Edenbrook North
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Pennsylvania.
- Location
- 300 Leader Drive, Williamsport, Pennsylvania 17701
- CMS Provider Number
- 395364
- Inspections on file
- 27
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Edenbrook North during CMS and state inspections, most recent first.
A resident developed significant bruising to the left arm, reported by the responsible party with photos, but staff did not document a detailed assessment of the bruise, did not record it on the weekly skin check, and did not conduct a thorough investigation or report it as an injury of unknown origin per facility policy. Staff accepted the resident’s statement that he had scratched himself without further inquiry. In a separate incident, the same resident’s responsible party filed a grievance alleging that prescription glasses had been stolen, yet the facility did not initiate or document an investigation, obtain witness statements, or notify law enforcement or the Department of Health regarding the potential misappropriation of resident property.
A resident who was assessed as dependent on staff for oral hygiene had a care plan directing that teeth be brushed twice daily, but electronic ADL documentation showed that staff did not document providing this assistance on multiple days within the review period. There was no record that the ordered twice-daily oral hygiene care was consistently provided, leading to a deficiency under ADL care requirements for dependent residents.
A resident who was fully dependent on staff was found with unexplained bruising and swelling on the forehead and hand. The injury was not immediately reported by a nurse aide who first observed it, and the required investigation and reporting to the Department of Health were not completed as per facility policy. The DON confirmed that the incident was not handled according to established procedures.
The facility failed to maintain sanitary conditions in the main kitchen, with debris on a mobile rack, floor drains, and grease trap. A windowsill had dust, a dead bug, and a potato chip. A storage room refrigerator and freezer lacked temperature monitoring records, and tray line food temperatures were undocumented for several dates. The Nursing Home Administrator confirmed these deficiencies.
The facility did not ensure timely return of residents' personal clothing after laundering, affecting multiple residents across all nursing units. A resident reported missing clothing, and observations confirmed that clean laundry was not distributed for at least four days. This issue was acknowledged by the housekeeping supervisor and the Nursing Home Administrator.
The facility failed to assist dependent residents with bathing and personal hygiene, resulting in missed showers and inadequate hair washing for several residents. Observations and records indicated multiple instances of neglect, with some residents receiving minimal assistance despite requiring substantial or complete help. Concerns were raised by family members and documented refusals were not followed by reattempts, highlighting a pattern of neglect in meeting residents' hygiene needs.
A facility failed to document pain levels for a resident receiving Oxycodone for severe pain, as per physician orders. The MAR showed multiple instances where pain levels were not recorded, indicating non-compliance with pain management protocols. This issue was confirmed by the DON and had been previously cited.
The facility failed to implement enhanced barrier precautions for three residents, including one with pressure ulcers, another with ESBL, and a third with a Foley catheter. Observations revealed a lack of signage and PPE, and staff did not use gowns during high-contact activities, contrary to infection control policies.
The facility failed to maintain a clean and safe environment on the 200 Nursing Unit, with issues such as a ripped-off handrail, strong urine odor, stained privacy curtain, damaged drywall, and dusty fan shroud affecting several residents. These deficiencies were confirmed during an interview with the Nursing Home Administrator and DON.
A facility failed to investigate and report an allegation of theft involving a resident's missing $40. Despite the policy requiring immediate notification and investigation, the Nursing Home Administrator only completed a concern form without further action, such as obtaining witness statements or notifying authorities.
A facility failed to implement a comprehensive care plan for a resident with a cardiac pacemaker. Despite a physician's order noting the presence of the pacemaker, no care plan was developed to address the necessary monitoring and assessment. This deficiency was confirmed by the DON during meetings with the Nursing Home Administrator.
A resident expressed concerns about her leg function and had not received therapy for a week. Despite being discontinued from therapy due to limited progress, no restorative ROM program was initiated, contrary to facility policies. The resident's clinical records indicated limited active ROM and slight weakness, but no restorative program was documented.
The facility failed to timely assess and intervene in significant weight loss for two residents. One resident lost 24.5 pounds over several months without proper reweights or interventions, while another experienced a severe weight loss that went unaddressed for four weeks. The facility lacked a system to notify the dietitian of significant weight changes, resulting in inadequate nutritional care.
A facility failed to provide appropriate respiratory care for a resident. Observations showed the resident's oxygen nasal cannula was left unbagged on the bed, and the nebulizer machine and tubing were found on the floor unbagged. Proper cleaning and storage of respiratory equipment are necessary to reduce infection risk, as per the American Association for Respiratory Care.
A facility failed to create an individualized care plan for a resident with dementia. Despite the resident's admission with a dementia diagnosis and a subsequent assessment confirming the condition, the care plan lacked specific interventions to address cognitive loss. This issue was identified during a review with the Nursing Home Administrator.
A facility failed to ensure safe storage of personal food in a resident's refrigerator, which lacked a temperature log. Observations revealed expired and undated food items, and the Nursing Home Administrator confirmed that monitoring should occur to prevent foodborne concerns.
The facility failed to maintain a sanitary environment in an outside employee break area, where various discarded items, including medical gloves and cigarette butts, were observed. An overflowing garbage can and a metal bucket with brown water were also noted. These conditions were reviewed with the Nursing Home Administrator and DON.
The facility failed to meet the required nurse aide-to-resident ratios during day, evening, and overnight shifts over a 21-day period. On several occasions, the number of nurse aides was insufficient, such as on December 25, when only 6 nurse aides were available during the day shift for 118 residents, while 11.80 were required. Similar shortages were noted during evening and overnight shifts, impacting the facility's compliance with state regulations.
The facility did not meet the required 3.2 hours of direct resident care per patient day for 18 out of 21 days reviewed. Nursing staffing hours were insufficient on several days in September, October, and December 2024, with hours ranging from 2.47 to 3.19 PPD. This was confirmed by the Administrator.
