the physician order, which may also reflect any limited interventions (such as intubation) match the residents code preferences noted on the POLST and/or the Advanced Directive as indicated. 5 resident charts will be audited weekly x4 then 5 resident charts will be audited monthly x2 or until substantial compliance is achieved. Results will be reported at the QAPI meeting.
Failure to Implement Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to ensure the proper implementation of a physician-ordered positioning device for a resident with range of motion impairment in the bilateral upper extremities. The resident had an active physician's order for a splint to be applied to the right hand at specific times throughout the day. However, observations and staff interviews revealed that the splint was not consistently applied as ordered. The resident was observed without the splint on multiple occasions, and staff confirmed that the splint was not applied after lunch as required. Further investigation showed that the splint was in poor condition, with worn-out Velcro and missing foam spacers due to the resident chewing on it. Despite recommendations from occupational therapy to use a tubi-grip sock over the splint to prevent chewing and extend its longevity, this was not implemented. The staff documented the application of the splint even when it was not in use, indicating a failure to adhere to the care plan and physician's orders. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 12's new right-hand splint arrived before the exit conference. Staff on duty at the time were verbally re-educated on the splint schedule (which specifies when to apply and remove the hand splint) for this resident. Resident was wearing splint as directed without difficulty. The plan of care was reviewed and updated as indicated. 2. All residents with hand splints were reviewed to ensure the splint was present and in good repair. Staff also reviewed the current hand splint schedule (which specifies when to apply and remove the hand splint). The plan of care was reviewed and updated as indicated. 3. The Director of Nursing and/or designee will educate the RNs, LPNs, and CNAs on the need to ensure splints are present and in good repair and where to note the current hand splint schedule. 4. DON or designee will audit residents with hand splints to ensure splints are on as per the plan of care and in good repair weekly x4 then monthly x2 or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to obtain routine dental services for a resident, as evidenced by clinical record reviews, observations, and interviews. The resident, who had severe cognitive impairment, was observed to have several missing and discolored teeth. Documentation from the facility's consultant dental provider indicated that the resident had significant dental issues, including decay, a fractured tooth, and heavy plaque and calculus buildup. Despite these findings, there was no evidence of professional dental cleaning or treatment to address these issues. The resident's cognitive status, as recorded in her MDS assessments, showed severe impairment, which prevented her from effectively participating in her care planning decisions. The facility's documentation noted that the resident had previously refused dental treatment due to a lack of pain and progressing cancer. However, the facility did not ensure that the resident received necessary dental care, such as extractions recommended by the dental provider, and failed to assist her in making appointments or arranging transportation for dental services.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 1 was seen by dentist on 4/22/25. Reviewed dentist recommendations for resident and follow-up as indicated with resident/resident representative; follow-up will be completed as indicated and the plan of care will be updated. 2. A retrospective review of all residents' most recent dental consult will be completed to ensure recommendations for oral specialists were reviewed with the resident/resident responsible party and scheduled follow-up is coordinated as indicated. 3. The Administrator and/or designee will educate all RNs, LPNs, and Social worker regarding the need to ensure recommendations for oral specialists were reviewed with the resident/resident responsible party and scheduled follow-up is coordinated as indicated. 4. The Social Worker and/or designee will audit all new dental consult notes to ensure recommendations for oral specialists were reviewed with the resident/resident responsible party and scheduled follow-up is coordinated as indicated. Audits will be completed bi-weekly for 2 months, or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.
