Edenbrook South
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Pennsylvania.
- Location
- 101 Leader Drive, Williamsport, Pennsylvania 17701
- CMS Provider Number
- 395396
- Inspections on file
- 31
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Edenbrook South during CMS and state inspections, most recent first.
A nurse aide, without proper credentials, administered medications and performed medical treatments—including oral, PEG tube, and subcutaneous medication administration, as well as a dressing change—for three residents. These actions were facilitated by an LPN, in violation of professional standards and state regulations requiring specialized training for such tasks.
A resident with schizoaffective disorder did not receive prescribed Ingrezza on multiple occasions because the facility failed to obtain the medication from its pharmacy, instead relying on the resident's family to supply it. Nursing staff documented repeated missed doses and lack of medication availability, with no evidence that the pharmacy was contacted to resolve the issue.
A resident experienced a deficiency in bowel management care due to the facility's failure to adhere to the established protocol. The resident did not have a bowel movement for an extended period, and there was no evidence that prescribed PRN medications were offered. Documentation gaps and a lack of adherence to the protocol led to the resident seeking medical attention independently, resulting in hospital visits for fecal disimpaction and further evaluations.
A resident experienced significant weight loss, but the facility failed to implement necessary interventions or notify the physician. The registered dietitian was aware of the weight loss but did not assess or address the issue, violating the facility's policy on monitoring and intervening in cases of undesirable weight changes.
The facility's main kitchen failed to meet food safety standards, with undated bulk containers, soiled potholders, and dust and debris on equipment and floors. A cooler had rusted shelves, and ceiling vents and tiles were dusty. Food temperatures were not recorded for breakfast meals on two consecutive days. These issues were discussed with the Nursing Home Administrator and DON.
The facility failed to provide consistent ADL care for two residents, one with dementia and another dependent on staff for bathing. Documentation showed infrequent bathing, refusals without re-approach, and lack of hair cleansing. Observations revealed poor grooming, and care plans lacked interventions for refusals. These issues were discussed with the DON.
The facility failed to provide necessary services to maintain or improve ROM and mobility for three residents. A resident had a therapy referral for daily ROM exercises, but the program was delayed and inconsistently documented. Another resident with impairments had a ROM program established but not initiated until a month later, and a splint brace program was also delayed. A third resident's ROM program was never started, as confirmed by the DON. These issues were previously cited, indicating a recurring problem.
The facility failed to document the competencies of four nursing staff members, including RNs and LPNs, in essential care tasks such as enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. This deficiency was identified through a review of facility documentation and staff interviews, affecting the care of residents with specific medical needs.
The facility failed to maintain and address pharmacy recommendations for three residents. For one resident, a pharmacist's review note indicated a completed medication review, but there was no evidence of the pharmacist's report or physician's response. Similarly, for another resident, a medication review was completed, but no documentation of recommendations or responses was found. These deficiencies were previously cited earlier in the year.
The facility failed to manage psychotropic medications appropriately for two residents. One resident's Cymbalta dosage was not reduced as recommended by a consultant pharmacist, and another resident received multiple PRN orders for Ativan without proper evaluations or documentation. The facility did not ensure non-medicinal interventions were attempted before administering PRN Ativan, leading to deficiencies in medication management.
The facility failed to follow proper infection control practices during medication administration and a dressing change. An LPN handled medications with bare hands, and a nurse did not use enhanced barrier precautions or maintain a clean field during a dressing change for a resident with a pressure ulcer. These actions were confirmed by staff interviews, indicating a breach in infection prevention protocols.
A resident's dignity was compromised when their catheter bag was observed full, uncovered, and on the floor on two occasions while they were sleeping. This issue was previously cited, indicating a recurring problem with maintaining proper care standards.
The facility failed to maintain a clean and safe environment, with observations of unclean enteral feeding pumps for two residents and persistent strong urine odors in several rooms. Additionally, one resident's room had disorganized items and broken furniture, while another had a damaged wall. These issues were discussed with the Nursing Home Administrator and DON.
A facility failed to thoroughly investigate an injury of unknown origin for a resident with a bruise on the face. The resident was known to be combative during care, but the investigation lacked witness statements and evidence of staff education on managing such behavior. This deficiency was previously cited, indicating a repeated failure to comply with regulations.
A facility failed to ensure accurate assessments for a resident, as a quarterly MDS inaccurately indicated the resident received an anticoagulant medication. Clinical records showed no evidence of such medication being administered during the assessment period. The DON confirmed the MDS was coded in error.
A facility failed to provide the highest practical care for a resident by not implementing a physician's recommendations for hand therapy and warm soaks, despite the resident's complaints of a 'cold hand' and a specialist's advice. The resident had seen a plastic surgeon who noted improvement with exercise and recommended further treatment, which was not documented or implemented until questioned by a surveyor.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy and BiPAP for sleep apnea. The resident's oxygen concentrator was set at 9 LPM without humidification, contrary to the physician's order of 5 LPM. Additionally, the BiPAP mask was improperly stored, increasing infection risk. This deficiency was discussed with the DON.
A facility failed to secure treatments in a resident's room, where open bottles of Dakin's solution and Derma wound cleanser were found on the windowsill. These antiseptics, which should be kept out of reach of children, were improperly stored, as confirmed by the Nursing Home Administrator and DON. This was a repeat deficiency from a previous citation.
The facility failed to follow CDC guidelines for TB screening of newly hired health care personnel. Two newly hired nurse aides did not receive the required pre-employment TB screening, despite providing evidence of prior negative TB tests within 12 months. This deficiency highlights a lapse in the facility's adherence to recommended TB screening procedures.
The facility did not meet the required nurse aide-to-resident ratios during both day and night shifts on multiple occasions. During the day shift, the facility was understaffed on two days, with fewer nurse aides than required for the resident census. Similarly, during the night shift, the facility failed to provide the necessary number of nurse aides on three separate days, as confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day on three occasions. The nursing staff care hours were below the required threshold, with specific deficiencies noted on three days. The Nursing Home Administrator confirmed the shortfall in meeting the regulatory daily hours PPD.