The facility failed to assist residents with bathing, grooming, and dressing, despite their dependency on staff. A resident was found with a soiled shirt and unshaven, while others did not receive showers as per their preferences. These issues were discussed with the facility's administration.
The facility failed to adhere to physician orders for several residents, including not documenting weights, blood sugar levels, and vital signs as required. A resident's weight was not monitored or reported as ordered, another resident received insulin despite low blood sugar levels, and a third resident's bowel management protocol was not followed. Additionally, vital signs for a resident with hypotension were not recorded timely.
The facility failed to maintain ROM for two residents. One resident's care plan included a restorative program for immobility, but staff often did not complete or document the tasks. Another resident's care plan involved AROM to reduce fall risk, but documentation showed frequent refusals by a specific employee, despite the resident's usual acceptance of assistance. These issues were discussed with the Nursing Home Administrator and DON.
The facility failed to provide appropriate pain management for four residents due to unclear guidelines for administering pain medications based on severity. Instances were noted where medications like Tramadol and Percocet were given for inappropriate pain levels, indicating systemic issues in pain management practices.
The facility failed to provide trauma-informed and culturally competent care for two residents with PTSD. One resident, admitted in 2022, had a history of premorbid PTSD, but the facility did not identify trauma history or triggers, nor collaborate with family or professionals for care planning. Similarly, another resident admitted in 2023 was diagnosed with chronic PTSD, yet the facility did not address trauma history or collaborate for individualized care. These issues were discussed with the administration.
The facility failed to develop and implement person-centered care plans for two residents diagnosed with dementia, as required. Despite assessments indicating the need for such plans, reviews revealed no evidence of individualized strategies to manage their cognitive loss. This deficiency was discussed with the facility's administration.
A resident's Ativan prescription was not discontinued despite a 14-day non-use period, contrary to physician orders. The medication was administered 17 times without attempting non-pharmacological interventions, highlighting a failure in adhering to medication management protocols.
The facility's main kitchen was found to have unsanitary conditions, including a dirty dry storage room floor, undated and expired food items in refrigerators, and incomplete temperature logs for dishwashers and refrigeration units. Black dirt particles were observed on food storage units, attributed to the air-conditioning unit. These deficiencies were noted during an observation and discussed with a dietary cook and the Nursing Home Administrator.
A resident was unable to exercise their choice to smoke due to a facility policy change that prohibited smoking for new admissions, while grandfathered residents and staff were allowed to smoke in designated areas. The resident, a tobacco user, felt this was unfair and was informed they could only smoke off the property, highlighting a failure to promote resident self-determination.
The facility failed to maintain a clean and safe environment, as two residents reported dirty bathrooms and inadequate room maintenance. Additionally, a resident's bladder scanner was broken, despite a physician's order for its use. The facility was aware of the equipment issue but lacked documentation of repair efforts.
A resident suffered a head injury after falling in her room due to neglect. The fall occurred when the resident attempted to reach a call bell that was not within reach, contrary to her care plan. A physical therapist left the resident in a stationary chair without notifying nursing staff or ensuring the call bell was accessible, leading to the incident.
The facility failed to provide written notice of the bed hold policy to two residents or their representatives at the time of hospital transfer. One resident was transferred due to a change in mental status, and neither received the required notification. The Nursing Home Administrator confirmed these findings.
A resident was not provided with necessary eyeglasses despite an optometry evaluation indicating their need. The resident reported using readers but experiencing blurred vision when watching TV. Documentation showed that bifocal glasses were ordered, but there was no record of their delivery or a follow-up visit. The Nursing Home Administrator stated the glasses were lost, and a new pair was ordered.
A facility failed to timely assess and implement interventions for a resident's pressure ulcer. Despite being identified as at risk, the resident developed a Stage 3 ulcer on the right ankle, with no new treatment orders documented. A care plan was not initiated until seven weeks after the ulcer was identified, and the Director of Nursing confirmed the lack of further documentation of assessment or intervention.
A resident experienced severe weight fluctuations without timely re-weighing or assessment, contrary to the facility's Weight Policy. The resident gained 20 pounds and then lost 14.2 pounds within a short period, but the re-weight was delayed by seven days. The registered dietitian did not provide new recommendations, and there was no notification to the resident's physician or responsible party.
A resident with mild cognitive impairment expressed distress about being held against his will and not being allowed to contact the ombudsman. Despite being oriented and having minimal confusion, the facility did not address his concerns or explore alternative living arrangements. Additionally, there was no evidence of a home assessment to verify claims about the uninhabitability of his home.
The facility failed to properly account for, secure, dispose of, or return medications for two residents. For one resident, there was no documentation of the disposition or security of controlled medications after the resident expired. For another resident, there was no documentation of the disposition of multiple medications upon discharge to the hospital, where the resident later expired.
A facility did not address pharmacy recommendations for a resident's medication diagnosis. The pharmacist requested corrections to the diagnosis for Seroquel on multiple occasions, but the facility failed to update the diagnosis from behaviors to bipolar disorder. The DON confirmed these findings.
The facility's laundry area was found to be unsafe and unclean due to an extensive build-up of wet lint and debris, including medical gloves, a plunger head, and a dirty blanket behind the main washing machines. This was observed during a survey with a laundry aide and the Nursing Home Administrator, highlighting a potential fire hazard.
The facility did not post daily nurse staffing information on the First, Second, and Third floors in a prominent place accessible to residents and visitors at the beginning of each shift. This issue was observed on two separate occasions and discussed with the Nursing Home Administrator and DON.
