Edenbrook Of Greenwood Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Pottsville, Pennsylvania.
- Location
- 420 Pulaski Drive, Pottsville, Pennsylvania 17901
- CMS Provider Number
- 395344
- Inspections on file
- 33
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Edenbrook Of Greenwood Hill during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of dementia-related behaviors, including verbal aggression and unsafe wandering, did not have an individualized care plan that addressed her specific needs. Despite ongoing documentation of escalating behaviors and safety risks, the facility relied on generic interventions such as room changes and redirection, without revising the care plan to include dementia-specific strategies or environmental modifications. The facility also lacked a documented Dementia Care Program or policy, and staff education on dementia care was not translated into individualized care planning or consistent implementation.
The facility failed to protect a resident from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
Surveyors found that multi-dose vials of Tuberculin in two medication rooms were either not dated upon opening or not discarded within the required 30-day period, contrary to facility policy and manufacturer guidelines. Staff interviews confirmed that these procedures were not followed, resulting in improper medication storage and labeling.
A resident with major depressive disorder was not referred for a required PASRR Level II evaluation after a suicide attempt, psychiatric hospitalization, and readmission, despite a significant change in condition and newly evident serious mental health issues. Staff and record reviews confirmed the facility did not initiate the necessary referral process.
A resident with diabetes and severe cognitive impairment experienced a low blood glucose event, but did not receive prompt carbohydrate treatment as required by protocol. Documentation also showed that the RN supervisor and physician were not notified of the hypoglycemic episode until after the resident had a fall and was found lethargic.
Two residents did not have fully developed or implemented care plans to address their individualized needs. One resident with severe cognitive impairment and language barriers lacked communication interventions and updated fall and elopement prevention strategies in the care plan. Another resident with significant mobility deficits had care plan interventions for bed mobility that were not reflected in the Kardex or communicated to direct care staff, resulting in a lack of implementation.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors. These lapses resulted in a deficiency related to environmental safety and resident supervision.
The facility did not provide required written notifications, including the specific reason for transfer, to several residents and their representatives when initiating transfers to a hospital. Documentation was lacking, and notifications were not given in a manner understandable to the residents or their representatives.
Multiple residents with various medical conditions experienced significant delays in staff response to call lights, often waiting from 20 minutes to several hours for assistance with needs such as toileting, pain medication, and incontinence care. These delays occurred across all shifts and led to discomfort, distress, and residents sometimes attempting unsafe self-care. The facility's policy requires prompt responses, but this standard was not met, as confirmed by resident interviews and grievance reviews.
A resident at Edenbrook of Greenwood Hill was sexually abused by a nurse aide, which was witnessed by another staff member. The resident, who was cognitively intact, confirmed the abuse had been ongoing for a month. The facility failed to prevent and detect the abuse, leading to Immediate Jeopardy.
The facility's administration failed to prevent the sexual abuse of a resident due to inadequate use of resources and non-fulfillment of essential job duties by the NHA and DON. The facility did not implement effective policies to prevent abuse and failed to investigate and report alleged violations properly.
The facility's abuse prohibition policy lacks specific procedures for identifying and investigating abuse, including guidance on recognizing different types of abuse and handling evidence in sexual abuse cases. The policy does not provide staff with clear instructions, increasing the risk of incomplete investigations and failure to protect residents.
A facility failed to conduct a thorough investigation into an alleged sexual abuse incident involving a resident and a nurse aide. The resident, who was cognitively intact, confirmed the incident and previous similar interactions. The investigation was incomplete as it did not include interviews with all potential witnesses or involved staff members present during the incident.
The facility failed to provide adequate activities for residents, with complaints about limited evening options and lack of variety. Two residents did not have personalized activity plans or documented participation, despite their specific needs and preferences. The NHA confirmed the deficiency.
The facility failed to provide necessary dental services for two residents. One resident, with multiple sclerosis, did not receive assistance in obtaining recommended dentures until a survey inquiry. Another resident, with paraplegia, reported a missing lower denture, but the facility did not investigate or document the issue. These actions resulted in deficiencies under federal dental service guidelines.
The facility failed to provide consistent evening snacks to residents, despite a policy requiring snacks if the time between dinner and breakfast exceeds 14 hours. Eight cognitively intact residents reported not receiving snacks, citing shortages and staff not distributing them. The NHA could not explain the discrepancy, confirming the policy to offer snacks.