The facility failed to provide adequate assistance with activities of daily living for three residents. A resident requiring supervision for personal hygiene did not receive shaving assistance as scheduled. Another resident with urinary incontinence had lapses in documented oral care and toileting assistance. A third resident, needing help with bathing and oral care, was observed with overgrown fingernails and missed scheduled care. These deficiencies were discussed with the DON and Nursing Home Administrator.
The facility failed to consistently implement restorative programs for two residents with mobility deficits. One resident expressed concerns about walking and was discharged from physical therapy without a restorative program, while another required assistance due to poor balance. Documentation revealed frequent failures to provide and document the required restorative ambulation programs, as confirmed by staff interviews.
A resident reported dissatisfaction with meals, receiving food she is allergic to and dislikes, despite communicating preferences. Staff failed to address meal discrepancies, and the food service director acknowledged mismatched menu tickets, indicating systemic issues in meal planning.
The facility was found to have multiple deficiencies in maintaining a clean and homelike environment across four nursing units. Observations included moisture-related spots on vents, dust accumulation, slimy substances on drip trays, and dead insects in various areas. These issues were noted in dining rooms, nurse stations, hallways, and resident areas, indicating a widespread problem with cleanliness and maintenance.
A resident was prescribed Temozolomide, a cancer medication, without a proper diagnosis or indication for its use. Despite not having a history of cancer or radiation treatments, the medication was ordered and administered for the duration of radiation therapy. The oversight was confirmed by interviews with the facility's administration and medical staff.
The facility failed to investigate and report an allegation of mental abuse involving a resident. Employee 1 was reported to have used her phone inappropriately, potentially taking and sharing photos or videos of residents. Despite a witness statement supporting this claim, the facility did not obtain further statements or notify relevant agencies, violating policy and regulatory requirements.
A facility failed to provide necessary bathing assistance to a dependent resident, as documented in the April 2024 report. The resident, assessed as dependent on staff for bathing, did not receive documented bed baths on three occasions. This deficiency was reviewed with the Nursing Home Administrator.
A resident was administered Temozolomide, a cancer medication, without an appropriate diagnosis. Despite multiple reviews by CRNPs, the medication was not flagged as inappropriate. The facility failed to provide evidence of a medical evaluation before ordering the medication.
A resident was prescribed Temozolomide without a cancer diagnosis or radiation therapy, and the consultant pharmacist failed to report this irregularity to the physician or DON. This oversight was confirmed by the facility's administration.
A resident experienced neglect resulting in harm due to a failure in communication and response by staff. The resident showed signs of a stroke, which were not reported by an LPN to the RN on duty. The resident's condition was only addressed after a shift change, leading to emergency medical intervention.
Unlicensed Staff Administered Medications and Treatments
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of quality for three residents. On a specific date, a nurse aide (NA) administered prescribed medications and performed medical treatments, including oral, PEG tube, and subcutaneous medication administration, as well as a dressing change, for three residents. These actions were performed on behalf of a licensed practical nurse (LPN), who was aware of and facilitated the NA's involvement in medication administration and treatment procedures. The NA's actions included administering oral medications and subcutaneous insulin to one resident, administering medications via PEG tube and subcutaneous insulin to another, and completing a dressing change on a surgical site for a third resident. Pennsylvania regulations require specialized training and credentialing for medication administration, which the NA did not possess. Resident interviews and facility documentation confirmed that the NA performed these tasks, and the LPN acknowledged facilitating the NA's actions. The incident was discovered and reported to the Director of Nursing (DON) several days later. The facility's failure to ensure that only appropriately licensed and credentialed staff administered medications and performed medical treatments resulted in a breach of professional standards of quality for the affected residents.
Failure to Provide Prescribed Medication Due to Pharmacy Service Lapse
Penalty
Summary
The facility failed to obtain and provide a prescribed medication, Ingrezza, for a resident with a history of schizoaffective disorder. Upon admission, the resident's hospital discharge records indicated the need to continue Ingrezza 40 mg nightly. However, nursing documentation showed that the pharmacy did not supply the medication, and instead, the resident's sister was expected to bring it in. There was no documentation explaining why the pharmacy was not contacted or able to provide the medication, and the Ingrezza was the only medication not obtained through the facility's pharmacy. Review of the Medication Administration Record (MAR) revealed that nursing staff did not administer the resident's nightly Ingrezza on multiple occasions, documenting that the medication was not available from the pharmacy or not found in the medication cart. Further nursing notes indicated ongoing communication with the resident's sister regarding the medication, but no evidence was found that the pharmacy was contacted to resolve the issue. These findings were confirmed by a registered nurse during an interview.
