Concordia At Arbutus Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnstown, Pennsylvania.
- Location
- 207 Ottawa Street, Johnstown, Pennsylvania 15904
- CMS Provider Number
- 396069
- Inspections on file
- 28
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Concordia At Arbutus Park during CMS and state inspections, most recent first.
The facility did not complete required pre-employment screenings for several nursing staff, including missing nurse aide registry verification, criminal background checks, and nursing license checks with the state board, as well as lacking reference checks for some staff prior to hire, contrary to facility policy and state regulations.
A resident with COPD and end stage heart failure did not receive a prescribed Trelegy Ellipta inhaler for about two weeks due to delays in delivery and lack of follow-up by staff. The resident reported increased shortness of breath, and there was no documentation of attempts to resolve the issue with the pharmacy or physician. The DON was unaware of the missing medication until notified by pharmacy.
The facility did not ensure proper care for two residents with indwelling urinary catheters by failing to document required catheter drainage bag changes and not consistently measuring or recording urinary output as outlined in care plans and facility policy. Nursing leadership confirmed these lapses in documentation and adherence to protocol.
Surveyors found that food items in the kitchen, including pre-sliced meats, a milk shake/ice cream mix, and iced coffees, were not properly labeled, dated, or discarded according to facility policy and manufacturer guidelines. The Dietary Supervisor confirmed these items should have been handled differently.
Two nurse aides did not receive the required 12 hours of annual in-service training, as confirmed by a review of facility records and staff interviews. The facility lacked documentation to show that these nurse aides completed the mandated training in areas such as dementia care and abuse prevention.
A resident who was cognitively impaired and dependent for care experienced a coughing episode after taking medications. The physician instructed staff to monitor the resident and provide a status update the next day to decide on further treatment, but there was no documentation that the physician was contacted as requested.
A resident with Alzheimer's dementia, assessed as at moderate risk for wandering, was able to exit the facility undetected due to failures in safety protocols. The resident's care plan included a door alarm, which was not activated by the responsible LPN. Additionally, the facility failed to document monthly checks and replacement of door alarm batteries, leading to dead batteries and non-functioning alarms. The resident was found outside, indicating a significant lapse in safety measures.
The facility failed to provide a clean and homelike environment in a secured unit, as observed by stained and dirty carpets and the use of duct tape on thresholds to address trip hazards. The Director of Maintenance and the DON confirmed the need for carpet replacement and inappropriate use of duct tape, violating resident rights and administrative responsibilities.
The facility did not comply with food service safety standards, as expired ice cream mixes were found in the cooler, and open chicken breasts were exposed in the freezer. Additionally, there was debris on the floors of the freezer and dry storage room, and a dusty fan was blowing onto the food prep area. The Food Service Director confirmed these issues.
A resident with diabetes was allowed to self-administer insulin via a pump without an assessment to ensure her safety, as required by facility policy. Despite physician orders permitting self-administration, there was no documented evaluation of her capability, and staff noted her anxiety and confusion. The DON confirmed the lack of assessment.
The facility did not ensure that residents could file grievances anonymously, as required by their policy. Residents were unaware of how to file grievances anonymously, and the DON confirmed that grievance forms were inaccessible to residents without nurse assistance.
The facility failed to provide written notification to residents and their responsible parties regarding the reasons for hospital transfers. A resident with a history of stroke was transferred due to sepsis without written notice, and another cognitively impaired resident was transferred multiple times without written notification. This deficiency was confirmed by the Business Office Manager.
The facility failed to issue bed-hold notices for two residents transferred to the hospital. One resident, with a history of stroke, was transferred due to sepsis, while another, with cognitive impairment, was transferred multiple times for various medical issues. In both cases, no bed-hold notices were documented, as confirmed by the Business Office Manager.
A resident with diabetes and an insulin pump did not have a care plan developed to address her individualized care needs, despite physician's orders and facility policy requiring such a plan. Observations confirmed the insulin pump was functioning, but the care plan was missing, as verified by the DON.
A facility failed to update a resident's care plan to address PTSD triggers, despite a psychiatry consult indicating the resident experienced PTSD symptoms from military service. The care plan lacked documentation on PTSD triggers, confirmed by the DON during an interview.