The facility failed to maintain sanitary food storage and service practices, increasing the risk of food-borne illness. Observations revealed thawed nutritional shakes without thaw or discard dates, uncovered and undated canned fruit cocktail, and food products stored directly on the floor. Additionally, a buildup of pink-colored slime was found on the ice machine's condensation hose. These unsanitary conditions were confirmed by the facility's registered dietitian and nursing home administrator.
A resident was observed smoking on facility grounds despite the facility's Non-Smoking Policy. The resident's care plan acknowledged their smoking habit but lacked specific details for safe smoking. The resident signed out for a leave of absence, retrieved smoking materials from the nurse's station, and smoked across the street without staff presence. Facility management was aware but failed to enforce the policy.
A resident with newly diagnosed schizophrenia and narcissistic personality disorder was not referred for a PASRR Level II evaluation. Despite the need for one-to-one supervision due to uncontrolled psychosis, the facility failed to report the resident's mental health conditions to the state's mental health authority.
A resident with dysphagia and a gastrostomy tube had a PEG-Tube dislodged due to the facility's failure to ensure the use of an abdominal binder as per the care plan. The binder was found on the bedside table, and the resident required hospital transfer for tube reinsertion. The DON confirmed the incident but lacked documentation of effective binder implementation.
A resident with a history of dysphagia, hypertension, and dementia received unnecessary antibiotics after a fall. The emergency room suspected a UTI and prescribed antibiotics, but the urine culture to confirm the infection was not completed. Despite no symptoms or lab confirmation, the resident received 14 doses of Bactrim DS. The DON confirmed the administration was unjustified.
The facility failed to notify the State Long-Term Care Ombudsman of resident transfers to hospitals, as required by regulations. Despite providing written notices to residents and their representatives, there was no evidence of notification to the Ombudsman for five residents transferred between March and September 2024. The Nursing Home Administrator confirmed this lapse, which had been ongoing since October 2020.
The facility did not ensure the Department of Health's survey results were accessible to residents and visitors in two nursing units. Residents were unaware of the survey results' location, and observations showed the results were either blocked or not posted. The NHA acknowledged the facility's responsibility to provide access.
Failure to Individualize and Revise Dementia Care Plan for Resident with Escalating Behaviors
Penalty
Summary
The facility failed to develop, revise, and consistently implement an individualized, person-centered care plan to address dementia-related behaviors for a resident with a history of cerebral infarct and alcohol-induced persisting dementia. The resident was moderately cognitively impaired and exhibited a sustained pattern of escalating behaviors, including verbal aggression, resistance to care, unsafe wandering, and entering other residents' rooms. The care plan included only broad and generic interventions, lacking specific, actionable strategies tailored to the resident's repeated aggressive behaviors and safety risks. Despite documentation over several months showing the resident ambulating independently during episodes of agitation, being verbally abusive, and having conflicts with roommates and visitors, the care plan was not revised to address these ongoing issues. Interventions primarily consisted of room changes, redirection, and brief calming measures, without evidence of meaningful updates to include dementia-specific strategies, environmental modifications, or structured interventions. Nursing documentation repeatedly noted the resident's inability to be redirected and disruptive behaviors affecting other residents and staff. The facility was unable to provide a Dementia Care Program or policy during the survey, and although staff education materials on dementia care were available, there was no evidence that this education was translated into individualized care planning or consistent implementation for the resident. Interviews with facility leadership confirmed the failure to revise and implement an effective care plan to address the resident's documented dementia-related behaviors.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Failure to Properly Label and Discard Multi-Dose Medications
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of multi-dose medications in accordance with its own policy and manufacturer guidelines. During an observation of the second-floor medication room, a multi-dose vial of Tuberculin was found in the medication refrigerator that had been opened and dated July 2, 2025, but had not been discarded within the required 30 days, remaining available for use 36 days past the recommended discard date. The manufacturer’s instructions specify that vials in use for more than 30 days should be discarded, and this was confirmed by a Registered Nurse Unit Manager at the time of observation. Additionally, in the third-floor medication room, another multi-dose vial of Tuberculin was found opened and available for use, but it was not dated when opened, making it impossible to determine if it was within the safe usage period. An LPN confirmed the vial was opened and not dated. Interviews with the Nursing Home Administrator and DON confirmed that facility policy requires medications to be dated upon opening and removed upon expiration, but these procedures were not followed in these instances.