Failure in Bowel Management Protocol
Penalty
Summary
The facility failed to provide the highest practical care related to bowel management for a resident, as evidenced by the lack of adherence to the established bowel management protocol. The protocol required the administration of Milk of Magnesia, Dulcolax suppository, and Fleet's enema in a sequential manner if the resident did not have a bowel movement over several days. However, documentation revealed that the resident did not have a bowel movement for an extended period, and there was no evidence that the prescribed PRN medications were offered or refused by the resident. Additionally, there was a gap in documentation from February 1 to 5, 2025, due to a transition in facility ownership, which contributed to the oversight in the resident's care. The resident experienced significant discomfort and sought medical attention independently, resulting in a hospital visit where fecal disimpaction was performed. The resident's condition was further complicated by rectal bleeding and abdominal pain, leading to additional hospital evaluations. The facility's failure to follow the bowel management protocol and adequately document the resident's bowel movements resulted in a deficiency in providing the highest practical care, as confirmed by interviews with facility staff and a review of the resident's clinical records.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to implement necessary interventions to maintain acceptable nutritional parameters for a resident, identified as Resident 1, who experienced significant weight loss. According to the facility's policy, a significant weight change is defined as a 5 percent change over 30 days, 7.5 percent over 90 days, or 10 percent over 180 days. Resident 1 was admitted on June 21, 2024, and experienced a severe weight loss of 8.04 percent in 30 days and 12.71 percent in less than 90 days. Despite these significant changes, there was no evidence that the staff obtained a re-weight or notified the resident's physician, nor were there any assessments or interventions documented to address the severe weight loss. The registered dietitian, identified as Employee 1, confirmed awareness of the resident's weight loss but admitted to waiting for weight verifications and did not assess or implement interventions to address the issue. The facility's policy requires cooperation between nursing staff and the dietitian to monitor and intervene in cases of undesirable weight variances, but this protocol was not followed. The lack of action and communication regarding the resident's significant weight loss constitutes a deficiency in the facility's care practices.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its main kitchen, as observed during a survey. Two large bulk containers labeled as 'flour' and 'sugar' lacked dates indicating when the products were placed or needed to be used by. Additionally, several white potholders were found on top of the convection oven, soiled with dried foods and significantly stained. The bottom shelf of the steamer and prep table, as well as the lower shelf of the production table, contained dust and dried food debris. The flooring under and behind the steamer and the table beside it had dried food and debris buildup, with a pipe area caked with dried food and debris. Further observations revealed that a two-door cooler had multiple shelves with exposed rust-colored metal due to worn-off protective coating. Ceiling vents and tiles over the coolers and serving line were covered in dust, with one tile significantly stained and drooping. The plate warming unit had dried food splatter and debris. The food serving temperature log for January 21 and 20, 2025, showed no recorded temperatures for breakfast meals, indicating a failure to check food temperatures. A follow-up observation on January 23, 2025, found potholders on the convection oven blackened and covered in dried food. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
Cited: Bulk containers and soiled potholders were removed from service, with the contents of the containers discarded. Shelves in the steamer and prep areas were immediately cleaned, along with the floor and pipes in the steamer area. Cooler shelves were replaced, ceiling tiles were changed, and vents were thoroughly cleaned. Additionally, the plate warmer underwent a deep cleaning. Although the temperature logs for the food on the trayline for the cited dates could not be completed, the cook received proper education, and logs for future meals were successfully recorded. Like: Potholders and cooler shelves will be inspected to ensure they remain in good condition. Items that are worn or soiled will be replaced proactively. The structured cleaning schedule was revised for the steamer area, prep areas, floors (including pipe), vents, and plate warmer. Staff will be assigned specific cleaning tasks with checklists. The food service director/designee will review the checklists to verify compliance. Cooks and staff will receive ongoing training on the importance of maintaining accurate temperature logs. The food service director/designee will review logs daily to ensure they are completed correctly. Educations: Food Safety and Sanitation training will be completed with all kitchen staff including the importance of maintaining cleanliness in food preparation areas with focus on proper cleaning and sanitizing procedures for kitchen equipment, shelves, and floors. Additionally, staff will be educated on the importance of maintaining accurate temperature logs for food safety compliance, proper techniques for measuring and recording food temperatures, and how to troubleshoot and respond to temperature irregularities. Audits: Food Service Director/designee will complete a daily audit to ensure temperatures, bulk container labeling and dating, and cleaning tasks for floors (including pipe area) and shelves are completed. The daily audit will also include visual inspection for the cleanliness of potholders, ceiling tiles, and vents. Daily audits will be completed x 21 days, and will then be completed weekly.
Failure to Provide Consistent ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for two residents, as evidenced by clinical record reviews and staff interviews. Resident 65, who was dependent on staff for bathing, had a significant change MDS assessment indicating the importance of choosing between different types of baths. However, task documentation showed inconsistent bathing schedules and instances where the resident refused or was not documented as having received a bath. There was no evidence that staff re-approached or offered bathing opportunities on subsequent shifts or days. Additionally, there were multiple instances where hair cleansing was either not documented or refused, with no follow-up actions taken by the staff. Observations of Resident 65 revealed disheveled hair, indicating a lack of proper grooming. Resident 89, admitted with dementia and adult failure to thrive, required assistance with bathing and personal hygiene. Task documentation indicated that showers were scheduled twice a week, but records showed infrequent bathing and numerous refusals without documentation of re-approach or alternative bathing opportunities. The care plan for Resident 89 lacked interventions for addressing bathing refusals. These deficiencies were discussed with the Director of Nursing during the survey, highlighting the facility's failure to ensure consistent and adequate ADL care for dependent residents.
Plan Of Correction
Cited: Resident 65 and resident 89 bathing preferences were collected and honored. • Like: Facility wide sweep will be completed to ensure residents bathing preferences are honored. • Education: NHA/designee will educate staff on resident bathing preferences. • Audits: NHA/designee will audit 5 residents weekly x 4 weeks and monthly x2 months to ensure resident bathing preferences are being honored. Results will be taken through QAPI.
Failure to Implement ROM Programs for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) and mobility for three residents. Resident 65 had a therapy restorative referral indicating the need for active and active assisted range of motion exercises to be performed one to two times daily. However, the nursing staff did not implement the restorative nursing program until several days after the referral, and there were multiple dates where the program was not documented as completed. Resident 42 had impairments in her upper and lower extremities, and although a restorative ROM program was established, it was not initiated until nearly a month later, after the surveyor's intervention. Additionally, Resident 42 was supposed to have a splint brace program, which was also not implemented in a timely manner. Resident 70 had a limited ROM on one side of his body, and a ROM program was established for him as well. However, there was no evidence that the program was ever initiated. The Director of Nursing confirmed that the ROM program for Resident 70 was never started. These deficiencies were previously cited in earlier surveys, indicating a recurring issue with the facility's ability to provide adequate nursing services to maintain or improve residents' ROM and mobility.