Non-Compliance with Infection Control Committee Requirements
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. This plan mandates that a health care facility develop and implement an internal infection control plan aimed at improving the health and safety of residents and health care workers. The plan should include a multidisciplinary committee with representatives from various departments, such as medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, a patient safety officer, members from the infection control team, and community representatives. However, the facility was unable to provide evidence of the infection control committee meetings and attendance records since the last standard survey. During interviews with the Nursing Home Administrator and the Director of Nursing, who also serves as the facility's infection preventionist, the surveyor requested documentation of the infection control committee meetings. Despite repeated requests, the facility did not provide the necessary evidence, indicating a failure to adhere to the infection control plan's requirements. This deficiency highlights the facility's non-compliance with the established standards for infection control, as outlined in the Act 52 Infection Control Plan.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. No individual resident was identified as impacted. 2. A multidisciplinary committee is being assembled that meets the requirements of Act 52, and a meeting will be scheduled to be held at least quarterly. 3. The Regional Director of Operations will educate the current NHA on the need to assemble a multidisciplinary committee that meets the requirements of Act 52, and that a meeting is to be scheduled and held on a quarterly basis. 4. The Regional Director of Operations will audit to ensure that a multidisciplinary committee that meets the requirements of Act 52 is in place, and that a meeting was scheduled and held on a quarterly basis. Audit findings will be reviewed at the QAPI meeting.
Deficiencies in Infection Control and Personal Property Management
Penalty
Summary
The facility was found to have deficiencies in infection control and management of residents' personal property. There was no evidence of infection control committee meetings after February 2024, indicating a lapse in ongoing infection control oversight. Additionally, a review of closed clinical records revealed that the facility failed to document the disposition of a resident's personal belongings following their discharge. Specifically, Resident 16, who was admitted on February 8, 2025, and passed away on March 5, 2025, had personal items such as prescription glasses, clothes, shoes, a cell phone, and a charger listed in their inventory. However, there was no documentation indicating what happened to these belongings after the resident's death. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 16 personal belonging inventory disposition was completed and reviewed with the resident's representative. 2. A retrospective review of the last 3 months of discharges was reviewed for the presence of a personal belonging inventory disposition and completed as indicated. 3. The Director of Nursing and/or designee will educate RNs, LPNs, and Housekeeping to ensure that the personal belongings inventory disposition is completed and reviewed with the resident/resident representative as indicated. 4. The Director of Nursing and/or designee will audit all closed records to ensure that the personal belongings inventory disposition is completed and reviewed with the resident/resident representative as indicated. The audit will be completed for 3 months or until substantial compliance is achieved. Results will be reviewed at the quarterly QA meeting.
Non-Compliance with Overnight NA Staffing Ratios
Penalty
Summary
The facility failed to meet the regulatory requirement of maintaining a minimum of one nurse aide (NA) per 15 residents during the overnight shift for five out of the 21 days reviewed. Specifically, on February 9, 2025, with a census of 18 residents, only 1.00 NA was scheduled, whereas 1.20 NAs were required. On February 11, 2025, with a census of 20 residents, 1.00 NA was scheduled, but 1.33 NAs were needed. Similarly, on April 11, 12, and 13, 2025, with a census of 17 residents each night, only 1.00 NA was scheduled, while 1.13 NAs were required. This deficiency was confirmed through an interview with the Nursing Home Administrator and Director of Nursing on April 16, 2025.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. At the time of the finding, the ratios and total nursing hours for the current working schedule were reviewed and staffing was sufficient to meet the needs of the residents or there was sufficient time to coordinate sufficient staffing. 2. The RNs and LPNs will be re-educated on the nursing assistant ratio requirements, and the importance of monitoring staffing as the day and/or shift progress. Education will be completed by the Director of Nursing and/or designee. 3. The Director of Nursing and/or designee will audit the current working schedule, and the deployment sheets prior to the day and after the day is complete to ensure nursing assistant ratios have been met. 4. Audits will be completed 3 times per week for 1 month, and weekly for 1 month thereafter or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.