Failure to Refer Resident for PASRR Level II Evaluation After Psychiatric Hospitalization
Penalty
Summary
The facility failed to refer a resident with newly evident serious mental health issues for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. The resident, who had a diagnosis of major depressive disorder, was admitted to the facility and subsequently experienced a suicide attempt, leading to transfer to a community emergency department and involuntary commitment to a psychiatric hospital for evaluation and stabilization. Upon readmission to the facility, there was no documented evidence that the facility initiated a PASRR Level II referral through the state mental health authority, despite the resident's significant change in condition and emergence of serious maladaptive behaviors. Staff interviews and clinical record reviews confirmed that the facility did not communicate the need for a PASRR Level II evaluation following the resident's psychiatric hospitalization and readmission. This omission was acknowledged by the Nursing Home Administrator, who confirmed that the required referral was not made after the resident's suicide attempt and subsequent return to the facility.
Failure to Provide Timely Hypoglycemia Management and Notification
Penalty
Summary
The facility failed to provide person-centered care and adhere to professional standards of practice for diabetes management for one resident with severe cognitive impairment and a diagnosis of diabetes. The resident had physician orders for insulin administration based on blood glucose levels, with specific instructions to notify the physician and RN supervisor if blood glucose was less than 70 mg/dL, and to treat hypoglycemia promptly with 15 to 20 grams of fast-acting carbohydrates. On the date in question, the resident's blood glucose was recorded at 54 mg/dL, and the scheduled insulin dose was held as per orders. Despite the low blood glucose reading, there was no documented evidence that the resident received orange juice or any other carbohydrate in a timely manner as required by the hypoglycemic protocol. Additionally, there was no documentation that the RN supervisor or physician were notified of the hypoglycemic event until after the resident experienced a fall from their wheelchair and was found to be lethargic but responsive. The lack of timely intervention and notification was confirmed by the Nursing Home Administrator, and the documentation did not reflect adherence to the facility's policy or physician orders regarding hypoglycemia management.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to fully develop, revise, and implement person-centered comprehensive care plans for two residents. For one resident with dementia and diabetes, who was severely cognitively impaired and primarily Spanish-speaking, the care plan did not include interventions for effective communication, despite staff acknowledging the need for Spanish-speaking support or an interpreter. Additionally, after the resident experienced a fall and was identified as high risk for both falls and elopement, the care plan was not updated to reflect new treatment goals or interventions for fall prevention or wandering risk. For another resident with cerebral palsy, quadriplegia, and significant mobility deficits, the care plan specified the need for two staff members to assist with repositioning and turning in bed. However, this intervention was not reflected in the Kardex system used by nurse aides, and there was no documentation that direct care staff were informed of the requirement for two caregivers for safe bed mobility. The Nursing Home Administrator was unable to provide evidence that these care plan interventions were communicated to staff, resulting in a lack of implementation of the resident's individualized care needs.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Written Transfer Notifications to Residents and Representatives
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding facility-initiated transfers to a community hospital. Specifically, for five residents, the facility did not document or deliver written notices that included the specific reason for each transfer. The notifications were either missing the required information or were not provided in a language and manner understandable to the resident or their representative. This was identified through a review of clinical records, transfer notification forms, and staff interviews. For each of the five residents reviewed, the transfer notification forms did not specify the reason for the transfer in writing, nor was there evidence that the notifications were communicated in an understandable way. During an interview, the nursing home administrator was unable to provide documentation that these notifications had been given as required. The deficiency was cited under 28 Pa. Code 201.14(a) for failure to meet the responsibility of the licensee regarding required notifications.
Failure to Respond Timely to Resident Requests for Assistance
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life by not responding promptly to residents' requests for assistance, as required by facility policy. Multiple residents reported significant delays in staff response after activating their call lights, with wait times frequently ranging from 20 minutes to over an hour, and in some cases, up to four hours. These delays were corroborated by resident interviews and a review of grievances filed with the facility. The facility's policy mandates prompt and courteous responses to call lights, but this standard was not met according to the residents' accounts. Several residents with varying medical conditions, including heart failure, major depressive disorder, agoraphobia, diabetes, morbid obesity, COPD, acute respiratory failure, and peripheral vascular disease, described repeated experiences of waiting extended periods for assistance. For example, one resident reported waiting over four hours for help, often when requesting pain medication, while another resident described being left on the toilet for over an hour, resulting in discomfort and pain. Another resident stated that she frequently soiled herself due to long waits for bathroom assistance, and a grievance documented a two-hour wait for toileting help. Delays were reported across all shifts, with particular issues noted during the night shift. Residents also expressed frustration and distress due to these delays, with some resorting to self-transfer to avoid soiling themselves, despite recognizing the safety risks. The Nursing Home Administrator confirmed that all residents should be treated with dignity and respect and receive timely care but was unable to explain the cause of the untimely staff responses. The findings were based on clinical record reviews, facility policy, grievances, and resident and staff interviews.
