Concordia At Villa St Joseph
Inspection history, citations, penalties and survey trends for this long-term care facility in Baden, Pennsylvania.
- Location
- 1030 State Street, Baden, Pennsylvania 15005
- CMS Provider Number
- 396026
- Inspections on file
- 25
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Concordia At Villa St Joseph during CMS and state inspections, most recent first.
A resident with multiple medical conditions experienced a fall while preparing for bed. Two nurse aides, without notifying or obtaining an assessment from an RN, used a mechanical lift to return the resident to bed, contrary to facility policy requiring RN evaluation after a fall. The DON confirmed the lack of RN assessment prior to the transfer.
A resident with diabetes, heart failure, and obstructive uropathy had a suprapubic catheter, but the physician order and care plan did not specify the catheter size or balloon inflation amount as required by facility policy. This omission was confirmed by the DON during review.
The facility failed to ensure nursing staff had the necessary competencies to care for residents with Life Vests, placing two residents in immediate jeopardy. Staff were not adequately trained on the device's operation, and care plans lacked instructions for the Life Vest. The facility was unaware of the presence of a second Life Vest, highlighting a communication gap with hospitals.
A facility failed to provide a dignified dining experience for a resident, as an employee stood while feeding her. Additionally, two residents' privacy was compromised when a nurse aide entered their rooms without knocking, and an LPN did not close the door during a wound dressing change.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in person-centered care. A resident with heart failure did not have a care plan for a Life Vest, another resident's dietary needs were not reflected in their care plan, and a third resident's care plan lacked interventions for a Life Vest. These issues were confirmed by facility staff.
The facility failed to maintain three crash carts in safe operating condition. Observations revealed missing documentation on checklists for the Ebensburg, Fontbonne, and Carondelet crash carts. Additionally, the Carondelet cart contained an expired bag valve mask. These issues were confirmed by an LPN, an RN, and the Nursing Home Administrator.
The facility failed to develop baseline care plans that included necessary interventions for two residents wearing a Life Vest, a wearable defibrillator. One resident's care plan did not mention the Life Vest despite having heart-related diagnoses, while another's plan acknowledged the Life Vest but lacked person-centered goals and safety measures. This deficiency was confirmed by a Corporate Clinical Coordinator.
The facility failed to update care plans for two residents, resulting in inaccuracies regarding their medical needs. One resident's care plan did not include a fluid restriction and allergy, while another's did not reflect current tube feed orders. These deficiencies were confirmed by staff interviews.
The facility failed to clarify physician orders for four residents, leading to deficiencies in care. Two residents were admitted with Life Vests, but the facility did not have physician orders for their care. Another resident had a fluid restriction order without specified fluids, and a fourth resident had an enteral feeding order lacking administration details. These omissions were confirmed by staff interviews.
A resident with an enteral feeding tube was inappropriately administered oral medications despite being NPO. The facility's policy allowed enteral feedings for those unable to take food orally, yet the resident received oral medications, confirmed by the DON. This oversight led to a deficiency in care.
The facility failed to obtain complete physician orders and develop care plans for two residents requiring respiratory care. One resident with a tracheostomy lacked specific orders for the tracheostomy tube, while another resident using a CPAP machine had no physician order or care plan for its use. These deficiencies were confirmed by facility staff.
A facility failed to maintain consistent communication with a dialysis center for a resident with end-stage renal disease. The resident, who required dialysis three times a week, had incomplete communication forms for two out of four days. This issue was confirmed by a registered nurse during an interview.
A facility failed to act on a pharmacist's recommendations in the MRR for a resident with high blood pressure, GERD, and hyperlipidemia. Despite the physician agreeing to change Prilosec to Protonix due to a potential interaction with Clopidogrel, no changes were made in the EMR. Additionally, recommendations to taper Omeprazole based on Beer's Criteria were not implemented, leading to a deficiency in timely action on medication irregularities.
The facility failed to properly store medications in the Ebensburg Second Hall Med Cart. The narcotic lock box was found unlocked, and the cart contained an expired Humalog Insulin Pen and an Insulin Glargine Pen without an opened date. These issues were confirmed by an RN and the DON, highlighting a breach in medication storage protocols.
The NHA and DON failed to ensure nursing staff had the necessary skills to care for residents with Life Vests, leading to an immediate jeopardy situation for two residents. The facility did not provide adequate training, resulting in a violation of Pennsylvania Code regulations.