Failure to Meet LPN Staffing Requirements Overnight
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one licensed practical nurse (LPN) per 40 residents during the overnight shift. This deficiency was identified during a review of nursing staffing hours and confirmed through staff interviews. Specifically, on April 13, 2025, the facility had a resident census of 17 but did not have any LPNs scheduled for the night shift, thereby not meeting the required LPN-to-resident ratio. This finding was confirmed in an interview with the Nursing Home Administrator and the Director of Nursing on April 16, 2025.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. At the time of the finding, the LPN ratios for the current working schedule were reviewed, and no issues were noted. 2. The Director of Nursing and/or designee will educate the RNs and LPNs on the LPN ratios and the importance of monitoring staffing as the day and/or shift progress as well as the ability to substitute an RN for an LPN; the designated RN charge nurse may take on an assignment and be counted in ratios. A facility such as Cole Place with a census of 59 or under may substitute an LPN for an RN on the overnight shift only if an RN is on call and located within a 30-minute drive of the facility. 3. The Director of Nursing and/or designee will audit the current working schedule, and the deployment sheets prior to the day and after the day is complete to ensure compliance. 4. Audits will be completed 3 times per week for 1 month, and weekly thereafter for 1 month or until substantial compliance is achieved. Results will be reviewed at the QAPI meeting.
Laundry Area Fire Hazard Due to Lint Build-Up
Penalty
Summary
The facility failed to prevent potential accident hazards in the laundry area, as observed by surveyors. During an inspection, it was noted that the dryer vent and piping had a significant build-up of lint inside the vent/pipe area, with additional white lint observed on the ground below the vent. This condition poses a potential fire hazard. The observation was confirmed during an interview with the manager and supervisor of environmental services. The issue was further discussed with the Nursing Home Administrator and Director of Nursing Home.
Incomplete Bed Rail Risk Assessment
Penalty
Summary
The facility failed to properly assess the risk of side rail entrapment for five residents, as required by their own policy. The policy mandates the assessment of seven potential zones of bed entrapment, but the facility only evaluated zones two, three, and four. This incomplete assessment was documented in the Bed System Measurement Device Test Results Worksheet for Residents 3, 4, 6, 7, and 11. The facility's oversight in not assessing zones one, six, and seven was a significant lapse in ensuring resident safety. For Residents 3 and 4, the facility's documentation indicated that they were assessed as high risk for enabler bar use, which should have prompted a halt in their use. However, the facility proceeded with the installation of enabler bars despite the high-risk assessment. Additionally, the documentation lacked signatures, making it impossible to determine who completed the assessments. This lack of accountability and adherence to the facility's own policy contributed to the deficiency. Observations of Residents 6, 7, and 11 revealed that they were using enabler bars without a complete assessment of all entrapment zones. The facility's failure to conduct a comprehensive risk assessment for these residents, as well as the lack of informed consent and proper documentation, highlights a systemic issue in the facility's approach to managing accident hazards related to bed rails.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for three residents, leading to potential infection control issues. Resident 14, who was on enhanced barrier precautions due to a chronic coccyx wound and a history of MRSA, was observed receiving wound care from an LPN who did not wear a gown, only gloves, during the procedure. The LPN was unsure about the requirement to wear a gown and confirmed with a registered nurse that the resident was indeed on enhanced barrier precautions. Resident 120, who had a physician-ordered Foley catheter, did not have enhanced barrier precaution signage or personal protective equipment available outside her room. Similarly, Resident 3, who had an indwelling urinary catheter and was receiving treatment for a urinary tract infection and bloodstream infection, also lacked signage and PPE outside his room. Staff confirmed that enhanced barrier precautions were not in place for Resident 3 at the time of the surveyor's observation. Additionally, the facility's laundry area was found to be lacking in infection control measures. There were no gowns available for staff to use when handling soiled items, and there was no handwashing sink or hand sanitizer available for staff to clean their hands after processing soiled laundry. This lack of infection control measures in the laundry area further contributed to the potential spread of infection within the facility.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its abuse prohibition policy effectively, as evidenced by the lack of thorough investigation into the employment history of two newly hired employees. The policy, titled 'Abuse, Neglect, Exploitation General Policy,' mandates that the facility make reasonable efforts to obtain personal and/or professional reference information before an employee's first day of work. However, upon review, it was found that the personnel records for Employee 4, an Activities Assistant hired on April 22, 2024, and Employee 5, a Service Assistant hired on March 16, 2024, contained no evidence of attempts to obtain such reference information. This deficiency was confirmed by the Nursing Home Administrator and a Human Resources representative on May 9, 2024.