Sexual Abuse by Staff Member at LTC Facility
Penalty
Summary
Edenbrook of Greenwood Hill was found to be non-compliant with federal and state regulations following an incident involving sexual abuse of a resident by a facility staff member. The deficiency was identified during an abbreviated complaint survey, which revealed that a nurse aide, Employee 3, engaged in sexual acts with a resident, Resident 1, who was cognitively intact. The incident was witnessed by another staff member, Employee 1, who reported seeing Employee 3 receiving oral sex from Resident 1. This incident was not isolated, as further investigation revealed that Employee 3 had engaged in similar inappropriate conduct with Resident 1 over the course of a month. The facility's failure to prevent, identify, and respond appropriately to the sexual abuse placed Resident 1 and all other residents at risk for further harm. Despite having an abuse prevention policy in place, the facility did not detect the ongoing abuse, which was only brought to light when Employee 1 witnessed the act and reported it. Interviews with staff and the resident confirmed the occurrence of prior sexual encounters initiated by Employee 3, which went unnoticed by the facility's management. The deficiency was classified as Immediate Jeopardy due to the facility's inability to protect residents from abuse by staff members. The report highlights the facility's lack of effective monitoring and intervention, which allowed the abuse to continue undetected. The Immediate Jeopardy was identified on February 13, 2025, following the incident on February 9, 2025, when the sexual act was observed.
Plan Of Correction
1. Accused perpetrator suspended. Employee who left resident to obtain assistance suspended. Investigation completed. Nursing agency was notified. Abuse policy reviewed and revised. The facility staff educated on the Abuse Policy protecting the resident's safety which includes remaining with the resident, guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The facility staff will be educated on the appropriate abuse procedure including remaining with the resident involved in a potential abuse investigation, secluding/observing the alleged perpetrator, if possible safely, until police arrive, and preserving an investigation scene including materials and victim for potential testing. Education will include that while alleged perpetrator is onsite, escort the alleged perpetrator to the nursing supervisor office or lobby area to wait and be available to be interviewed when the police arrive. Directed in-servicing will be completed for licensed nurses to include a review of the federal regulation citation F600 and the accompanying guidelines for these regulatory requirements. 4. A random sampling of residents (BIMS 12 and above) interviews to determine if any abuse occurred and if appropriate steps were followed. Audits will occur daily for 7 days, weekly x 12 weeks with results reported to QAPI for further review.
Removal Plan
- An internal investigation was immediately initiated.
- The employee who left the resident with the perpetrator was suspended.
- The accused perpetrator was removed from the facility.
- The nursing agency was notified of the alleged accusation towards their employee.
- The abuse policy will be reviewed and revised.
- The facility staff will be educated on the abuse policy and procedure, protecting resident safety which includes remaining with the resident, and guidelines on preserving an investigative scene. Further no staff will be permitted to work until this education has been completed.
- The facility immediately completed resident interviews with those residents with BIMS of 12 and above to determine if any other residents were affected.
- The facility assessed residents with BIMS under 12 for signs of abuse.
- The QAPI Committee will reconvene to review the root cause of the noncompliance.
- The NHA or designee will take a random sampling of residents and interview them to determine if any abuse has occurred and if appropriate steps were followed. Further, a random sampling of employee interviews will be completed to ensure they know how to identify and respond to abuse. These audits will occur daily until further direction.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility's administration failed to effectively utilize its resources to ensure the safety and well-being of its residents, resulting in the sexual abuse of one resident. The investigation revealed that the nursing home administrator (NHA) and the director of nursing (DON) did not fulfill their essential job duties, which include ensuring resident safety and adherence to regulatory guidelines. The job descriptions for both the NHA and DON emphasize the importance of managing safety, responding to resident concerns, and preventing abuse, neglect, and exploitation. However, these responsibilities were not adequately executed, leading to the cited deficiencies. The deficiencies were identified under the Code of Federal Regulatory Groups for Long Term Care, specifically related to the Freedom from Abuse, Neglect, and Exploitation. The facility failed to develop and implement effective policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents. Additionally, there was a lack of evidence that alleged violations were thoroughly investigated, and measures were not taken to prevent further potential abuse while investigations were in progress. The failure to report the results of investigations to the appropriate authorities within the required timeframe further highlights the administration's shortcomings in maintaining resident safety.