Plan Of Correction
Cited: Residents 42, 65, and 70 range of motion programs were reviewed with IDT team and were reevaluated by therapy. - Like: The facility will complete a two-week look back on residents who were discharged from therapy to review if resident is appropriate for ROM program and ensure it is initiated. - Educations: DON/designee will educate nursing staff and ensuring ROM program recommendations from therapy are followed appropriately. - Audits: DON/designee will audit 5 residents weekly x 4 weeks then monthly x 2 months to ensure residents who are discharged from therapy have appropriate ROM programs initiated if appropriate. Results will be taken through QAPI.
Deficiency in Nursing Staff Competency Documentation
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets for specific care tasks, including enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. This deficiency was identified during a review of facility documentation and staff interviews, which revealed that the facility could not provide evidence of competencies for four employees, including two registered nurses (RNs) and two licensed practical nurses (LPNs). These employees were responsible for the care of residents with various medical needs, such as enteral tube feedings, tracheostomies, indwelling catheters, and pressure ulcers. The facility had a total of 121 residents receiving medications, 10 residents with indwelling catheters, five residents with pressure ulcers, five residents with enteral tube feedings, and one resident with a tracheostomy. Despite these care requirements, the facility was unable to provide documentation confirming that Employees 4, 5, 6, and 7 had the specific competencies and skill sets necessary to meet these residents' needs. This lack of documentation was confirmed during an interview with the Director of Nursing, indicating a failure to ensure that nursing staff were adequately prepared to provide the required care.
Plan Of Correction
Cited: Employees 4, 5, 6, and 7 completed the following competencies: enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. • Like: HR/designee will complete audit of current employees to ensure appropriate competencies are completed. • Education: NHA/designee will educate the staff educator to ensure plan of current staff to obtain appropriate competencies. • Audits: Staff educator/designee will audit 5 employees including new hires weekly x 4 weeks then monthly x 2 months to ensure staff have appropriate competencies completed. Results will be taken through QAPI.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to maintain and address pharmacy recommendations for three residents, as required by §483.45(c) Drug Regimen Review. For Resident 23, a pharmacist's monthly medication review note dated June 10, 2024, indicated that a medication review was completed, but there was no evidence of the pharmacist's report of recommendations or a physician's response to these recommendations. The Nursing Home Administrator and Director of Nursing confirmed that the pharmacy recommendation for this date could not be located. Similarly, for Resident 49, a medication review was completed by the consultant pharmacist on November 10, 2024, but there was no documentation of the pharmacist's recommendations or any response from the physician or facility. For Resident 42, a pharmacist's review note also dated June 10, 2024, indicated a completed medication review with a directive to "see report for recommendation," yet no evidence of the pharmacist's report or physician's response was found. The Nursing Home Administrator and Director of Nursing confirmed the absence of the pharmacy recommendation for this date. These deficiencies were previously cited on February 16, 2024, and May 22, 2024.
Plan Of Correction
Cited: Residents 23, 42, and 49 pharmacy recommendations were reviewed by the physician with a response. • Like: The facility will complete a two-week look back to review pharmacy recommendations to ensure there is a physician response. • Education: DON/designee will educate the licensed staff to ensure responses are provided to pharmacy recommendations. • Audits: DON/designee will audit 5 resident pharmacy recommendations weekly x 4 weeks then monthly x 2 months to ensure physician response is provided. Results will be taken through QAPI.
Failure to Manage Psychotropic Medications Appropriately
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications for two residents. Resident 9 was admitted on January 16, 2023, and was receiving Buspar and Cymbalta. A consultant pharmacist recommended a dose reduction of Cymbalta from 90 mg to 60 mg on July 13, 2024, which the physician agreed to on July 24, 2024. However, the facility did not implement this change until January 17, 2025, as confirmed by the Nursing Home Administrator and Director of Nursing. Resident 65 had multiple PRN orders for Ativan, a psychotropic medication, without appropriate stop dates or evaluations by a physician to justify the extensions beyond 14 days. The facility's documentation lacked evidence of non-medicinal interventions before administering the PRN Ativan. The consultant pharmacist recommended evaluating the necessity of the PRN Ativan, but the facility's physician and contracted physician's assistant opted to continue the medication with a 90-day stop date due to ongoing anxiety, without proper documentation of behaviors or provider evaluations to justify this decision. The facility's failure to adhere to regulatory requirements for psychotropic medications resulted in deficiencies related to unnecessary drug use. The surveyor confirmed these findings with the Nursing Home Administrator and Director of Nursing, highlighting the lack of compliance with medication management protocols and the absence of necessary documentation to support the continued use of psychotropic medications for Resident 65.
Plan Of Correction
• Cited: Resident 9 and resident 65 medication regime was reviewed and properly addressed by the physician. • Like: The facility will complete a medication regime review for current residents to ensure they are free for unnecessary medications directly related to physician recommendation to decrease Cymbalta and review of PRN antianxiety medication without supporting documentation. • Education: DON/designee will educate nursing staff to ensure the pharmacist and resident 39's recommendations are followed to avoid unnecessary medications as well as recommendation to decrease Cymbalta and review of PRN anti-anxiety medications without supporting documentation. • Audits: DON/designee will audit 5 random residents weekly x 4 weeks then monthly x 2 months to ensure the pharmacist resident 39's recommendations are followed to avoid unnecessary medications. Audit will also include recommendation to decrease Cymbalta and review of PRN anti-anxiety medications without supporting documentation. Results will be taken through QAPI.
Infection Control Deficiencies During Medication Administration and Dressing Change
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for two residents. An LPN was observed preparing medications for two residents using her bare hands, which is against standard infection control procedures. She handled various medications, including Famotidine, Mucinex, and Clopidogrel, without wearing gloves, and placed them into medication cups. This practice was confirmed during an interview with the LPN, indicating a breach in infection prevention protocols. Additionally, during a dressing change for a resident with a left lateral heel pressure ulcer, the facility's infection preventionist and wound nurse did not follow proper infection control measures. The nurse failed to clean the overbed table before placing supplies on it, did not change gloves after removing the old dressing, and did not use enhanced barrier precautions, such as wearing a gown. The absence of a sign indicating the need for enhanced barrier precautions on the resident's door further highlighted the lapse in infection control practices. The Nursing Home Administrator and Director of Nursing were informed of these deficiencies, which included improper medication handling and inadequate infection control during a dressing change. These observations demonstrate a failure to maintain a safe and sanitary environment, as required by the facility's infection prevention and control program.