The facility did not implement a complete facility-wide assessment to identify necessary resources for its resident population, failing to include the management of Life Vests for two residents with cardiac conditions. Both residents were observed with Life Vests and charging stations, but the facility's assessment did not account for this complex medical care requirement.
The facility failed to coordinate hospice services for two residents receiving end-of-life care. For one resident with Alzheimer's, the care plan lacked hospice contact information and access instructions. Another resident with cancer had no hospice provider identified in physician orders, and the care plan also lacked coordination details. These deficiencies were confirmed by facility staff.
A facility failed to implement proper infection control practices during a dressing change for a resident with an unhealed pressure ulcer. The LPN did not use a gown as required by enhanced barrier precautions and failed to clean the stand used after the procedure, despite multiple handwashing and glove changes. This deficiency was identified as a failure to follow the facility's infection control policies.
The facility failed to provide necessary treatment for pressure ulcers for two residents. One resident did not receive prescribed wound care on multiple occasions, while another resident's care plan lacked interventions for multiple pressure wounds. These deficiencies were confirmed by facility staff.
The facility failed to protect a resident with high blood pressure, hemiplegia, and Multiple Sclerosis from verbal abuse by a Nurse Aide (NA). The NA admitted to yelling at the resident during care, causing emotional distress. The incident was reported by an RN, and the Director of Nursing confirmed the facility's failure to ensure a safe environment.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked goals and interventions for catheter care and dementia, while another resident's care plan lacked goals and interventions for dementia. These deficiencies were confirmed by the LPNAC, RNAC, and DON during interviews.
The facility failed to maintain sanitary conditions of respiratory equipment for two residents. One resident's nebulizer machine was not labeled with a date, and another resident's nasal cannula was also not labeled with a date. These lapses were confirmed by RNs during interviews.
The facility failed to properly store and secure medications and biologicals for two residents, with items found on an overbed table and window sill. Additionally, an unlabeled open tube of antifungal cream was found in a medication cart. These actions were confirmed and corrected by nursing staff.
The facility failed to properly disinfect reusable equipment between residents and did not implement proper infection control practices during a dressing change for a resident with multiple medical conditions. Staff inconsistencies and improper training were observed and confirmed, highlighting lapses in adherence to infection control policies.
A facility failed to provide appropriate treatment for a resident with an indwelling catheter. An RN flushed the catheter multiple times without verifying a physician's order, and the Director of Nursing confirmed the deficiency.
Failure to Assess Resident by RN After Fall Prior to Transfer
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care following a fall. According to the facility's policy, any injuries resulting from incidents or accidents are to be assessed by a licensed nurse or practitioner, and the affected individual should not be moved until it is deemed safe. However, after a resident with diagnoses including diabetes, heart failure, and obstructive uropathy experienced a fall, two nurse aides used a mechanical lift to return the resident to bed without first notifying or obtaining an assessment from a Registered Nurse (RN) or practitioner. The nursing notes and investigative report confirmed that the RN was not notified prior to moving the resident. The resident described the fall as occurring while preparing for bed, using a walker, and slowly slumping to the left side. The aide present ensured the resident was alright and, with another aide, used a lift to return the resident to bed. There was no documentation of an RN assessment prior to this transfer, which was contrary to both facility policy and the re-education provided to staff. The Director of Nursing confirmed that the required assessment was not completed before the resident was moved.
Lack of Specific Physician Order and Care Plan for Suprapubic Catheter
Penalty
Summary
The facility failed to ensure that a physician order and care plan for a resident with a suprapubic catheter included specifications for the catheter size and balloon inflation amount. According to the facility's policy, catheter care must be provided in accordance with current professional standards and resident care policies. However, review of the clinical record for a resident admitted with diagnoses including diabetes, heart failure, and obstructive uropathy showed that the physician order only directed the suprapubic catheter to be changed every four weeks, without specifying the required size or balloon inflation amount. Additionally, the resident's care plan, which was revised during their stay, noted the use of a suprapubic catheter but also failed to include the necessary specifications for catheter size and balloon inflation. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the required details were missing from both the physician order and the care plan for this resident.