The facility failed to provide required written notifications to residents and their responsible parties for hospital transfers, affecting five residents. Additionally, the facility did not notify the State Long-Term Care Ombudsman for four of these transfers. This issue was confirmed by the Nursing Home Administrator and had been previously cited.
Failure to Investigate Injury of Unknown Origin and Alleged Misappropriation of Property
Penalty
Summary
The facility failed to follow its abuse, neglect, and injury-of-unknown-origin policies when a resident developed significant bruising to the left arm and when an allegation of stolen prescription glasses was made. The facility’s policies required immediate notification of the Nursing Home Administrator and DON, coordination of a thorough investigation with witness statements, interviews of all potentially involved or observing parties, assessment and documentation of injuries, and timely reporting to the state agency and law enforcement when indicated. The resident’s responsible party emailed the social worker with photos of serious bruising on the resident’s left arm and questioned its cause. Although an RN assessed the arm and noted a large bruise to the upper forearm, there was no clinical record documentation of the bruise, including size or color, and the weekly skin check for that date recorded no skin issues. Staff statements indicated the resident reported he had scratched himself and denied anyone grabbing him, and the Administrator and DON acknowledged that no thorough investigation was completed due to accepting this explanation. The facility also failed to investigate and report an allegation of potential misappropriation of the same resident’s prescription glasses. The resident’s responsible party filed a grievance stating that the resident’s prescription glasses had been stolen previously and that another pair left at the bedside was now missing, using the word “stolen,” and noting that the eyeglass case remained in the room but not the glasses. The social worker documented the grievance and the use of the term “stolen,” but there was no investigation documented in the clinical record into the potential misappropriation of property. The Administrator and DON confirmed that the facility did not complete an investigation, obtain witness statements, or notify law enforcement or the Department of Health regarding this allegation. These failures occurred despite facility policies requiring timely and thorough investigations and reporting of alleged neglect, injuries of unknown origin, and misappropriation of resident property.
Failure to Provide Ordered Oral Hygiene Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide required activities of daily living (ADL) assistance with oral hygiene to a dependent resident. Clinical record review showed that the facility admitted Resident CR2 on October 8, 2025, and the most recent MDS dated January 14, 2026, assessed the resident as dependent on staff for oral hygiene. The resident’s Kardex directed that his teeth were to be brushed twice daily. However, review of the Documentation Survey Report for January 1 through February 11, 2026, showed no documentation that staff assisted the resident with oral hygiene twice daily on 18 of 41 days reviewed, and there was no documentation indicating that staff were providing the ordered twice-daily oral hygiene assistance. These findings were discussed with the Nursing Home Administrator and DON on March 9, 2026. This deficiency was cited under 42 CFR 483.24(a)(2) for failure to provide ADL care for dependent residents and referenced a previously cited deficiency from April 4, 2025, as well as 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate and report an injury of unknown origin for a resident who was dependent on staff for all activities of daily living. The resident was found with a discolored and swollen forehead, and later developed bruising under her left eye and on her right hand. Documentation showed that the resident stated she had fallen and was picked up off the floor, but could not recall who assisted her. A nurse aide observed bruising during a shower but did not report it immediately, only notifying the LPN after the bruising worsened the next morning. The facility's policy required immediate assessment, notification, and investigation of such injuries, including prompt reporting to the Department of Health if abuse or neglect was suspected. Despite these requirements, the facility did not ensure timely reporting or a thorough investigation to rule out neglect or prevent further injuries. The DON confirmed that staff are expected to report all injuries of unknown origin at the time of identification, but this did not occur in this case. The failure to follow policy resulted in a lack of appropriate investigation and reporting to the necessary authorities regarding the resident's injuries.
Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and maintain the environment in a safe and sanitary condition in the main kitchen. During an observation with the dietitian, it was noted that a mobile rack holding bowls had debris and felt greasy, two floor drains contained extensive debris, and the perimeter of the grease trap in the dishwasher area had a significant build-up of food debris. Additionally, a windowsill was found with dust, a dead bug, and a discarded potato chip. In a storage room adjacent to the main kitchen, a refrigerator and freezer holding resident food items lacked documented temperature monitoring. Furthermore, there were missing documented tray line food temperatures for several dates in March 2025. The Nursing Home Administrator confirmed the absence of temperature monitoring records for the refrigerator and freezer units.
Failure to Timely Return Residents' Personal Clothing
Penalty
Summary
The facility failed to assist residents in retaining and using their personal possessions, specifically their clothing, across all three nursing units. An interview with Resident 22 revealed that she was unable to locate several pairs of pants and shirts. Observations in the facility's laundry area showed a large bin overflowing with bagged dirty personal laundry and nine large bins of clean laundry that had not been distributed to residents for at least four days. This clean laundry belonged to multiple residents, including Residents 2, 19, 22, 64, 88, 92, 106, and 121, indicating a systemic issue in the timely return of laundered clothing to residents. The observations were confirmed by Employee 3, the housekeeping supervisor, and the Nursing Home Administrator.
Failure to Assist Dependent Residents with Bathing
Penalty
Summary
The facility failed to assist dependent residents with bathing and personal hygiene, as evidenced by multiple instances of missed showers and inadequate hair washing for several residents. Resident 2 reported missing scheduled showers multiple times across January, February, and March 2025, despite requiring substantial assistance with bathing. Resident 21 was observed with disheveled and greasy hair, and records indicated he only had his hair washed a few times in February and March 2025, despite scheduled shower days. Resident 96 was also observed with unkempt hair and had several missed bath days documented, although she was dependent on staff for bathing. Resident 121's family expressed concerns about the resident's hygiene, and records showed only one bed bath was completed in March 2025, with several days marked as non-applicable without documented reasons. Resident 121 required substantial assistance for bathing, and there was no evidence of staff reapproaching after a refusal. Resident 88, who required substantial assistance, only received seven showers in three months, with several days marked as not applicable. Resident 92, dependent on staff for bathing, received only four showers in three months, with no evidence of reattempts after refusals. Resident 117, requiring partial to moderate assistance, also received only four showers since admission, with refusals documented but no reapproaches. The facility's failure to provide adequate bathing assistance for these residents was discussed with the Nursing Home Administrator and Director of Nursing, highlighting a pattern of neglect in meeting the personal hygiene needs of dependent residents.