Plan Of Correction
Cited: Employee's #8 was required to complete a medication administration pass competency with the DON. Employee #9 was required to complete a treatment completion competency and was provided education relating to adherence to Enhanced Barrier Precautions. Like: Licensed staff will complete a medication administrator competency directly related to infection prevention with medication preparation as well as following enhanced barrier precautions, and general infection control practices with dressing changes. Education: DON/designee will educate nursing staff to ensure medication administration follows infection control procedures as well as following enhanced barrier precautions, and general infection prevention practices with dressing changes. Audits: Infection Preventionist/designee will audit 4 residents weekly then monthly x2 months to ensure medication administration follows infection control guidelines. Results will be taken through QAPI.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of the residents sampled. Specifically, Resident 61 was observed on two separate occasions with their catheter bag full of urine, uncovered, and laying on the floor. These observations were made from the hallway while the resident was sleeping in bed, indicating a lack of privacy and dignity in the care provided. The observations were made on January 21 and January 22, 2025, and were discussed with the Director of Nursing on January 24, 2025. This deficiency was previously cited on February 16, 2024, indicating a recurring issue with maintaining resident dignity and proper care standards. The facility's failure to address this issue demonstrates a lack of adherence to the resident's rights to a dignified existence and quality care.
Plan Of Correction
Cited: Resident 61's Catheter bag was placed in a cover and moved to the non-hallway side of the bed. • Like: Residents requiring the use of a urinary catheter were audited to ensure the catheter bags were covered and placed on the non-hallway side of the bed. • Education: DON/designee will educate nursing staff catheter bags being in covers and on non-hallway side of the beds. • Audits: DON/designee will audit residents with catheter bags to ensure they are in covers and placed on non-hallway sides of the bed. Audits will be completed weekly x4 weeks then monthly x 2 months. Results will be taken through QAPI.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment across all four nursing units, as evidenced by multiple observations of unclean conditions and strong odors. Resident 85 was observed with an enteral feeding pump that had dried brown liquid splatters on its exterior, indicating a lack of proper cleaning. Similarly, Resident 56's feeding pump, pole, and bagged supplies were also found with dried brown liquid splatters. These observations were reviewed with the Director of Nursing and the Nursing Home Administrator. Additionally, the West Nursing Unit was noted to have a persistent strong odor of urine in the rooms and bathrooms of Residents 68 and 14 over several days. Resident 39's room was found to have a strong urine smell, a dirty floor, and disorganized items on nightstands with broken handles. The walls were marred and peeling. Resident 50's room had a cove base coming off the wall with crumbled pieces on the floor. These issues were brought to the attention of the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
Cited: Resident 85 and resident 56 feeding pump pole was cleaned. Resident 68 and resident 14's rooms and bathroom were cleaned to ensure free of urine odor. Resident 39's night stand handles were repaired by maintenance director. Items in resident 39's room were organized. Resident 50's cove base was repaired in his room behind the head of the bed. • Like: Feeding pumps and poles facility wide were cleaned. Resident rooms and bathrooms facility wide were cleaned to ensure free of urine odor. Resident room floors were cleaned and resident room cove basing and walls were cleaned and repaired as needed. • Education: NHA/designee will educate the environmental staff on ensuring feeding poles and pumps and resident rooms and bathrooms are properly cleaned. NHA/designee will educate maintenance department on ensuring handles of night stands and wall and cove basing are repaired appropriately. • Audits: Environmental Director/designee will audit 5 random resident rooms and bathrooms to ensure cleanliness as well as odor weekly x 4 weeks and monthly x 2 months. Maintenance director/designee will audit 5 night stands and 5 resident rooms weekly x 4 weeks then monthly x 2 months to ensure night stands are appropriate as well as cove basing and walls. Results will be taken through QAPI.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as Resident 42, who was reviewed for abuse. A clinical record review revealed that on December 30, 2024, a nurse noted a bruise on the right side of Resident 42's face, measuring 3 cm x 2 cm, with a dark bluish and purplish color. The bruise was located outside the right eye. The resident was known to be combative during care, and staff were instructed to walk away if the resident became combative to prevent self-inflicted injuries. However, there were no follow-up progress notes related to the event until January 22, 2025, after a surveyor inquired about the incident. The facility's investigation into the event was inadequate, as it did not include witness statements from staff regarding how the injury may have occurred, nor was there evidence of staff education on interventions for managing the resident's combative behavior. An interview with the Director of Nursing confirmed the lack of witness statements and staff education documentation. This deficiency was previously cited on May 22, 2024, indicating a repeated failure to comply with regulations prohibiting and preventing abuse, neglect, and exploitation of residents.
Plan Of Correction
Cited: Per follow up investigation, abuse and neglect was ruled out for resident 42. Like: Facility will do a two week look back of injuries of unknown origin to ensure a full investigation was completed. Education: DON/designee will educate nursing staff on the facility Abuse Policy and Procedure, Incident and Accident Investigations to ensure residents with injuries of unknown origins are fully investigated to rule out potential abuse/neglect. Audits: Residents with injuries of unknown origins will be audited weekly x4 then monthly x2 to ensure injuries are fully investigated. Results will be taken through QAPI.
Inaccurate MDS Assessment for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for one resident. A clinical record review for this resident revealed a discrepancy in the quarterly Minimum Data Set (MDS) dated November 6, 2024. The facility staff had assessed the resident as receiving an anticoagulant medication during the last seven days of the assessment period. However, further review of the clinical records showed no evidence that the resident had received such medication during that time. An interview with the Director of Nursing confirmed that the MDS was coded in error regarding the administration of the anticoagulant medication.