Lack of Staff Competency in Managing Life Vests
Penalty
Summary
The facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to provide care for residents with a Life Vest, a wearable defibrillator designed to protect residents from sudden cardiac death. This deficiency placed two residents, identified as R314 and R49, in immediate jeopardy, impacting their health and safety. The report highlights that the facility did not have a care plan or physician orders for the Life Vest for these residents, and staff were not adequately trained or informed about the device's operation and care requirements. Resident R314 was admitted to the facility with a Life Vest, as confirmed by a discharge form from the hospital. However, interviews with various staff members, including nurse aides and nurses, revealed a lack of knowledge and training regarding the Life Vest. Staff members were unaware of the device's alarms, how to care for the batteries, and the specific needs for bathing residents wearing the Life Vest. The care plan for Resident R314 did not include instructions for the Life Vest, and there were no physician orders for its use. Similarly, Resident R49 was admitted with a Life Vest, but the facility's clinical record did not include orders or a care plan for the device. Interviews with staff members assigned to Resident R49 indicated that they had not received education on the Life Vest and were unaware of its presence and requirements. The Director of Nursing acknowledged that the facility was unaware of the second Life Vest and that hospitals did not notify them about such equipment needs. This lack of communication and training led to the immediate jeopardy situation for the residents involved.
Removal Plan
- Clinical staff will complete education on the care and operation of Life Vests that includes but is not limited to what the different alarms mean, the dangers of electrical shock, the care of the batteries, the care of the garment for laundering, and special needs for bathing.
- The facility will demonstrate competency of all clinical staff through completion of a test following the education.
- A resident centered comprehensive care plan outlining the care of Resident R314, and R49 related to the Life Vest has been completed.
- A care plan addressing the Life Vest, and the management of the Life Vest has been completed for Resident R314, and R49.
- The facility obtained physician orders for the implementation of the Life Vest.
- Clinical staff will be educated on the policies and procedures related to the use of the Life Vest.
- Resident R314's physician's orders and care plan were updated.
- Resident R49's physician's orders and care plan were updated.
- The facility will produce a policy related to the Life Vest and will provide in an education to staff.
- The facility will provide a policy/procedure related to the admission of residents with anticipated equipment needs that will be provided to clinical staff and admissions team.
- Audits will be conducted of five clinical staff for one day to demonstrate competency of caring for a resident with a Life Vest.
- Audits will continue to include five staff weekly to demonstrate competency of caring for a resident with a Life Vest for 2 weeks or until substantial compliance is achieved.
- Education and initial audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.
Failure to Ensure Dignified Dining and Privacy for Residents
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident in the Carondelet dining room. During an observation, it was noted that a resident was being assisted with lunch by an employee who was standing beside her while feeding her, which was confirmed by the employee as not providing a dignified dining experience. Additionally, the facility did not protect and value residents' private space. On the [NAME] Unit, a nurse aide was observed entering two residents' rooms without knocking or requesting permission, which the aide confirmed. Furthermore, on the Fontbonne Unit, an LPN was observed performing a wound dressing change without closing the door for privacy, which the LPN acknowledged.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed specific needs for three residents, leading to deficiencies in person-centered care. Resident R49, who was diagnosed with high blood pressure, septicemia, and heart failure, did not have a care plan that included goals and interventions for a Life Vest, a critical component of their care. This oversight was confirmed by the Nursing Home Administrator during an interview. Similarly, Resident R228, with a history of fractures and falls, had a physician's order for a gluten-free and lactose-restricted diet, but the care plan did not reflect this dietary requirement. This was confirmed by the Registered Dietitian. Additionally, Resident R314, who was wearing a Life Vest, did not have a care plan that included goals and interventions for its use, as confirmed by the Nursing Home Administrator. These deficiencies indicate a failure to ensure that care plans were updated and comprehensive for the residents' specific needs.
Crash Cart Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that equipment was in safe operating condition for three crash carts. During observations, it was found that the Ebensburg crash cart's checklist lacked documentation for checks on specific dates in February 2025. Similarly, the Fontbonne crash cart's checklist was missing entries for other dates in the same month. The Carondelet crash cart not only had missing checklist entries but also contained a bag valve mask with an expiration date of November 13, 2023. These deficiencies were confirmed through interviews with LPN Employee E9 and RN Employee E8, as well as the Nursing Home Administrator, who acknowledged the failure to maintain the crash carts as required.