A facility failed to provide trauma-informed care for a resident with PTSD, as there was no documentation of specific triggers or measures to prevent them. The resident's care plan lacked a trauma-informed care assessment, confirmed by the DON.
A resident's biological and herbal supplements were found improperly labeled in the facility's medication refrigerator. The supplements, prepared by the resident's son, were stored in unlabeled zip-lock baggies, contrary to the facility's policy requiring proper labeling. The resident, diagnosed with multiple sclerosis, was ordered to self-administer these supplements. The issue was confirmed by an LPN and acknowledged by the DON.
A facility failed to maintain complete clinical records for a resident managing her insulin with a pump. Despite a physician's order requiring the resident to notify staff before self-administering insulin boluses, the MAR lacked documentation of the insulin amounts administered. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling urinary catheters, as required by infection control guidelines. Observations confirmed the absence of EBP, including necessary signage and PPE, which was acknowledged by staff.
The facility failed to maintain a safe and sanitary environment in a shower room and a resident's bathroom. Observations revealed loose toilet grab bars and rust stains with a black, removable substance around the toilet. The Director of Maintenance confirmed these conditions were not acceptable, violating the administrator's responsibility under 28 Pa. Code 207.2(a).
A resident, who was at risk for falls, was left unattended in the bathroom by a nurse aide who did not follow the care plan. This resulted in the resident falling and sustaining a nasal bone fracture and a UTI. The investigation confirmed neglect due to the failure to provide the required assistance and use of a gait belt.
A resident identified as a fall risk fell and sustained a nasal bone fracture and UTI after a nurse aide failed to follow the care plan, which required the use of a gait belt and assistance from two staff members during toileting. The nurse aide left the resident unattended, leading to the fall and injury.
A resident, who was at risk for falls, fell and sustained a nasal fracture after a nurse aide failed to use a gait belt and left the resident unattended in the bathroom. The aide did not follow the care plan, which required two-person assistance and constant supervision during toileting.
Failure to Complete Required Pre-Employment Screenings for Nursing Staff
Penalty
Summary
The facility failed to follow its own abuse prevention policy and state regulations by not completing required pre-employment screenings for several nursing staff members. Specifically, for one nurse aide, there was no documented evidence that her standing on the Pennsylvania State Nurse Aide Registry was verified, nor were reference checks from previous or current employers obtained prior to her start date. Another nurse aide's personnel file lacked documentation of a completed criminal background check before employment. Additionally, for two registered nurses, there was no documented evidence that their licenses were checked with the Pennsylvania State Board of Nursing prior to their start dates, and for one of them, reference checks from previous employers were also missing. These deficiencies were confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of documentation for registry verification, licensure verification, criminal background checks, and reference checks for the mentioned nursing staff prior to their hire dates. The facility's failure to complete these required screenings is not in accordance with its abuse policy and state regulations.
Failure to Provide Ordered Inhaler Medication to Resident
Penalty
Summary
A resident with a history of COPD, chronic respiratory failure, end stage heart failure, and who was receiving hospice services, was admitted with physician's orders for a daily Trelegy Ellipta inhaler, to be self-administered at the bedside. During a medication administration observation, it was found that the resident did not have access to the prescribed inhaler. Staff confirmed that the inhaler had been ordered but had not yet been delivered, and the resident reported not having the medication for approximately two weeks, resulting in increased shortness of breath. Review of the Medication Administration Record showed the medication was marked for unsupervised self-administration, but there was no documentation of any follow-up with the pharmacy or physician regarding the missing medication. The DON was unaware of the issue until notified by pharmacy that the order was cancelled due to authorization and cost approval requirements. There was no evidence that the facility took timely action to ensure the resident received the prescribed medication as ordered.