Plan Of Correction
Step 1: Re-education on coding accuracy. Please obtain signatures of all applicable MDS coordinators from the facility (See attached Section N of the RAI Manual): Immediate Remedy and Re-education/MDS modification submitted by Regional. Step 2: Audit most recently completed OBRA MDS Assessment 100% of current residents, any coding errors identified to be fixed. **See Audit tool. **Tip** You can pull an MDS item response specific for MDSs and how this question N0415E was coded- then review the MAR for that time frame. To be completed by Facility MDS. Completed Audit to be reviewed by Regional MDS. Step 3: Continued Audit needs: 10 completed MDSs to be reviewed by 2nd MDS coordinator and/or regional. To be completed weekly x 4 weeks:
Failure to Implement Consultant Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure the highest practical care for a resident, identified as Resident 93, by not implementing consultant recommendations. Resident 93, who had a history of pain and stiffness in his right hand, was observed on January 21, 2025, complaining of a 'cold hand' with no grasp and partially contracted fingers. He mentioned that he sits on his hand to warm it and straighten his fingers. A review of his clinical record showed that he had seen a plastic surgeon on January 13, 2025, who noted improvement in his range of motion with some exercise. The physician recommended warm soaks twice a day and resuming hand therapy. However, there was no documentation that the facility implemented these recommendations. The Director of Nursing confirmed these findings during an interview on January 24, 2025, acknowledging that the recommendations were only implemented after the surveyor's inquiry.
Plan Of Correction
Cited: Resident 93 has orders regarding soaking hands and orders reflecting therapy to assist with hand therapy. • Like: The facility will do a two-week look back to ensure residents who attend appointments and return with follow up recommendations, that recommendations are timely addressed. • Education: DON/designee will educate nursing staff on ensuring appointment follow up recommendations are addressed timely. • Audits: DON/designee will audit 5 residents weekly x 4 weeks and monthly x2 months to ensure recommendations from resident appointments are followed up timely. Results will be taken through QAPI.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident who required oxygen therapy and BiPAP for sleep apnea. The clinical record for the resident indicated a physician's order for oxygen to be administered at 5 liters per minute (LPM) via nasal cannula continuously during the day and evening, and 6 to 7 LPM at bedtime with BiPAP. However, observations revealed that the resident's oxygen concentrator was set at 9 LPM without humidification, which deviated from the prescribed order. Additionally, the resident's BiPAP mask was found unbagged and improperly stored, lying on the floor behind the oxygen concentrator and on the bedside stand during different observations. This improper handling and storage of respiratory equipment could increase the risk of infection, as noted by the American Association for Respiratory Care, which emphasizes the importance of proper cleaning and storage of nebulizer equipment to reduce infection risk. The deficiency was discussed with the Director of Nursing during the survey.
Plan Of Correction
Cited: Resident 43's oxygen order was clarified. Resident 43's Bipap mask was placed in an appropriate bag. • Like: Facility-wide sweep was completed to ensure residents who have active oxygen orders are correctly being followed. Facility-wide sweep also completed to ensure appropriate respiratory supplies are stored in bags appropriately. • Education: DON/designee will educate nursing staff on ensuring oxygen orders are followed and respiratory equipment is stored appropriately. • Audits: DON/designee will audit 5 residents per week x 4 weeks then monthly x 2 months to ensure oxygen orders are appropriately followed and that respiratory equipment is stored appropriately. Results will be taken through QAPI.
Failure to Secure Treatments in Resident's Room
Penalty
Summary
The facility failed to secure treatments on one of its nursing hallways, specifically the North Hall, involving a resident identified as Resident 56. During observations conducted on three separate occasions, open bottles of Dakin's solution and a bottle of Derma wound cleanser were found on the windowsill in Resident 56's room. These items are antiseptics used for treating and preventing infections in wounds, and their labels indicated that they should be kept out of reach of children and that medical help should be sought if swallowed. The deficiency was confirmed during a meeting with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the items should not have been stored on the windowsill. This incident was a repeat deficiency, as a similar issue had been cited previously on February 16, 2024. The facility's failure to properly store these drugs and biologicals violated both federal regulations and state codes related to pharmacy and nursing services.
Plan Of Correction
Cited: All solutions and cleansers were removed from the window sill of resident 56. • Like: Facility-wide sweep will be completed to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. • Educations: DON/designee will educate staff to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. • Audits: DON/designee will audit 5 resident rooms weekly x 4 weeks then monthly x 2 months to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. Results will be taken through QAPI.
Failure to Implement TB Screening for New Hires
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) recommendations for tuberculosis (TB) screening and testing for newly hired health care personnel. Specifically, the facility did not implement the required pre-employment TB screening procedures for two of the five newly hired employees reviewed. According to the CDC guidelines, all U.S. health care personnel should be screened for TB upon hire using either a TB blood test or a two-step TB skin test. Additionally, if a previous documented negative TB result is provided within 12 months before new employment, only a single test is required. However, the facility did not follow these guidelines for Employees 2 and 3. Employee 2, a nurse aide, was hired on November 14, 2024, and provided evidence of a negative TB skin test dated March 4, 2024, which was within 12 months of being hired. Despite this, there was no evidence of any further testing, such as a one-step, blood test, or chest x-ray, upon their employment at the facility. Similarly, Employee 3, also a nurse aide, was hired on December 10, 2024, and provided evidence of a prior negative TB blood test dated August 5, 2024, within 12 months of hire. Again, there was no evidence that Employee 3 received any further testing prior to employment with the facility. This lack of adherence to the CDC's TB screening guidelines constitutes a deficiency in the facility's pre-employment screening procedures.