Failure to Include Life Vest Interventions in Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary interventions for residents wearing a Life Vest, a wearable defibrillator designed to protect against sudden cardiac death. This deficiency was identified for two residents, R49 and R314, out of ten reviewed. Resident R49, admitted on an unspecified date, had a baseline care plan dated 2/9/25 that did not mention the Life Vest, despite having diagnoses of high blood pressure, septicemia, and heart failure. Similarly, Resident R314, admitted on an unspecified date, had a baseline care plan completed on 2/13/25 that acknowledged the presence of a Life Vest and heart failure but failed to provide person-centered initial goals or address specific health and safety concerns related to the Life Vest. The deficiency was confirmed during an interview with the Corporate Clinical Coordinator, Employee E7, on 2/28/25. The facility's failure to include Life Vest interventions in the baseline care plans for these residents indicates a lack of effective and person-centered care planning. This oversight could potentially impact the residents' health and safety, as the care plans did not address the necessary interventions to prevent decline or injury associated with the use of a Life Vest.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, resulting in deficiencies in accurately reflecting their current medical needs. Resident R70, who was admitted with diagnoses including sepsis, bacterial pneumonia, and dysphagia, had a physician's order for a 1500cc fluid restriction and an allergy to fish/shellfish. However, the care plan dated 2/3/25 did not include these critical details. This oversight was confirmed by a Registered Dietetic Technician during an interview. Similarly, Resident R90, who was admitted with difficulty swallowing, malnutrition, and aphonia, had a physician's order for Glucerna 1.2 via a feeding tube, with specific instructions for administration and water flushes. Despite these orders, the care plan dated 12/20/24 did not reflect the resident's current tube feed and flush orders. This deficiency was confirmed by a Registered Dietitian during an interview. Both cases highlight the facility's failure to update care plans to ensure they are person-centered and reflective of the residents' current medical needs.
Failure to Clarify Physician Orders for Residents
Penalty
Summary
The facility failed to clarify physician orders for four residents, leading to deficiencies in care. Resident R49 was admitted with a Life Vest, a wearable defibrillator, but the facility did not have a physician's order for its care. Despite the presence of a charging station and confirmation from the resident that they were wearing the Life Vest, the clinical record lacked the necessary orders. Similarly, Resident R314 was admitted with a Life Vest, confirmed by both the resident and the presence of a charging station, yet there was no physician order documented for its care. Additionally, Resident R70 had a physician order for a 1500cc fluid restriction, but the order did not specify which fluids were to be provided by nursing or dietary staff. Resident R57 had an order for enteral feeding with Nepro at 45 ml/hr, but the order did not specify the administration route or what the tube was providing. These omissions were confirmed by staff interviews, indicating a failure to clarify physician orders as required, which is a deficiency in the facility's responsibility to provide appropriate treatment and care according to orders and resident needs.
Inappropriate Administration of Oral Medications to NPO Resident
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services, as evidenced by the administration of oral medications despite the resident being NPO (nothing by mouth). The facility's policy on enteral feeding, dated 1/2/25, states that enteral feedings may be prescribed for individuals unable to take food by mouth in sufficient amounts. However, a review of Resident R90's clinical record revealed that the resident, who was admitted with diagnoses including high blood pressure, cancer, and diabetes, had a feeding tube and was ordered to be NPO. Despite this, current physician orders for Resident R90 included medications to be administered orally, such as Amoxicillin-Pot Clavulante, Levsin, and Synthroid. During an interview, the Director of Nursing confirmed that the facility failed to ensure the resident received appropriate treatment and services, as the medications were ordered to be taken by mouth, contrary to the resident's NPO status. This oversight was identified as a deficiency in the care provided to Resident R90.
Failure to Provide Complete Respiratory Care Orders and Plans
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, Resident R90 and Closed Resident Record CR264. For Resident R90, the facility did not obtain a complete physician order for the tracheostomy care, as the physician orders and care plan did not specify the correct kind and size of the tracheostomy tube used. Additionally, the care plan lacked appropriate respiratory care instructions for the resident, who had a tracheostomy and required specific care procedures. This deficiency was confirmed by the Director of Nursing during an interview. For Closed Resident Record CR264, the facility did not obtain a physician order for the use of a CPAP machine, nor did it develop a care plan with goals and interventions related to the resident's CPAP usage. The resident had diagnoses of high blood pressure, respiratory failure, and obstructive sleep apnea, which necessitated the use of a CPAP machine. The absence of a physician order and a care plan for CPAP usage was confirmed by the Corporate Clinical Coordinator. These deficiencies indicate a failure to adhere to the facility's policy on noninvasive ventilation and to ensure proper respiratory care for residents.