Failure to Document Pain Levels for Pain Medication Administration
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for a resident, identified as Resident 108. The clinical record review revealed that the resident had physician orders for Oxycodone 5 mg, 2 tablets by mouth every 4 hours as needed for severe pain rated between 7 to 10. However, the medication administration record (MAR) for February and March 2025 showed that staff did not document the resident's pain level on multiple occasions when the medication was administered. This lack of documentation occurred on several dates and times, indicating a failure to adhere to the physician's orders regarding pain management. The deficiency was identified during a review of the resident's clinical records and was confirmed in an interview with the Director of Nursing. The report highlights that the staff did not administer the pain medications according to the physician-ordered pain scale levels, which is a requirement under the facility's pain management protocols. This oversight was previously cited in a survey conducted on May 23, 2024, indicating a recurring issue with the facility's compliance with pain management standards.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for three residents, leading to deficiencies in infection prevention and control. Resident 106, who had bilateral heel pressure ulcers and was receiving wound care and antibiotic treatment, was not placed on enhanced barrier precautions. Observations revealed that there was no signage or personal protective equipment (PPE) available in the resident's room, and staff did not wear gowns during wound care activities, despite the presence of wound drainage. Resident 2, who had a urinalysis indicating ESBL in her urine and was hospitalized, did not have enhanced barrier precautions initiated upon her return to the facility. Similarly, Resident 67, who had a Foley catheter for bilateral obstructive uropathy, did not have appropriate signage or PPE available outside their room. These observations were confirmed during meetings with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to adhere to infection control policies.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and orderly environment on the 200 Nursing Unit, affecting several residents. Observations revealed multiple deficiencies: a handrail in Resident 67's bathroom was ripped off the wall, leaving six open holes in the drywall; a strong urine odor was present in the 2 East hallway; Resident 108's privacy curtain had a large yellow dried stain; the drywall near Residents 97 and 84's areas was marred and gouged; and Resident 19's fan shroud was covered in dust and debris. These issues were confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Investigate and Report Alleged Theft
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of misappropriation of resident property, specifically involving Resident 38. The policy titled 'Vulnerable Adult Abuse and Neglect Prevention' mandates that upon receiving a complaint of alleged maltreatment, the Nursing Home Administrator must be notified immediately, and an investigation coordinated by the Director of Nursing or their designee. This investigation should include obtaining witness statements and interviewing all parties involved. Additionally, the facility is required to report to the State agency within specified timeframes depending on the severity of the incident and notify law enforcement if the concern is criminal in nature. In this case, Resident 38 reported to a licensed practical nurse that $40 was missing, indicating potential theft. However, the Nursing Home Administrator, upon being informed, only completed a resident concern form and did not proceed with a full investigation, nor did they obtain witness statements, notify law enforcement, or report the incident to the Department of Health. This inaction was confirmed during an interview with the Nursing Home Administrator, highlighting a failure to adhere to the facility's established policies and procedures for handling such allegations.
Failure to Implement Care Plan for Resident with Pacemaker
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with a cardiac pacemaker. The clinical record review revealed that the resident had a medical history that included a surgically implanted cardiac pacemaker, as noted in a physician's order dated July 2, 2021. However, upon review of the resident's clinical record on April 1, 2025, it was found that no care plan had been developed to address the pacemaker or the necessary monitoring and assessment associated with it. This deficiency was confirmed by the Director of Nursing during a meeting with the Nursing Home Administrator and Director of Nursing on April 2, 2025, and again on April 3, 2025.
Failure to Implement Restorative ROM Program for a Resident
Penalty
Summary
The facility failed to provide appropriate restorative range of motion (ROM) programs for a resident, identified as Resident 64, to maintain her range of motion. Resident 64 expressed a desire to return home but was concerned about her legs not functioning properly. Despite her ability to use her arms, she had not received any therapy for about a week. Clinical records indicated that she was discontinued from occupational and physical therapy on March 8, 2025, due to limited progress and non-compliance. The occupational therapy discharge summary noted limited active ROM due to general weakness, while the physical therapy discharge summary indicated slight weakness in her bilateral extremities. Both therapy summaries concluded that no restorative program was indicated, and her prognosis to maintain her current level of functioning was excellent with consistent staff support. However, there was no documentation in Resident 64's clinical record that any restorative programs were initiated. An interview with the Nursing Home Administrator confirmed these findings, indicating a failure to implement a range of motion program for Resident 64, as required by the facility's resident care policies and nursing services regulations.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide timely assessments and implement interventions to maintain acceptable nutritional parameters for two residents. Resident 112 experienced a significant weight loss of 24.5 pounds over a period from November 2024 to January 2025, with no weight obtained in December 2024 and no reweight conducted after the significant weight loss was noted in January 2025. Despite the resident's diet being upgraded, there was no further monitoring or intervention for her weight loss until February 2025, when a dietitian noted the resident's significant weight loss and risk for malnutrition, yet no new interventions were initiated. The resident's weight continued to fluctuate without appropriate reweights or interventions. Resident 88 also experienced a severe weight loss of 14 pounds in March 2025, which was not assessed in a timely manner. The facility lacked a system to notify the dietitian of significant weight changes, resulting in a delay in addressing the resident's nutritional needs. The dietitian only completed a weight change note four weeks after the severe weight loss was identified. These deficiencies highlight the facility's failure to adhere to its policy for monitoring and addressing significant weight changes, leading to inadequate nutritional care for the residents.