Failure to Document and Provide Required Catheter Care and Output Monitoring
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters, as evidenced by a lack of documentation and adherence to care plans and facility protocols. For one resident with a Foley catheter placed due to a stage 4 pressure ulcer and urinary incontinence, the care plan required the catheter drainage bag to be changed twice monthly. However, there was no documented evidence that the drainage bag was changed on the specified dates, despite staff interviews confirming this was standard practice and part of the facility's protocol. The Director of Nursing acknowledged the absence of documentation for these required changes. Additionally, another resident with a suprapubic catheter had a care plan requiring urinary output to be measured and documented every shift. A review of the clinical record revealed multiple dates and shifts over several months where there was no documented evidence that urinary output was measured as required. The Director of Nursing confirmed the lack of documentation for these periods, indicating that the facility did not follow its own policy and the resident's care plan regarding urinary output monitoring.
Failure to Properly Label, Date, and Discard Food Items
Penalty
Summary
The facility failed to comply with its own food labeling and dating policy, as well as professional standards for food storage and handling. Observations in the kitchen revealed that a package of pre-sliced bologna and ham, which was wrapped in plastic wrap and dated August 10, 2025, with a discard date of August 15, 2025, had not been discarded as required. Additionally, an opened gallon container of vanilla milk shake/ice cream mix in the walk-in refrigerator was not dated when opened and lacked a manufacturer's expiration date. Three unopened iced coffees in the same refrigerator were found to be past their stamped use by date and had not been discarded. Staff interviews confirmed that these food items should have been properly labeled, dated, and discarded according to facility policy and manufacturer guidelines. The Dietary Supervisor acknowledged that the pre-sliced meats and iced coffees should have been discarded after their respective dates, and that the milk shake/ice cream mix should have been dated when opened. These findings indicate a failure to ensure that food was stored, labeled, and discarded in accordance with both facility policy and regulatory requirements.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of annual in-service training for two out of five nurse aides reviewed. A review of the facility's list of nurse aides, including their hire dates and training hours, revealed that Nurse Aide 7 and Nurse Aide 8 did not have documented evidence of completing the mandated in-service training within their respective annual periods. Staff interviews, including one with the Nursing Home Administrator, confirmed the absence of documentation for the required training hours for these nurse aides. This deficiency was identified through a review of records and staff interviews, and it was determined that the facility did not meet the regulatory requirements for ongoing nurse aide education, specifically in the areas of dementia care and abuse prevention, as required by state code.
Failure to Notify Physician After Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice by not following a physician's request for follow-up after a change in condition. A cognitively impaired resident who required assistance with daily care experienced a coughing fit after taking bedtime medications with water. The physician was informed of the incident and instructed staff to monitor the resident and provide a status update the following day to determine if a chest x-ray was needed. However, there was no documented evidence that the physician was contacted the next day as requested. This was confirmed by the Director of Nursing during an interview.
Failure to Maintain Safe Environment for Resident at Risk of Wandering
Penalty
Summary
The facility failed to ensure a safe environment for a resident, who was at risk for wandering and falls. The resident, diagnosed with Alzheimer's dementia, was assessed as being at moderate risk for wandering. Despite this, the resident was able to exit the facility undetected due to a series of failures in the safety measures that were supposed to be in place. The care plan for the resident included the use of a door alarm to alert staff if the resident left her room, but this alarm was not activated by the LPN responsible for the resident's care. Additionally, the facility's preventative maintenance log showed a lack of documentation for the monthly checks and replacement of door alarm batteries. This oversight contributed to the failure of the door alarms, as the batteries were found to be dead, allowing the resident to exit the facility without triggering an alarm. The resident was later found outside near the smoke shed, indicating a significant lapse in the facility's safety protocols. Interviews with the Director of Nursing confirmed that the door alarm on the resident's room was not turned on as required, and the door leading to the chapel and the exit door did not function properly due to dead batteries. This series of inactions and failures in following established safety protocols led to the resident being able to leave the facility undetected, highlighting a critical deficiency in maintaining a safe environment for residents at risk of wandering.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for residents in one of its secured units. Observations made on September 16, 2024, revealed that the carpet in the hallway on the 400 side of the secured unit was stained and dirty. Additionally, duct tape was used on the carpet at the threshold between the hallway and certain resident rooms, which was confirmed by the Director of Maintenance to address a trip hazard caused by a missing strip. The Director of Maintenance acknowledged that the carpet was supposed to be scrubbed nightly and was due for replacement. The Director of Nursing confirmed that the carpeting in the secured unit needed replacement and that duct tape should not have been used on the thresholds. These conditions were found to be in violation of resident rights and the administrator's responsibility as per 28 Pa. Code 201.29(j) and 28 Pa. Code 207.2(a).