Plan Of Correction
Cited: Employees 2 and 3 will have a full TB screen completed. • Like: HRD/designee will complete a sweep of current staff members to ensure all staff have completed a TB screen. • Educations: NHA/designee will educate the HRD to ensure all staff have completed a TB screen upon hire. • Audits: HRD/designee will audit 5 staff members' files weekly x4 weeks and monthly x 2 months to ensure all staff have completed a TB screen upon hire. Results will be taken through QAPI.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. Specifically, during the day shift, the facility did not provide the minimum of one nurse aide per 10 residents on two occasions. On December 29, 2024, with a census of 97 residents, only 9.55 nurse aides were available, falling short of the required 9.70. Similarly, on January 18, 2025, with a census of 101 residents, only 8.50 nurse aides were present, whereas 10.10 were needed. Additionally, during the night shift, the facility failed to maintain the required one nurse aide per 15 residents on three occasions. On January 1, 2025, with a census of 96 residents, only 4.85 nurse aides were available, while 6.10 were required. On January 19, 2025, with a census of 103 residents, 6.10 nurse aides were present, but 6.87 were needed. Lastly, on January 21, 2025, with a census of 102 residents, only 4.47 nurse aides were available, whereas 6.80 were required. These deficiencies were confirmed through an interview with the Nursing Home Administrator on January 23, 2025.
Plan Of Correction
Cited: Unable to correct staffing ratios for CNA's on the five days selected during the review. • Like: Staffing coordinator/designee will review the last two weeks to ensure staffing ratios are met. The facility is rolling out a new recruitment and retention plan under new ownership. This includes recruiting for regional recruiter, facility wage analysis, mentor program and employee retention initiatives. • Educations: NHA/designee will educate the staffing coordinator to ensure staffing ratios are met. • Audits: Staffing coordinator/designee will audit five random days weekly x 4 weeks then monthly x 2 months to ensure staffing ratios are met.
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 three specific days. This deficiency was identified during a review of nursing staff care hours for the periods of November 23, 2024, through November 29, 2024, December 26, 2024, through January 1, 2025, and January 17, 2025, through January 23, 2025. On January 1, 2025, the facility provided 3.05 hours PPD, on January 18, 2025, 3.07 hours PPD, and on January 19, 2025, 3.14 hours PPD. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required daily hours PPD on these dates.
Plan Of Correction
Cited: Unable to correct the staffing PPD for the three days reviewed. Like: Staffing coordinator/designee will review the last two weeks to ensure staffing PPD are met. The facility is rolling out a new recruitment and retention plan under new ownership. This includes recruiting for regional recruiter, facility wage analysis, mentor program and employee retention initiatives. Educations: NHA/designee will educate the staffing coordinator to ensure staffing PPD are met. Audits: Staffing coordinator/designee will audit five random days weekly x 4 weeks then monthly x 2 months to ensure staffing PPD is met.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for three residents, as observed and documented by surveyors. Resident 2, who requires supervision and cueing for personal hygiene, was observed with several days of beard growth and reported not receiving shaving assistance during his shower, which was provided on an unscheduled day. Resident 3, with a history of urinary incontinence and recurrent urinary tract infections, did not receive documented oral care on multiple occasions across three months, and there were significant lapses in documented toileting assistance, particularly during the night shift. Resident 4, who requires assistance with bathing and oral care, was observed with overgrown fingernails and reported that staff should trim them. Documentation revealed missed shower and oral care assistance on several occasions over three months. The surveyor discussed these deficiencies with the Director of Nursing and the Nursing Home Administrator, highlighting the facility's failure to adhere to the care plans developed for these residents. The facility had previously been cited for similar deficiencies, indicating ongoing issues with providing necessary nursing services as required by regulations. The lack of documentation and observed lapses in care suggest a systemic issue in ensuring that residents receive the assistance they need for daily living activities.
Inconsistent Implementation of Restorative Programs for Mobility Deficits
Penalty
Summary
The facility failed to provide adequate services for mobility deficits for two residents. Resident 2 expressed concerns about walking and requested an evaluation, which led to physical therapy services being initiated. However, after being discharged from skilled physical therapy, there was no restorative program implemented. The plan of care for Resident 2 included encouraging participation in restorative programs, but documentation revealed inconsistent assistance with the restorative ambulation program. Interviews confirmed that the program was not consistently completed as required. Similarly, Resident 4 required restorative programs due to poor balance and an unsteady gait. The plan of care included instructions for staff to encourage participation in restorative programs. However, task list documentation showed that staff frequently failed to document assistance with the restorative ambulation program. The surveyor's review highlighted these deficiencies in the care provided to both residents, indicating a lack of consistent implementation of restorative programs as outlined in their care plans.
Failure to Accommodate Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to provide food that accommodated the preferences and allergies of a resident, identified as Resident 5. During an interview, Resident 5 expressed dissatisfaction with the meals, rating them a seven out of ten, and reported receiving food she is allergic to, such as strawberries, and food she dislikes, such as rice. Despite having communicated her preferences during care conferences, these were not reflected in her meal tray tickets. On one occasion, her meal included peaches, which were listed as a disliked food, and rice, which was not listed as disliked, while the tray ticket indicated she should receive noodles and green beans, which were not provided. The issue was further compounded by the inaction of staff members. Employee 2, an activities staff member, confirmed the meal provided did not match the tray ticket but did not know how to address the concern and failed to report it. Employee 1, the food service director, acknowledged that the menu tickets did not match the planned meal items, indicating a systemic issue in meal planning and delivery. The concerns were reviewed with the Nursing Home Administrator and the Director of Nursing, highlighting a failure in dietary services as per 28 Pa. Code 211.6 (a).