Incomplete Dialysis Communication for Resident
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for a resident receiving hemodialysis. Resident R165, diagnosed with end-stage renal disease, diabetes mellitus, and abnormalities of gait and mobility, had physician orders for dialysis on Mondays, Wednesdays, and Fridays. However, a review of the resident's dialysis binder revealed that the dialysis communication forms were incomplete for two out of four days, specifically on 2/19/25 and 2/24/25. This deficiency was confirmed during an interview with Registered Nurse Employee E15, who acknowledged the incomplete communication forms.
Failure to Act on Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely action on irregularities identified in the medication regimen reviews (MRR) for one resident. The facility's policy requires that recommendations from the pharmacist regarding drug therapy be communicated and acted upon in a timely manner. However, for a resident with diagnoses including high blood pressure, GERD, and hyperlipidemia, the pharmacist's recommendations to change the medication from Prilosec to Protonix due to a potential drug interaction with Clopidogrel were not implemented despite the physician's agreement. This issue persisted over several months, with multiple MRRs indicating the same recommendation without any change being made in the electronic medical record. Additionally, the pharmacist recommended considering the tapering and discontinuation of Omeprazole based on the Beer's Criteria, which identifies potentially inappropriate medications for older adults. Despite the physician agreeing to this recommendation, no action was taken. The Corporate Clinical Coordinator confirmed that the facility did not ensure that the irregularities submitted in the MRRs were acted upon in a timely manner, as required by the facility's policies and state regulations.
Improper Storage of Medications in Medication Cart
Penalty
Summary
The facility failed to properly store medical supplies in one of its medication carts, specifically the Ebensburg Second Hall Med Cart. During a medication cart review, it was observed that the narcotic lock box on this cart was not locked, which is a violation of the facility's policy requiring narcotics to be stored under double lock. Additionally, the cart contained a Humalog Insulin Pen that was expired and an Insulin Glargine Pen that did not have an opened date on it. These findings were confirmed by a Registered Nurse and the Director of Nursing during interviews, indicating a lapse in adherence to medication storage protocols.
Failure to Ensure Staff Competency for Life Vest Care
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that the nursing staff possessed the necessary competencies and skills to care for residents equipped with a Life Vest, a wearable defibrillator designed to protect against sudden cardiac death. This deficiency was identified through a review of job descriptions, clinical records, and staff interviews. The job descriptions for both the NHA and DON outlined their responsibilities to lead and manage the facility's operations and nursing services to ensure high-quality care. However, the facility did not provide adequate training or ensure that staff had the specific skills required to care for residents with Life Vests. This oversight resulted in an immediate jeopardy situation for two residents, identified as Resident R49 and Resident R314, who were at risk due to the staff's lack of training and competency in handling Life Vests. During an interview, both the NHA and DON acknowledged their failure to manage the facility effectively in this regard. The report cites specific Pennsylvania Code regulations that were violated, highlighting the responsibility of the licensee and management to ensure proper nursing services.
Facility Fails to Include Life Vest Management in Assessment
Penalty
Summary
The facility failed to implement and document a complete facility-wide assessment to determine the necessary resources for caring for its specific resident population. The facility's policy, dated 1/2/25, requires a comprehensive assessment to identify the resources needed for both day-to-day operations and emergencies. However, the facility's assessment did not include the use of Life Vests, which are wearable defibrillators for residents with specific cardiac conditions, as a condition requiring complex medical care and management. Two residents, identified as R49 and R314, were admitted to the facility with Life Vests, which were not accounted for in the facility's assessment. Resident R49 had a history of high blood pressure, septicemia, and heart failure, and was observed wearing a Life Vest with a charging station in his room. Similarly, Resident R314, with diagnoses of heart failure, diabetes, and high blood pressure, was also observed with a Life Vest and charging station. The facility's failure to include the management of Life Vests in their assessment was confirmed by the Nursing Home Administrator.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to properly coordinate hospice services for two residents, R59 and R90, who were receiving end-of-life care. For Resident R59, the facility did not include the hospice provider's contact information or instructions on accessing the hospice's 24-hour on-call system in the comprehensive care plan. This oversight was confirmed by the Corporate Clinical Coordinator during an interview. Resident R59 had been diagnosed with Alzheimer's Disease, malnutrition, and depression, and was receiving hospice care as indicated in the Minimum Data Set (MDS). Similarly, for Resident R90, the facility did not identify a hospice provider in the physician orders and failed to include necessary hospice coordination details in the care plan. Resident R90 had diagnoses of cancer, high blood pressure, and diabetes, and was also receiving hospice care. The Director of Nursing confirmed the lack of coordination and identification of hospice services for Resident R90 during an interview. These deficiencies indicate a failure to ensure the coordination of hospice services with facility services to meet the residents' needs for end-of-life care.