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations and staff interviews. The facility's policy required that food be discarded on or immediately after the expiration date. However, during an inspection, it was found that two gallons of chocolate ice cream mix and one gallon of vanilla ice cream mix were stored in the cooler past their expiration dates. Additionally, in the freezer, two bags of frozen chicken breasts were left open and exposed to air, and there were opened ice cream cup containers and food container debris on the floor. The dry storage room also had food crumbs and debris on the floor, which was sticky. Further observations revealed a fan with a large accumulation of dust blowing onto the food prep area, and dirt and debris on the floors of both the freezer and dry storage room. The Food Service Director confirmed these findings, acknowledging that the expired items should have been discarded and the areas should have been clean.
Failure to Assess Resident's Ability to Self-Administer Insulin
Penalty
Summary
The facility failed to determine if a resident was safe to self-administer medications, specifically insulin, for one of the residents reviewed. The facility's medication policy allows self-administration when authorized by a physician, with control and supervision being the responsibility of the facility. However, there was no documented evidence in the clinical record of the resident to indicate that an assessment was completed to determine her safety in self-administering her medication. The resident, who was admitted with a diagnosis of diabetes, had physician's orders allowing her to use an insulin pump and manage her insulin bolus, provided she notified staff prior to self-administration. Despite these orders, a nurse's note indicated that the resident appeared anxious and confused at times, raising concerns about her ability to safely manage her diabetes. Observations confirmed that the resident had an insulin pump attached and reported it functioning properly. An interview with the Director of Nursing confirmed that no assessment had been conducted to evaluate the resident's capability to self-administer her medications safely, which is a requirement under the facility's policy.
Failure to Ensure Anonymous Grievance Filing
Penalty
Summary
The facility failed to ensure that residents and their representatives could file grievances anonymously, as required by their Grievance Process policy dated January 10, 2024. During an interview with a group of residents, it was revealed that they were unaware of how to file a grievance anonymously. The Director of Nursing confirmed that grievance forms were located behind each nursing station and could only be accessed by nurses, preventing residents or their representatives from filing grievances independently. This deficiency was identified during a review of policies and interviews with residents and staff.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their responsible parties regarding the reasons for hospital transfers, as required by regulations. For Resident 54, who had a history of a cerebral vascular accident with hemiplegia, the deficiency occurred when the resident was transferred to the hospital with a diagnosis of sepsis. Despite the critical nature of the transfer, there was no documented evidence that a written notice was provided to the resident or their legal guardian explaining the reason for the hospitalization. This was confirmed through an interview with the Business Office Manager. Similarly, for Resident 83, who was cognitively impaired and dependent on staff for daily care, the facility failed to provide written notices for multiple hospital transfers. The resident was transferred to the hospital on several occasions due to decreased urine output, abnormal drainage, and changes in condition such as fever and elevated heart rate. In each instance, there was no documented evidence that the resident's responsible party was notified in writing about the reasons for these transfers. This lack of documentation was also confirmed by the Business Office Manager.
Failure to Issue Bed-Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to issue a bed-hold notice at the time of an anticipated leave of absence for two residents, resulting in a deficiency. Resident 54, who had a history of a cerebral vascular accident with hemiplegia, was transferred to the hospital with a diagnosis of sepsis after experiencing complications with a foley catheter. Despite the transfer, there was no documented evidence that a bed-hold notice was issued to the resident or his responsible party. This was confirmed by the Business Office Manager during an interview. Similarly, Resident 83, who was cognitively impaired and dependent on staff for daily care, was transferred to the hospital on multiple occasions due to various medical conditions, including decreased urine output, a distended abdomen, and a change in condition with fever and elevated heart rate. In each instance, there was no documented evidence of a bed-hold notice being issued to the resident or his responsible party. The Business Office Manager confirmed that the facility was not providing written bed-hold notices during these transfers.