Plan Of Correction
1. Accused perpetrator suspended. Employee who left resident to obtain assistance suspended. Investigation completed. Nursing agency was notified. Abuse policy reviewed and revised. The facility staff educated on the Abuse Policy protecting the resident's safety which includes remaining with the resident, guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The NHA and DON will be educated by the Regional Director of Operations or designee on their job descriptions. The NHA and DON will participate in the directed education to include a review of the federal regulation citation F600 and the accompanying guidelines for these regulatory requirements. 4. The Regional Director of Operations or designee will review facility incidents weekly for 12 weeks to ensure compliance and report findings to the facility QAPI Committee.
Inadequate Abuse Policy and Investigation Procedures
Penalty
Summary
The facility failed to fully develop and implement an abuse prohibition policy that includes specific procedures for identifying and investigating abuse. The existing policy, titled "Abuse and Neglect Prevention," outlines the facility's commitment to providing care in an environment free from abuse, neglect, mistreatment, or exploitation. However, the policy lacks detailed guidance on recognizing different types of abuse, such as mental/verbal, sexual, physical abuse, and deprivation of goods and services. This omission leaves staff without clear procedures to identify abuse, neglect, and exploitation of residents, and misappropriation of resident property. Additionally, the facility's policy on investigating allegations of abuse is incomplete. While it requires immediate notification of the administrator and removal of implicated staff from resident care areas, it does not include procedures for handling evidence in cases of sexual abuse. The policy fails to instruct staff on preserving evidence, such as avoiding washing linens or clothing, destroying documentation, or bathing the resident before a forensic examination. This lack of guidance could interfere with thorough investigations by the facility and external authorities. An interview with the Nursing Home Administrator confirmed these deficiencies, highlighting the risk of incomplete investigations and failure to protect residents from further harm.
Plan Of Correction
1. The Abuse Policy was reviewed and updated, including guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The facility staff will be educated on the appropriate abuse procedure including remaining with the resident involved in a potential abuse investigation, secluding/observing the alleged perpetrator if possible safely until police arrive, and preserving an investigation scene including materials and victim for potential testing. Education includes that while the alleged perpetrator is onsite, escort the alleged perpetrator to the nursing supervisor office or lobby area to wait and be available to be interviewed when the police arrive. 4. A random sampling of staff will be interviewed to validate knowledge of Abuse Policy and preserving an investigation scene. Audits will occur daily for 7 days, weekly x 12 weeks with results reported to QAPI for further review.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough and complete investigation into an alleged incident of sexual abuse involving a resident and a nurse aide. The incident was reported by another nurse aide who witnessed inappropriate sexual conduct between the resident and the implicated staff member. The resident, who was cognitively intact, later confirmed the occurrence of the incident and previous similar interactions with the staff member. Despite these serious allegations, the facility's investigation was incomplete as it did not include interviews or statements from all staff members present during the incident. The resident involved in the incident was admitted to the facility with chronic obstructive pulmonary disease, type 2 diabetes, and muscle wasting. A recent assessment indicated that the resident was cognitively intact, with a BIMs score of 15. The incident was reported when a nurse aide observed the staff member engaging in inappropriate conduct with the resident. The resident later confirmed the incident and previous similar interactions with the staff member, indicating a pattern of inappropriate behavior. The facility's investigation was found lacking as it did not include interviews with all potential witnesses or involved staff members, such as the LPN and RN Supervisor who were present on the unit during the incident. This omission left gaps in the investigation, failing to provide a complete account of the events and staff awareness of the interactions between the resident and the implicated staff member. The facility's failure to conduct a thorough investigation was confirmed by the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Investigation completed. 2. The NHA or designee will review abuse investigations within the last 30 days to validate abuse investigations are completed timely. 3. The Regional Director of Operations will educate the NHA on timely completion of investigations, investigation process, preservation of evidence. The NHA will educate the IDT on the timely and accurate completion of abuse investigations. 4. The NHA or designee will audit abuse investigations weekly for 12 weeks to ensure investigations are completed timely and report findings to the QAPI committee.