Inaccurate MDS Assessment for Resident with PASRR Needs
Penalty
Summary
The facility failed to ensure the accuracy of MDS assessments for one of the eight residents reviewed. Specifically, Resident 2's clinical record indicated several diagnoses, including cerebral palsy, major depressive disorder, generalized anxiety, dementia, and unspecified psychosis. A PASRR assessment from 2003 confirmed that Resident 2 required specialized services due to these conditions. However, the annual MDS assessment inaccurately recorded that Resident 2 was not considered by the state level II PASRR process to have a serious mental illness or intellectual disability, which was incorrect. The Nursing Home Administrator confirmed during an interview that the coding on the annual MDS was an error, acknowledging that Resident 2 did indeed meet the criteria for specialized services as per the level II PASRR process. This discrepancy highlights a failure in accurately assessing and documenting the resident's needs, which is crucial for ensuring appropriate care and services are provided.
Deficiencies in Catheter Care and UTI Prevention
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent or treat urinary tract infections (UTIs) for residents with indwelling catheters. Specifically, for Resident 3, the facility's policy on urinary catheters was found to be contradictory and not aligned with current CDC guidelines. The policy recommended maintaining a closed sterile drainage system but also suggested using an intermittent method for irrigation, which would break the closed system. Resident 3 had active physician orders for two different catheter sizes and instructions to change the collection bag as needed, which also disrupted the closed system. Despite discovering a hole in the catheter bag and bloody drainage, staff changed only the collection bag and not the catheter, failing to document the change in the MAR/TAR. The facility also lacked evidence of urologist consultations for Resident 3. For Resident 5, the facility failed to appropriately address a suspected UTI. Documentation indicated that Resident 5 experienced acute dysuria, but the registered nurse incorrectly completed the Suspected UTI SBAR form, reporting to the physician that the nursing home protocol was not met. As a result, Resident 5 did not receive a urinalysis or antibiotic treatment. The facility had no evidence of any new interventions implemented in response to Resident 5's complaint. The facility's policies and procedures were found to be lacking in professional standards and not in compliance with current guidelines. Interviews with the Director of Nursing confirmed the contradictions in the facility's indwelling catheter policy and the absence of clear instructions for catheter changes. The facility's failure to adhere to proper catheter maintenance and UTI prevention protocols resulted in deficiencies in the care provided to Residents 3 and 5.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to adhere to professional standards of practice in storing CPAP equipment for a resident with obstructive sleep apnea. The resident's CPAP mask was observed on multiple occasions to be unprotected from environmental contaminants, as it was placed on top of the CPAP machine on a dresser next to the bed. Interviews with the Nursing Home Administrator and a licensed practical nurse revealed that the facility's policy required CPAP masks to be bagged to prevent contamination, but this practice was not being followed. Additionally, the facility's policy on CPAP cleaning and disinfection did not address proper storage of the mask to prevent contamination. Another deficiency was identified in the care of a resident using a flutter valve to manage a dry, non-productive cough. The resident had a physician's order for the device but was not provided with a specified frequency for its use. The resident expressed uncertainty about how often to use the flutter valve and mentioned that staff had only instructed her once, which she had since forgotten. There was no documentation in the clinical records to indicate that staff ensured the resident was using the device correctly or followed up to clarify usage frequency.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.14 percent based on 28 medication opportunities with two errors. During a medication administration pass, an LPN prepared medications for a resident but omitted one of the two required calcium citrate tablets, resulting in only eight and one-half tablets instead of the prescribed nine and one-half. This error was confirmed by the LPN after recounting the tablets and reviewing the medication labels. In another instance, the same LPN administered medications to a second resident without adhering to the specific timing instructions. The resident received Gemfibrozil, which should be taken 30 minutes before a meal, after they had already finished breakfast. Additionally, the schedule for the resident's medications included conflicting instructions, with some medications requiring administration with food. The active physician order for Gemfibrozil was discontinued later that day. These issues were discussed with the Nursing Home Administrator and the Director of Nursing.
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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