Failure to Develop Care Plan for Diabetes Management
Penalty
Summary
The facility failed to develop a care plan to address the individualized care needs of a resident, identified as Resident 99, who was admitted with a diagnosis of diabetes. Despite having physician's orders dated September 11 and September 12, 2024, for the use of an insulin pump and self-management of insulin bolus, there was no documented evidence of a care plan being established to manage these needs. The facility's policy requires that a care plan be established within 24 hours of admission and reviewed as needed, but this was not adhered to in the case of Resident 99. Observations on September 17, 2024, confirmed that Resident 99 had an insulin pump attached and functioning properly, yet the care plan was still missing. An interview with the Director of Nursing on September 18, 2024, further confirmed the absence of a care plan for the resident's diabetes management and insulin pump use. This oversight was a violation of the facility's policy and the regulatory requirement under 28 Pa. Code 211.10(d) for resident care plans.
Failure to Update Care Plan for PTSD Triggers
Penalty
Summary
The facility failed to update and revise the care plan for a resident to reflect specific care needs related to Post Traumatic Stress Disorder (PTSD). The facility's policy requires that a resident care plan be established within 24 hours of admission and reviewed and revised as needed, including for new or revised interventions. However, for one resident, the care plan did not include any documented evidence addressing triggers related to PTSD, despite a psychiatry consult note indicating the resident experienced PTSD symptoms due to military service. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not attempt to identify the resident's PTSD triggers or revise the care plan accordingly. This oversight was identified during a review of the resident's quarterly Minimum Data Set (MDS) assessment, which highlighted the resident's need for assistance with daily care and understanding, as well as diagnoses of dementia and PTSD.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate or eliminate triggers. A quarterly Minimum Data Set (MDS) assessment for the resident indicated that they were understood, could usually understand others, required assistance for daily care needs, and had diagnoses including dementia and PTSD. However, the care plan did not document any specific triggers for the resident or measures to prevent or minimize these triggers. An interview with the Director of Nursing confirmed that a trauma-informed care assessment was not completed for the resident. This deficiency was identified during a review of the clinical record and staff interviews, highlighting a lack of trauma-informed care for the resident.
Improper Labeling of Resident's Medications
Penalty
Summary
The facility failed to ensure that medications were properly labeled for one of the residents, identified as Resident 36. The facility's policy, dated January 10, 2024, requires that medications brought by residents from home or another facility must be properly labeled and ordered by a physician. However, during an observation on September 19, 2024, it was found that Resident 36's biological and herbal supplements were stored in eight unlabeled plastic zip-lock baggies in the medication refrigerator. These baggies contained multiple tablets and capsules without any labeling to indicate ownership or contents. Resident 36, who has a diagnosis of multiple sclerosis, was ordered by a physician to self-administer approximately sixty-one different over-the-counter biological and herbal supplements. The supplements were prepared by the resident's son and brought into the facility without proper labeling. An interview with an LPN confirmed the lack of labeling, and the Director of Nursing acknowledged the issue, noting that a list of the supplements was maintained for the nursing staff. This deficiency was cited under 28 Pa. Code 211.9(a)(1) Pharmacy Services and 28 Pa. Code 211.12(d)(3) Nursing Services.
Incomplete Documentation of Insulin Administration
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for a resident with diabetes. The resident was admitted with a physician's order allowing her to manage her insulin bolus using an insulin pump, provided she notified staff before each administration. On a specific date, the resident experienced nausea and vomiting and reported administering a small insulin bolus. However, the Medication Administration Record (MAR) for that month lacked documentation of the insulin amounts self-administered by the resident. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of documented evidence regarding the resident's insulin bolus administration.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to prevent the spread of infections and cross-contamination. Specifically, the facility did not implement Enhanced Barrier Precautions (EBP) for two residents who had indwelling urinary catheters, which are considered high-contact care activities requiring gown and glove use. The facility's policy, updated in January 2024, mandates the use of EBP for residents with wounds or indwelling medical devices, regardless of their MDRO status. Observations revealed that Resident 25, who was cognitively intact and had an indwelling urinary catheter, did not have EBP in place, as confirmed by a registered nurse. Similarly, Resident 37, who was cognitively impaired and also had an indwelling urinary catheter, was observed without EBP, as confirmed by the Director of Nursing. There was no signage or PPE available in or around the rooms of these residents, indicating a failure to implement the necessary precautions to prevent the spread of multidrug-resistant organisms.