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to provide adequate and ongoing activities tailored to meet the needs, interests, preferences, and functional and cognitive abilities of its residents. During a group interview, several alert and oriented residents expressed dissatisfaction with the limited variety and availability of evening activities. Specific complaints included the lack of engaging options beyond Bible study, a desire for more frequent bingo sessions, and a broader variety of activities, including arts and crafts and outdoor options. A review of the activity calendar confirmed that evening activities were limited, with a reduction planned for the following month. Additionally, the facility did not adequately address the activity needs of two specific residents. Resident 31, who is cognitively intact and has a preference for independent activities, reported not having a current activity calendar and no recent visits from the activities department. His care plan indicated a preference for activities such as watching the news, being outdoors, and playing cards, but there was no documented evidence of his participation in activities or room visits. Similarly, Resident 95, who is severely cognitively impaired, had no documented activity assessment or care plan to meet her needs, nor evidence of participation in activities. The Nursing Home Administrator confirmed the lack of an ongoing program of activities for these residents.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for two residents, leading to deficiencies in their care. Resident 92, who has multiple sclerosis and is cognitively intact, had a dental consultation in June 2024 recommending full upper dentures. Despite this recommendation, the facility did not assist the resident in obtaining the dentures until inquiries were made during the survey. The resident expressed frustration over the lack of assistance, and the facility's Nursing Home Administrator confirmed the responsibility to ensure residents receive dental care but could not provide evidence of follow-up actions until the survey. Resident 31, who has paraplegia and is also cognitively intact, reported a missing lower denture, which staff were aware of. The resident had received a full lower denture in April 2024, but there was no documentation indicating the facility identified or investigated the missing denture. The resident's care plan noted non-compliance with proper denture care, but the facility did not follow its policy to determine responsibility for the replacement of the denture. The facility's failure to assist Resident 92 with obtaining dentures and to investigate the missing denture for Resident 31 resulted in deficiencies under federal guidelines for dental services. The facility did not provide necessary follow-up or documentation to support their actions, leading to a lack of appropriate dental care for these residents.
Failure to Provide Consistent Evening Snacks
Penalty
Summary
The facility failed to consistently provide snacks as desired by residents, as evidenced by a review of scheduled facility mealtimes, facility policy, and resident and staff interviews. The facility's policy, last reviewed on September 26, 2024, mandates that all residents, unless NPO, should be offered a bedtime snack if the time between the evening meal and breakfast exceeds 14 hours. This snack should include items from at least two food groups, one of which provides protein. However, the scheduled mealtimes revealed that the time between dinner and breakfast does exceed 14 hours, yet residents reported not consistently receiving the required snacks. During a group interview, eight cognitively intact residents expressed that they were not consistently offered a nourishing evening snack, citing that the facility often runs out of snacks and staff do not always distribute them. The Nursing Home Administrator was unable to explain why the facility was not offering the snacks as per policy, despite confirming that it is the facility's policy to do so. This deficiency was noted under 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain acceptable food storage and service practices, which increased the risk of food-borne illness in three of four resident pantries. During an initial tour of the kitchen, it was observed that 40 four-ounce thawed nutritional shakes were stored in the refrigerator without a thaw or discard date, contrary to manufacturer instructions that required consumption within 14 days of thawing. Additionally, five sheet trays containing servings of canned fruit cocktail were found uncovered and undated in the refrigerator. Furthermore, six cases of assorted food products were improperly stored directly on the floor in the dry storage room. These practices were confirmed as unsanitary by the facility's registered dietitian. Further observations in the resident pantries revealed additional deficiencies. In the Third-Floor resident pantry refrigerator, two four-ounce thawed nutritional shakes were found without a thaw or discard date. Similarly, the Second-Floor resident pantry refrigerator contained one four-ounce thawed nutritional shake without a thaw or discard date. On the First-Floor, the end of the condensation hose from the ice machine had a heavy buildup of pink-colored slime, indicating unsanitary conditions. The nursing home administrator confirmed that sanitary practices for food and ice storage should be maintained in the resident pantries.