Inadequate Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident, identified as Resident 19. Observations on multiple occasions revealed that Resident 19's oxygen nasal cannula was left lying on their bed unbagged while the oxygen concentrator was running. Additionally, the resident's nebulizer machine was found sitting on the floor in front of the oxygen concentrator, with the nebulizer tubing also lying on the floor unbagged. These observations were made on April 1, 2, and 3, 2025, and were discussed with the Director of Nursing on April 3, 2025. According to the American Association for Respiratory Care, proper cleaning of nebulizer equipment is essential to reduce infection risk, and the equipment should be rinsed, washed with soap and hot water, and stored properly after each use.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The resident was admitted on April 1, 2024, with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. A significant change Minimum Data Set Assessment conducted on December 18, 2024, confirmed the diagnosis of dementia, and the facility determined that a care plan should be developed. However, the care plan initiated on April 5, 2024, did not include individualized interventions to address the resident's dementia and cognitive loss. This deficiency was identified during a review with the Nursing Home Administrator on April 3, 2025.
Failure to Monitor Resident Refrigerator for Food Safety
Penalty
Summary
The facility failed to ensure the safe and sanitary storage and handling of personal food products brought in from outside sources for a resident on the 200 Nursing Unit. During an observation of a resident's room, it was noted that the resident had a personal refrigerator without a temperature monitoring log. Inside the refrigerator, there were several items, including a container of cottage cheese with a best by date of January 13, 2025, a gallon of sweet tea with a sell by date of January 24, 2025, and two undated Styrofoam containers. A subsequent observation revealed additional items, including an undated Styrofoam container and two applesauce containers with a use by date of March 14, 2025. The Nursing Home Administrator acknowledged that resident refrigerators should be monitored for foodborne concerns.
Unsanitary Conditions in Employee Break Area
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in an outside designated employee break area located on the facility grounds. During an observation on April 1, 2025, various plastic and paper products, a hairnet, wet pieces of cardboard, and several balled-up medical gloves were found discarded on the ground. Additionally, multiple cigarette butts were scattered around the perimeter, and there was a significant build-up of dead leaves. An overflowing garbage can containing a brief and a metal bucket with brown-colored water and discarded cigarette butts were also observed. These findings were reviewed with the Nursing Home Administrator and Director of Nursing on April 2, 2025.
Staffing Deficiencies in Nursing Services
Penalty
Summary
The facility failed to comply with the Pennsylvania Long Term Care Licensure Regulations regarding nursing services staffing levels. Specifically, the facility did not maintain the required minimum number of nurse aides per resident during various shifts over a 21-day review period. During the day shift, the facility was understaffed on eight days, with the number of nurse aides falling short of the required ratio of one nurse aide per 10 residents. For example, on December 25, 2024, with a census of 118 residents, only 6 nurse aides were available, whereas 11.80 were required. The evening and overnight shifts also experienced staffing shortages. The evening shift was understaffed on 15 days, with the number of nurse aides not meeting the required ratio of one nurse aide per 11 residents. On December 25, 2024, with a census of 118 residents, only 7.20 nurse aides were available, while 10.73 were required. Similarly, the overnight shift was understaffed on 12 days, failing to meet the required ratio of one nurse aide per 15 residents. On December 25, 2024, with a census of 118 residents, only 6.40 nurse aides were available, whereas 7.87 were required. These findings were confirmed by the facility's administrator during an interview.
Plan Of Correction
Unable to retroactively correct. The facility will provide staffing to meet the ratio based on July 1, 2024 regulation change of 1 nurse aide per 10 residents on day shift, 1 nurse aide per 11 residents on evening shift, and 1 nurse aide per 15 residents on night shift. DON and RN Supervisors will be re-educated on staffing ratio minimums and the appropriate response to unplanned variations in ratio. NHA/designee during weekday daily review of nursing schedules will be discussed at the monthly QAI meeting for further review and recommendation.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient day (PPD) for 18 out of the 21 days reviewed. This deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Administrator. Specific dates where the facility did not meet the required hours include several days in September, October, and December 2024, with PPD ranging from 2.47 to 3.19 hours, all below the mandated 3.2 hours. The deficiency was confirmed by the Administrator on December 30, 2024.
Plan Of Correction
Unable to retroactively correct. The facility will provide staffing to meet the ratio based on July 1, 2024 regulation change of 3.2 hours PPD. DON and RN Supervisors will be re-educated on staffing ratio minimums and the appropriate response to unplanned variations in ratio. NHA/designee during weekday daily review of nursing schedules will review PPD to ensure that 3.2 is met. These audits will be discussed at the monthly QAPI meeting for further review and recommendation.
Failure to Assist Residents with Daily Living Activities
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, grooming, and dressing, for residents who were dependent on staff support. Resident 1 was observed with a soiled shirt and unshaven face, despite being assessed as requiring substantial assistance for personal hygiene. The resident expressed that staff only changed his shirt on shower days and refused to assist with shaving, which he could not perform himself due to his condition. His clinical records confirmed his dependency on staff for these tasks. Similarly, other residents were not provided with their preferred bathing schedules. Resident 3, who required maximum assistance for bathing, only received two showers in the past month, with minimal documentation of refusals. Resident 5, also needing substantial assistance, received only two showers in the same period, with some days marked as not applicable without explanation. Resident 7, who preferred showers twice a week, received only one shower in the last 30 days. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to meet the residents' care needs as per their preferences and assessments.