Deficiency in Maintaining Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in one of the two shower rooms on the secured unit and in a resident's bathroom. Observations made on September 16 and September 18, 2024, revealed that the toilet grab bars in the shower room were loose, and the toilet had rust stains and a black, removable substance around it. Additionally, the toilet grab bars in a resident's bathroom were also found to be loose and not securely attached to the wall or floor. An interview with the Director of Maintenance confirmed that the grab bars in both the shower room and the resident's bathroom should not be loose, and there should not be rust or a black, removable substance around the toilet. This deficiency was noted under the regulation 28 Pa. Code 207.2(a), which outlines the administrator's responsibility to ensure a safe and sanitary environment.
Neglect Leading to Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure that residents were free from neglect, resulting in a fall and fracture for a resident. The resident, who was cognitively intact and had a seizure disorder, was at risk for injury due to falls. The care plan specified that the resident should not be left alone during toileting, should be walked with a gait belt, and required assistance from two staff members during the evening and night shifts. However, Nurse Aide 1 left the resident alone on the toilet, did not use a gait belt, and did not provide the required two-person assistance, leading to the resident falling and sustaining a nasal bone fracture and a urinary tract infection (UTI). The incident occurred when Nurse Aide 1 walked the resident to the bathroom and left her unattended to assist another resident. Upon returning, he found the resident on the floor with a significant nosebleed. The investigation confirmed that Nurse Aide 1 did not follow the care plan, which constituted neglect. The resident's fall and subsequent injuries were directly linked to the failure to adhere to the specified care plan, as confirmed by the Director of Nursing and the Assistant Director of Nursing.
Failure to Implement Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that staff implemented care-planned interventions for a resident identified as a fall risk, resulting in a fall and fracture. The resident, who was cognitively intact and had a seizure disorder, was assessed as being at risk for injury due to falls related to decreased mobility, muscle weakness, gait abnormality, lack of coordination, and history of falls. The care plan specified that the resident should not be left alone during toileting, should be walked with a gait belt, and required assistance from two staff members during the evening and night shifts. However, on the night of the incident, the assigned nurse aide walked the resident to the bathroom without using a gait belt and left the resident unattended on the toilet, contrary to the care plan instructions. The resident subsequently fell and sustained a nasal bone fracture and a urinary tract infection. The nurse aide admitted to not following the care plan, including failing to use a gait belt and leaving the resident unattended. The Director of Nursing confirmed that the nurse aide's actions constituted neglect, as they directly led to the resident's fall and injury. The incident was thoroughly investigated, and it was determined that the nurse aide's failure to adhere to the care plan resulted in serious harm to the resident. The nurse aide was terminated from employment following the investigation.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to maintain a safe environment for a resident, resulting in a fall with a fracture. The resident, who was cognitively intact and had a diagnosis of seizure disorder, was at risk for injury due to falls related to decreased mobility, muscle weakness, gait abnormality, lack of coordination, and a history of falls. The resident's care plan specified that staff should use a gait belt for ambulation, not leave the resident alone during toileting, and provide assistance with two staff members during the evening and night shifts. On the night of the incident, the assigned caregiver, Nurse Aide 1, walked the resident to the bathroom without using a gait belt and left the resident unattended on the toilet while assisting another resident. The resident subsequently fell and sustained a closed fracture of the nasal bone. Nurse Aide 1 admitted to not following the care plan, which required the use of a gait belt and assistance from two staff members for ambulation and transfers, as well as not leaving the resident alone during toileting. The Director of Nursing confirmed that Nurse Aide 1's actions constituted neglect, as the failure to follow the care plan resulted in serious harm to the resident. The incident was investigated, and it was determined that the neglect led to the resident's fall and injury. The facility's policies on gait belts and transfers were not adhered to, leading to the deficiency cited as past non-compliance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