Inadequate Infection Control During Dressing Change
Penalty
Summary
The facility failed to implement proper infection control practices during a dressing change for Resident R8, who was diagnosed with coronary artery disease, diabetes, and Alzheimer's disease. The resident had an unhealed pressure ulcer, and a physician's order required enhanced barrier precautions (EBP) every shift, which includes the use of gown and gloves during high-contact care activities. However, during a wound care observation, the LPN did not use a gown and failed to clean the surface of the stand used after completing the dressing change. The LPN washed hands and changed gloves multiple times during the procedure but did not adhere to the EBP protocol by omitting the use of a gown. Additionally, the LPN confirmed during an interview that she did not implement the necessary infection control practices to prevent cross-contamination. This deficiency was identified as a failure to follow the facility's policy on enhanced barrier precautions and wound treatment management, which are designed to prevent the transmission of multidrug-resistant organisms.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, as per professional standards of practice. Resident R35, who was admitted with diagnoses including high blood pressure, diabetes, and heart failure, had stage 3 pressure ulcers on the left and right ischium. Despite a physician's order to cleanse the wounds and apply specific dressings daily, the Treatment Administration Record indicated that the prescribed treatment was not administered on several occasions. This was confirmed by the Director of Nursing during an interview. Additionally, the facility did not develop a care plan with goals and interventions for Closed Resident Record CR265, who had multiple pressure wounds and deep tissue injuries, including stage 4 and unstageable wounds. The resident's care plan lacked documentation of necessary interventions for these conditions. This oversight was confirmed by the Corporate Clinical Coordinator, highlighting a failure to adhere to the facility's policies on wound treatment management and pressure injury prevention.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving Resident R50. The resident, who has diagnoses of high blood pressure, hemiplegia, and Multiple Sclerosis, reported feeling verbally abused by Nurse Aide (NA) Employee E5. During care, NA Employee E5 yelled at Resident R50 and used inappropriate language, causing the resident emotional distress. This incident was reported by Registered Nurse (RN) Employee E4, who noticed signs of fearfulness in Resident R50 and immediately informed the unit nurse manager and facility administrator. The Nursing Home Administrator (NHA) conducted an interview with Resident R50, who confirmed the verbal abuse and expressed that her feelings were hurt by the interaction. NA Employee E5 admitted to yelling at the resident during a telephone interview, citing frustration and a bad night as reasons for the outburst. Further interviews revealed that Resident R50 continued to feel unsafe and dissatisfied with the care provided at the facility. The Director of Nursing confirmed that the facility failed to protect Resident R50 from verbal abuse. The facility's policy on abuse, neglect, and exploitation clearly defines verbal abuse and mandates protection for residents, but this policy was not effectively enforced in this case. The incident highlights a significant lapse in ensuring a safe and respectful environment for residents, particularly those with complex medical conditions like Resident R50.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans to meet the needs of two residents, R76 and R80. For Resident R76, the Minimum Data Set (MDS) assessment indicated diagnoses of dementia, obstructive uropathy, and renal insufficiency. The Care Area Assessment (CAA) Summary revealed that the Urinary Incontinence and Indwelling Catheter care area was triggered, and a decision was made to include it in the care plan. However, the care plan dated 1/16/24 did not include goals and interventions related to catheter care. Additionally, the Cognitive Loss/Dementia care area was also triggered, but the care plan failed to include goals and interventions for dementia. This was confirmed by the Licensed Practical Nurse Assessment Coordinator (LPNAC) during an interview on 3/14/24. Similarly, for Resident R80, the MDS assessment indicated diagnoses of dementia and high blood pressure. The CAA Summary revealed that the Cognitive Loss/Dementia care area was triggered, and a decision was made to include it in the care plan. However, the care plan initiated on 9/22/23 and revised on 1/26/24 did not include goals and interventions related to dementia. This deficiency was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview on 3/14/24. The Director of Nursing (DON) also confirmed that the facility failed to develop comprehensive care plans for these two residents during an interview on the same day.