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across four nursing units, as observed on August 6, 2024. In the main dining room of the [NAME] Nursing Unit, there were three ceiling vents with dark moisture-related spots and a smaller vent with a significant dust-like substance. A nourishment ice cart at the South/West nurse station had a drip tray with a slimy, black substance. Additionally, a brown moisture stain was noted on a ceiling tile near an exit sign, and a vent in the hallway had significant moisture accumulation. The nourishment room behind the South/West nurse's station also had a vent with a dust-like substance. Further observations on the South Nursing Unit revealed wall heating/air conditioning units with black substance accumulation and dead insects. Ceiling lights in the lounge and resident hallway contained debris and dead insects. The North Nursing Unit had a large water-stained ceiling tile and a refrigerator with dust, debris, and an unsmoked cigarette on top. Resident 1's bathroom vent had a significant dust accumulation, and the physical therapy area had dusty vents and ceiling tiles. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Unnecessary Medication Prescribed Without Proper Indication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications. A closed clinical record review and staff interviews revealed that a resident, who did not have a history of cancer or radiation treatments, was prescribed Temozolomide, a medication used to treat certain types of brain cancer. The initial verbal physician order for Temozolomide was dated April 10, 2024, and was signed electronically by a certified registered nurse practitioner on April 15, 2024. The order instructed staff to administer the medication daily for the duration of radiation therapy, despite the resident not being prescribed radiation therapy. The nursing staff discontinued the initial order on April 22, 2024, but a new verbal order with the same administration parameters was entered on the same day and electronically signed by a doctor on April 24, 2024. The practitioner did not identify that Temozolomide was included in the resident's medication profile without an appropriate diagnosis or indication for its use. Interviews with the Nursing Home Administrator, the Director of Nursing, and a medical records employee confirmed these findings. The facility implemented Temozolomide in the resident's medication regimen without adequate indications for its use, violating several Pennsylvania Code regulations related to pharmacy, medical director, and nursing services.
Failure to Investigate and Report Alleged Mental Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of mental abuse involving a resident. The CMS State Operations Manual defines mental abuse as conduct causing humiliation, intimidation, fear, shame, agitation, or degradation, including abuse facilitated by technology. The facility's policy, however, did not include the inappropriate use of technology, such as taking resident pictures or videos, as examples of mental abuse. This oversight contributed to the facility's failure to address the situation appropriately. The incident involved Employee 1, a nurse aide, who was reported to have used her electronic device inappropriately. An Employee Education/Counseling Form noted that Employee 1 was educated on the facility's policy prohibiting the use of recording devices. However, there was no detailed information on how Employee 1 used her phone, and her statement denied taking any photos or videos of residents. Despite this, a witness statement from another employee indicated that Employee 1 was allegedly taking pictures and videos of residents and sending them to others, including her boyfriend. The Nursing Home Administrator confirmed that the facility did not attempt to obtain statements from Employee 1's boyfriend or other involved staff members. Additionally, the facility failed to notify the Department or other agencies about the allegation of inappropriate photo or video taking. This lack of thorough investigation and reporting violated the facility's policy and regulatory requirements, leading to the deficiency.
Failure to Provide Bathing Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide necessary bathing assistance to a dependent resident, identified as Resident CR1, during her stay from an unspecified date to May 10, 2024. According to the admission MDS dated April 3, 2024, Resident CR1 was assessed as being dependent on staff for bathing. The Documentation Survey Report for April 2024 indicated that nurse aides were responsible for providing a bed bath to Resident CR1 on Tuesdays and Saturdays. However, the report showed that staff did not document the completion of a bed bath on three specific dates: April 13, April 16, and April 27, 2024. This deficiency was discussed with the Nursing Home Administrator on May 23, 2024.
Medication Administered Without Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure that a physician supervised the care of a resident, identified as Resident CR1, who was administered a medication without an appropriate diagnosis. Resident CR1 was given Temozolomide, a medication used to treat certain types of brain cancer, despite not having a history of cancer or undergoing radiation treatments. A verbal physician order for Temozolomide was issued on April 10, 2024, and signed by a certified registered nurse practitioner (CRNP) on April 15, 2024, without identifying the lack of an appropriate diagnosis. Throughout multiple visits, another CRNP reviewed Resident CR1's medication list but failed to identify the inappropriate inclusion of Temozolomide. Although the initial order was discontinued on April 22, 2024, a new verbal order with the same parameters was entered and signed by a doctor on April 24, 2024, again without recognizing the absence of a valid diagnosis. Interviews with the Nursing Home Administrator, Director of Nursing, and medical records staff confirmed these findings, and the facility could not provide evidence of a medical evaluation conducted before ordering the medication.
Failure in Drug Regimen Review for Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a thorough monthly drug regimen review for a resident, identified as Resident CR1, who was prescribed Temozolomide, a medication typically used for treating certain types of brain cancer. Resident CR1 did not have a cancer diagnosis nor was she undergoing radiation therapy, which was a parameter for the medication's administration. Despite this discrepancy, the consultant pharmacist did not report the potential medication irregularity to the attending physician or the Director of Nursing. This oversight was confirmed during an interview with the Nursing Home Administrator, the Director of Nursing, and a medical records employee. The deficiency was noted under 483.45(c)(4) Drug Regimen Review and had been previously cited on February 16, 2024.
Neglect of Resident Leading to Harm
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. The deficiency involved a resident on the East Hall Nursing Unit who experienced a significant change in condition that went unreported and unaddressed by the staff. On April 14, 2024, a licensed practical nurse (LPN) noted a concern with the facility's bladder scanner and documented the resident's urine output as below the physician's order threshold. Despite this, the LPN held the resident's insulin without documented parameters to do so and recorded multiple medication refusals by the resident throughout the day. The resident's condition deteriorated, showing signs of altered mental status, right-sided facial droop, and other symptoms indicative of a stroke. However, these changes were not communicated to the registered nurse (RN) on duty during the shift. The LPN failed to report the resident's condition to the RN, citing personal reasons for not speaking to the RN. The resident's condition was only addressed after the shift change when another RN assessed the resident and initiated emergency medical services for a suspected stroke. Witness statements from other staff members, including nurse aides, indicated that the resident appeared unwell throughout the day, with symptoms such as slurred speech and a request to go to the hospital. Despite these observations, the LPN did not take appropriate action to ensure the resident received timely medical attention. The facility's failure to ensure proper communication and response to the resident's condition resulted in neglect and harm to the resident.
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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