Failure to Adhere to Physician Orders and Monitor Residents
Penalty
Summary
The facility failed to provide the highest practicable care for several residents by not adhering to physician orders regarding weights, medications, and vital signs. For Resident 3, the facility did not document daily weights as ordered and failed to notify the physician when the resident's weight fell below 320 pounds or changed significantly over short periods. This lack of documentation and communication occurred on multiple occasions, indicating a pattern of non-compliance with the physician's orders. Resident 41's care was compromised by the facility's failure to monitor and document blood sugar levels consistently. There were instances where blood sugar levels were not recorded, and when they were, the facility did not notify the physician when levels were outside the prescribed parameters. Additionally, the facility administered Lantus insulin despite orders to hold it if blood sugar levels were below 120 mg/dL, which happened on several occasions. For Resident 88, the facility did not follow the bowel management protocol, failing to offer or document the administration of PRN medications for constipation over several days. Resident 67's vital signs were not monitored as ordered after a diagnosis of hypotension, with a significant delay in taking and recording vital signs. These deficiencies were identified during a survey and discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Maintain Range of Motion for Two Residents
Penalty
Summary
The facility failed to provide services to maintain the range of motion (ROM) for two residents, identified as Residents 28 and 56. For Resident 28, the clinical record review revealed a care plan that included a restorative program to address immobility, involving ROM exercises for the bilateral lower and upper extremities, and a program to ensure the resident was out of bed for at least one hour each day. However, documentation showed that staff frequently did not complete or document these restorative tasks on multiple occasions across March, April, and May 2024. Additionally, there were frequent refusals by Resident 28 to get out of bed, but there was no documentation indicating a change in the current level of function or notification to therapy. For Resident 56, the care plan included restorative nursing for active range of motion (AROM) to maintain bilateral lower extremity strength and reduce fall risk. However, task documentation indicated that a specific employee frequently documented resident refusals of services, despite the resident's usual acceptance of staff assistance. An interview with Resident 56 revealed that she was independent with her care and did not indicate refusals of her restorative program services. The surveyor discussed these findings with the Nursing Home Administrator and Director of Nursing.
Inadequate Pain Management Practices
Penalty
Summary
The facility failed to provide appropriate pain management for four residents, as evidenced by the lack of clear guidelines for administering physician-ordered pain medications based on pain severity. For Resident 3, there were orders for both Acetaminophen and Oxycodone, but no documentation indicated which medication should be used for mild, moderate, or severe pain. Similarly, Resident 96 had orders for Acetaminophen and Morphine Sulfate, but the facility did not specify which medication to administer for different pain levels, leading to potential confusion in pain management. Resident 56's medication administration records showed instances where pain medications were given for inappropriate pain levels, such as administering Tramadol for a pain level of 0. Resident 123 also received Percocet for pain levels that did not align with the prescribed parameters. These findings indicate a systemic issue in the facility's pain management practices, where staff administered medications without adhering to the prescribed pain level guidelines, potentially compromising the residents' care.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Resident 93 was admitted on May 19, 2022, and later diagnosed with chronic PTSD on October 9, 2022. Despite a psychiatry note from August 23, 2022, indicating a history of premorbid PTSD, the facility did not identify the resident's history of trauma or any triggers in the care plan. There was no evidence of collaboration with the resident, their family, or healthcare professionals to develop individualized interventions. Similarly, Resident 112 was admitted on October 27, 2023, and diagnosed with PTSD on February 11, 2024. A psychiatry note from February 5, 2024, confirmed the diagnosis of chronic PTSD, yet the facility again failed to identify the resident's trauma history or triggers. The clinical record showed no collaboration with the resident, family, or mental health professionals to create personalized care strategies. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing on May 22, 2024.
Failure to Implement Person-Centered Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia, leading to a deficiency in providing appropriate treatment and services. Resident 34 was admitted with a diagnosis of dementia with agitation, and her admission Minimum Data Set Assessment indicated the need for a care plan addressing her cognitive loss. However, a review of her care plan revealed no evidence of a person-centered approach to manage her dementia, which should have included direct care and activities focused on understanding, preventing, relieving, and accommodating her distress or loss of abilities. Similarly, Resident 87, diagnosed with dementia, also lacked a person-centered care plan despite the facility's assessment indicating the necessity for one. His significant change Minimum Data Set Assessment confirmed the diagnosis, yet the care plan review showed no implementation of strategies to address his cognitive loss. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to provide tailored care for residents with dementia.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications, specifically concerning the administration of Ativan for anxiety. Resident 41 had a physician's order for Ativan 0.5 mg to be taken as needed every 8 hours for increased anxiety, with a stipulation to discontinue after 14 days of non-use. Despite a pharmacy recommendation on February 8, 2024, to evaluate the necessity of the medication or to implement a 14-day stop date, the PRN Ativan order continued through March, April, and May 2024. During this period, staff administered the medication 17 times without attempting non-pharmacological interventions 19 times prior to administration. The clinical record review revealed that there were two separate 14-day periods of non-use, from March 14 to April 3, 2024, and from April 13 to April 27, 2024, which should have triggered the discontinuation of the medication as per the order dated February 11, 2024. However, the medication was not discontinued, indicating a failure to adhere to the physician's order and the pharmacy's recommendation. This oversight was identified during a surveyor's review with the Nursing Home Administrator on May 22, 2024.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed on May 20, 2024. The dry storage room floor was dirty with black marks and sticky substances, and debris such as cardboard, plastic utensils, and a coffee mate packet were found on the floor. Black dirt particles were noted on the top shelves of two food storage units, which Employee 4, a dietary cook, attributed to the air-conditioning unit, although it was not operational at the time. Additionally, the refrigerator contained undated food items, including a bag of lettuce, waffles, and sausage patties, while another refrigerator had expired cabbage and undated sandwiches and salads. Spillage and stuck cardboard were observed on the bottom shelf of a freezer. Temperature logs for the dishwasher were inaccurately recorded for lunchtime, despite the observation occurring at 8:15 AM. Furthermore, temperature logs for the refrigerators and freezers were incomplete, with no entries for the evening shift from May 14-17, 2024. These issues were discussed with Employee 4 during the observation, and the Nursing Home Administrator was informed of the concerns on May 21, 2024. The facility was previously cited for similar deficiencies on July 25, 2023, under 42 CFR 483.60(i)(2) and 28 Pa. Code 201.14 (a).