Failure to Maintain Sanitary Conditions of Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions of respiratory equipment for two residents. For Resident R2, the facility's policy required that nebulizer tubing and delivery devices be changed every seventy-two hours or as recommended by the manufacturer. However, during an observation, it was noted that Resident R2's nebulizer machine was not labeled with a date and was sitting on top of an unlabeled bag on a dresser. This was confirmed by a Registered Nurse (RN) during an interview. Resident R2 had multiple physician orders for inhalation medications, indicating a need for proper respiratory care and equipment maintenance. Similarly, for Resident R315, the facility's policy required that oxygen tubing and humidifiers be changed weekly if oxygen was used. During an observation, it was noted that Resident R315's nasal cannula was not labeled with a date. This was also confirmed by an RN during an interview. Resident R315 had a diagnosis of traumatic subarachnoid hemorrhage, hypertension, and multiple rib fractures, and was using oxygen via nasal cannula. The failure to label and date the respiratory equipment for both residents indicates a lapse in following the facility's policy and maintaining sanitary conditions.
Improper Storage and Security of Medications and Biologicals
Penalty
Summary
The facility failed to properly store medical supplies and biologicals in one of three medication carts and failed to properly secure medications and/or biologicals for two of six residents. Specifically, a tube of unlabeled Z-guard and peri-body cleanser was found on Resident R329's overbed table, and a Trelegy Ellipta inhaler was found on Resident R90's window sill. Both residents have diagnoses including COPD, hypertension, and diabetes. The items were confirmed and removed by Registered Nurse Employee E8 during the observation. Additionally, an unlabeled open tube of ciclopirox olamine cream was found in the bottom drawer of a medication cart on Hall 2 [NAME] unit. This was confirmed and removed by Registered Nurse Employee E9. The facility's policy on medication storage, which requires medications to be under direct observation or locked, and external products to be stored separately from internal and injectable medications, was not followed in these instances.
Infection Control Deficiencies in Equipment Disinfection and Wound Care
Penalty
Summary
The facility failed to properly disinfect reusable equipment between residents on one of the four nursing units observed. Specifically, a registered nurse was observed cleaning a glucometer with an alcohol prep pad instead of the approved disinfectant wipes as per facility policy and manufacturer's guidelines. This improper disinfection was confirmed by the nurse, who stated that she was trained to use the alcohol prep pad by the facility. Interviews with other staff members revealed inconsistencies in the understanding and implementation of the correct disinfection procedures for glucometers, further confirming the deficiency in infection control practices on the unit. Additionally, the facility failed to implement proper infection control practices during a dressing change for a resident with multiple medical conditions, including heart failure and hypertension. The licensed practical nurse did not clean the bedside table before placing clean supplies, used a pen from her pocket on the clean field, and handled the wound dressing supplies in a manner that risked contamination. The nurse also failed to set up a clean barrier field and did not follow proper hand hygiene and glove-changing protocols during the dressing change. These deficiencies were confirmed through staff interviews and direct observations, highlighting a failure to adhere to established infection control policies and procedures. The Director of Nursing acknowledged the lapses in proper disinfection and infection control practices, confirming the facility's failure to maintain a safe and sanitary environment for its residents.
Failure to Ensure Appropriate Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with an indwelling catheter. The resident, who had diagnoses of urinary tract infection, retention of urine, and diabetes, experienced issues with catheter blockage. A physician's order indicated that the catheter and catheter bag should be changed as needed for leakage or blockage. However, a Registered Nurse (RN) flushed the catheter multiple times with sterile water without verifying if there was a physician's order to do so. The RN later notified the Certified Registered Nurse Practitioner (CRNP) about the flushing but was unsure if it was in line with facility policy. Another RN stated that in such situations, they would check for a physician's order to flush the catheter or obtain one if it was not present. The Director of Nursing confirmed that the facility failed to provide appropriate treatment and services for the resident with the indwelling catheter. This deficiency was identified through a review of the facility policy, clinical records, and staff interviews.
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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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