Failure to Enforce Non-Smoking Policy
Penalty
Summary
The facility failed to implement its established Non-Smoking Facility Policy, which mandates a smoke-free environment for residents, staff, and visitors. Despite the policy, a resident, identified as Resident 100, was observed smoking on facility grounds. The resident's care plan acknowledged their smoking habit but lacked details on the location of smoking materials, specific times for smoking, or any necessary equipment for safe smoking. Additionally, the resident was noncompliant with the facility's smoking policy, and the last smoking assessment was outdated, having been completed in February 2024. During the survey, it was observed that Resident 100 signed out for a leave of absence without staff presence, retrieved a crossbody bag containing cigarettes and a lighter from the nurse's station, and proceeded to smoke across the street from the facility. The facility's management, including the Nursing Home Administrator and the Director of Nursing, were aware of the resident's actions but failed to provide documented evidence that the Non-Smoking Facility Policy was enforced. This oversight was confirmed during interviews with the facility's management.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with newly evident serious mental disorders for a Preadmission Screening and Resident Review (PASRR) Level II evaluation. Resident 114, who was initially screened negative for serious mental illness, was later diagnosed with schizophrenia and narcissistic personality disorder. Despite these diagnoses, there was no documented evidence of the facility reporting these conditions to the state's mental health authority for a PASRR Level II evaluation. The deficiency was identified through a review of clinical records and staff interviews. A psychiatric consultation note revealed that Resident 114's psychosis was not under control, requiring one-to-one supervision. The Director of Social Services admitted to not reporting the resident's mental health diagnoses, and the Nursing Home Administrator confirmed the facility's responsibility to ensure referrals for PASRR Level II evaluations for residents with newly evident serious mental disorders.
Failure to Implement Abdominal Binder Leads to PEG-Tube Dislodgement
Penalty
Summary
The facility failed to provide necessary care to prevent complications with a gastric feeding tube for a resident diagnosed with dysphagia and a gastrostomy tube. The resident had a physician's order for Jevity 1.5 Enteral Liquid to be administered via PEG-Tube at a rate of 68 ml/hr, with a water flush of 50 ml every hour during the pump infusion. The resident's care plan included the use of an abdominal binder to prevent the tube from being dislodged, along with frequent skin checks due to the resident's tactile response to the PEG placement. An investigation report revealed that nurse aides found the resident's g-tube dislodged, with the balloon intact, and the abdominal binder was found on the bedside table instead of being worn by the resident. The resident was sent to the hospital for reinsertion of the PEG tube. The director of nursing confirmed the incident but failed to provide documented evidence that the facility effectively implemented the use of the abdominal binder to prevent the dislodgement of the PEG-tube.
Unnecessary Antibiotic Administration Due to Lack of Confirmation
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic medication. Resident 88, who had a history of dysphagia, hypertension, and dementia, was admitted to the facility after a fall. During an emergency room visit, a slight urinary tract infection was suspected, and antibiotics were prescribed. However, the urine culture results, which were supposed to confirm the infection, were not available in the resident's clinical record. The facility's Infection Preventionist confirmed that the urine culture and sensitivity report was not completed as indicated in the emergency room record. Despite the lack of evidence confirming a urinary tract infection, Resident 88 received 14 doses of Bactrim DS, an antibiotic, over a period of seven days. The Director of Nursing later confirmed that the administration of the antibiotic was not clinically justified due to the absence of symptoms or laboratory confirmation of a urinary tract infection. This oversight led to the unnecessary administration of antibiotics, violating the regulations that require a resident's drug regimen to be free from unnecessary medications.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to comply with regulatory requirements regarding the notification of facility-initiated transfers. Specifically, the facility did not provide copies of written notices of transfers to a representative of the Office of the State Long-Term Care Ombudsman for five residents who were transferred to hospitals. These residents were transferred on various dates between March and September 2024, and although they received written notices, there was no documented evidence that the Ombudsman was notified as required. An interview with the Nursing Home Administrator confirmed that there was no evidence of such notifications being sent to the Ombudsman since October 1, 2020. This oversight was identified during a review of clinical records, facility-initiated transfer notices, and staff interviews, highlighting a systemic failure to adhere to the notification requirements set forth by the regulations.
Inaccessible Survey Results
Penalty
Summary
The facility failed to ensure that the Department of Health's most recent survey results were readily accessible to residents and visitors in two out of three nursing units. During a resident council interview, alert and oriented residents indicated they were unaware of where the survey results were posted. An observation in Unit 2 revealed that the survey results binder was blocked by a medication cart, and the binder did not contain the most recent survey from August 2024. In Unit 3, the survey results were not posted or accessible without staff assistance. The Nursing Home Administrator confirmed the facility's responsibility to make these results accessible.
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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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