Violation of Resident's Right to Self-Determination Regarding Smoking
Penalty
Summary
The facility failed to ensure that residents could make choices about significant aspects of their lives, such as smoking, for one of the residents reviewed. The Nursing Home Administrator (NHA) stated that the facility became non-smoking for new admissions starting in April 2023, although three grandfathered residents were still allowed to smoke in a designated area. Staff were also permitted to smoke in a separate designated area on the facility property. Resident 1, who was admitted after the policy change, expressed dissatisfaction with the inability to smoke on the premises, noting that it was unfair that others, including staff and grandfathered residents, were allowed to smoke. The NHA confirmed that Resident 1 was informed of the non-smoking policy upon admission and had signed a non-smoking agreement. Despite this, Resident 1, a tobacco user, felt that the policy was inequitable. Social Services documentation indicated that the policy and the grandfathering of certain residents were explained to Resident 1, and it was noted that the resident could smoke off the facility property. The facility's actions were found to be in violation of the resident's right to self-determination and choice, as outlined in 28 Pa. Code 201.29(a) Resident rights.
Deficiencies in Cleanliness and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by observations and interviews conducted by surveyors. On two of the three nursing units, residents expressed concerns about the cleanliness of their bathrooms. Resident 56 reported a dirty toilet and a blackened floor, which was confirmed by a surveyor's observation. Similarly, Resident 60 noted that the condition of her bathroom led to her clothing becoming soiled. The surveyor observed that the room had unpainted patches and holes in the walls, indicating inadequate maintenance. Additionally, the facility did not ensure the proper functioning of medical equipment, specifically the bladder scanner, for one resident. Resident 1 had a physician's order for bladder scanning five times a day, but the equipment was found to be broken. The bladder scanner had a cracked probe and was covered in a sticky substance, rendering it non-functional. Despite repeated documentation by staff about the malfunctioning equipment, there was no evidence that the physician was informed, nor was there documentation of efforts to repair or replace the device. Interviews with the Nursing Home Administrator and Director of Nursing revealed that they were aware of the broken bladder scanner but could not provide details on when repairs were requested or any interim solutions. The facility's failure to maintain a clean environment and ensure the availability of functional medical equipment resulted in deficiencies that compromised the residents' right to a safe and comfortable living space.
Neglect Resulting in Resident Injury Due to Inaccessible Call Bell
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in injury. Resident 60 experienced a fall in her room, which led to a head laceration requiring emergency medical attention and sutures. The incident occurred after a physical therapy session conducted by Employee 2, who left the resident in a stationary chair without ensuring the call bell was within reach. This was contrary to the resident's care plan, which required staff to ensure the call light was accessible to encourage the resident to use it for assistance as needed. The resident attempted to reach the call bell, which was placed across the bed, leading to her losing balance and falling. The facility's failure to ensure the call bell was within reach and to alert nursing staff about the resident's situation contributed to the neglect. The facility's management acknowledged that only a limited number of therapy department staff were re-educated on the importance of call bell accessibility, indicating a lack of comprehensive staff education on fall prevention and adherence to care plans.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that residents or their representatives received written notice of the facility's bed hold policy at the time of transfer to a hospital. This deficiency was identified for two residents during a clinical record review. Resident 19 was transferred to the hospital from May 13-17, 2024, without evidence of written notification of the bed hold policy being provided to him or his responsible party. Similarly, Resident 126 was transferred to the hospital on March 3, 2024, due to a change in mental status, and there was no evidence that she or her responsible party received written notification of the bed hold policy. The Nursing Home Administrator confirmed these findings during a meeting on May 23, 2024.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain vision for a resident. The resident reported that she was informed by an eye doctor last year that she needed eyeglasses, but she has not received them. She currently uses readers for close-up vision but experiences blurred vision when watching television. An optometry evaluation from June 1, 2023, indicated that bifocal glasses were ordered for the resident, with a follow-up visit recommended in six months. However, there is no documentation of the eyeglasses being delivered, a follow-up visit occurring, or the resident refusing these services. A Care Plan Note from August 28, 2023, shows the resident inquired about her glasses, and a voicemail was left to check on their status. The Nursing Home Administrator later revealed that the glasses were supposedly sent to the facility but could not be located, prompting a new order for the glasses.
Failure to Timely Address Pressure Ulcer
Penalty
Summary
The facility failed to adequately assess and implement timely interventions for a pressure ulcer on a resident's right ankle. The resident was admitted on July 9, 2021, and a skin check on January 9, 2024, revealed a red and painful ankle, but no new treatment orders were documented in the Treatment Administration Record for January 2024. The resident's pressure ulcer was assessed as a Stage 3 ulcer by wound care, measuring 0.5 cm by 0.5 cm by 0.1 cm. Despite the resident being identified as at risk for pressure ulcers in a Braden assessment on August 16, 2023, a subsequent assessment started on January 4, 2024, was not completed until January 11, 2024, after the ulcer was identified. The facility did not initiate a care plan to address the pressure ulcer until February 26, 2024, which was seven weeks after the ulcer was identified. The Director of Nursing confirmed that there was no further documentation of assessment or intervention for the pressure ulcer since January 15, 2024. The facility's policy required timely assessment and intervention for skin integrity issues, which was not adhered to in this case, leading to a deficiency in the care provided to the resident.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement necessary interventions to maintain acceptable nutritional parameters for a resident, identified as Resident 64. According to the facility's Weight Policy, any resident experiencing a weight change of five or more pounds should be re-weighed within 24 hours, and significant weight changes should be reviewed by a dietitian with potential interventions recommended. However, Resident 64 experienced a severe weight gain of 20 pounds (23.26 percent) between December 6, 2023, and January 3, 2024, followed by a severe weight loss of 14.2 pounds (13.25 percent) by January 16, 2024. Despite these significant fluctuations, the re-weight was not conducted until seven days after the initial severe weight gain, and there was no evidence of assessment or notification to the resident's physician or responsible party. The clinical record review revealed that Resident 64's medications did not include diuretics or appetite-enhancing medications, and the registered dietitian, identified as Employee 3, had no new recommendations at the time of the weight change note dated January 16, 2024. An interview with Employee 3 confirmed the delay in re-weighing and the lack of assessment or communication regarding the severe weight changes. This deficiency indicates a failure to adhere to the facility's policies and procedures concerning weight management and resident care, as outlined in the 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(3)(5).
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to Resident 6, who was admitted on April 1, 2024. Observations and interviews revealed that Resident 6 was visibly upset, expressing concerns about being held against his will and not being allowed to contact the local ombudsman. Despite having a BIMS score indicating only mild cognitive impairment, the resident felt imprisoned and was not informed about his rights or given the opportunity to discuss his situation with the Nursing Home Administrator, whom he had requested to see for over a month. Clinical records and staff interviews confirmed that Resident 6 was oriented and had minimal confusion, yet he was preoccupied with leaving the facility. Nursing documentation noted his repeated requests to speak with the facility's management and his threats to involve legal action or the police. Despite these concerns, there was no evidence that the facility addressed his desire to leave or explored alternative living arrangements, such as an assisted living facility. The facility also failed to verify claims made by the resident's emergency contact regarding the uninhabitability of his home. There was no documentation to suggest that a home assessment was conducted to confirm these allegations. Furthermore, the facility did not provide evidence that Resident 6 was deemed incapable of making his own decisions by a medical professional, highlighting a lack of appropriate social services to ensure his well-being.
Failure to Account for and Dispose of Medications
Penalty
Summary
The facility failed to properly account for, secure, dispose of, or return physician-ordered medications for two residents. For Resident 125, who had physician orders for Lorazepam, Morphine Sulfate, and Hyoscyamine Sulfate, there was documentation of counting the Lorazepam and Morphine medications after the resident expired. However, there was no documentation regarding the disposition or security of these controlled medications, nor was there any documentation accounting for the Hyoscyamine after the resident's death. This issue was discussed with the Director of Nursing during an interview. For Resident 126, who was admitted to the hospital and expired there, the facility failed to document the disposition of multiple medications upon her discharge from the facility. These medications included Dexamethasone, Furosemide, Gabapentin, Novolog, Cyclobenzaprine HCl, Dicyclomine HCl, Linzess, Methocarbamol, Apixaban, Breo Ellipta Inhaler, Cyanocobalamin, Empagliflozin oral, Ergocalciferol, Fluoxetine HCI, Insulin glargine, Levothyroxine, Ropinirole HCl, and Seroquel. The lack of documentation regarding the disposition of these medications was also reviewed with the Director of Nursing.
Failure to Address Pharmacy Recommendations for Medication Diagnosis
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for a resident. The clinical record review and staff interview revealed that the pharmacist conducted monthly medication reviews for the resident and made recommendations on several occasions, specifically on October 10, 2023, November 13, 2023, January 9, 2024, and February 8, 2024. The pharmacist requested that the nursing staff correct the diagnosis for Seroquel on the medication administration record to reflect bipolar disorder, as the current diagnosis was listed as behaviors. Despite these recommendations, there was no evidence in the resident's clinical record that the facility addressed the medication regimen reviews related to the diagnosis for Seroquel. The Director of Nursing confirmed these findings during an interview on May 23, 2024.
Unsafe and Unclean Laundry Area
Penalty
Summary
The facility failed to maintain a safe and clean environment in the laundry area, as observed during a survey. During an inspection of the main laundry area, an extensive build-up of wet lint and debris was found behind the main washing machines. The debris included three discarded medical gloves, a plunger head, and a dirty blanket. This accumulation of lint and debris not only affects the performance of the dryers but also poses a potential fire hazard. The observation was made in the presence of a laundry aide and the Nursing Home Administrator.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nursing staffing information was posted daily on all three resident floors, specifically the First, Second, and Third floors. This deficiency was identified through observations conducted on May 20, 2024, at 11:31 AM and again on May 23, 2024, at 11:27 AM. The nurse staffing data was not displayed in a prominent place that was readily accessible to residents and visitors at the beginning of every shift, as required. These findings were discussed with the Nursing Home Administrator and Director of Nursing during a meeting on May 23, 2024, at 11:45 AM.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their responsible parties regarding transfers to the hospital, as required by regulations. This deficiency was identified for five residents, where the facility did not document evidence of providing the necessary written notice that includes the reason for transfer, effective date, location, contact information for the State Long-Term Care Ombudsman, and details about the resident's appeal rights. Specifically, Residents 6, 64, 112, 19, and 126 were transferred to the hospital without the required written notifications being provided to their responsible parties. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman about the hospital transfers for four of these residents. The lack of notification was confirmed by the Nursing Home Administrator during an interview. This failure to comply with notification requirements was previously cited in June 2023, indicating a recurring issue with the facility's adherence to transfer and discharge notice regulations.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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