Edison Manor Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Pennsylvania.
- Location
- 222 West Edison Avenue, New Castle, Pennsylvania 16101
- CMS Provider Number
- 395536
- Inspections on file
- 34
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Edison Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that two nursing units lacked sufficient clean linens, with linen carts and storage rooms on both floors missing basic items such as wash cloths, towels, and bed sheets. Multiple rooms on one unit had unmade beds or beds made only with a flat sheet and no fitted sheet. An RN Supervisor reported that beds were left unmade because linens were unavailable until delivered from the laundry. In the laundry area, only one washer was operational, one staff member was handling all laundry tasks, and only a minimal number of clean linens were ready despite a census of 103 residents. The NHA confirmed there were not enough clean linens for all residents at the time.
Two residents experienced multiple missed doses of prescribed medications and supplements due to the facility's failure to obtain medications in a timely manner. Delays in transmitting orders, unclear pharmacy procedures for urgent needs, and lack of access to emergency medication supplies contributed to the deficiency, as confirmed by the Nursing Home Administrator.
The facility did not follow physician orders for daily wound dressing changes for multiple residents. During observations, wound dressings were found to be absent, and a nurse confirmed that dressings were not changed or reapplied as ordered. Clinical records and interviews with cognitively intact residents further confirmed that staff rarely performed the required daily dressing changes.
The facility failed to maintain the sprinkler system, as observed in the main floor laundry room corridor where three sprinkler heads were found to be dust-covered and dirty. This condition, confirmed by the maintenance supervisor, can potentially delay or limit sprinkler activation during emergencies.
The facility failed to provide documentation for the required three-year, four-hour load test of their generator, as discovered during a document review. An interview with the maintenance supervisor confirmed the absence of this documentation, indicating a lapse in maintaining proper records for essential electrical systems.
The facility failed to maintain cooking equipment properly, as kitchen staff were uncertain about the location and operation of the hood fire suppression system's manual activation. This deficiency was confirmed by the maintenance supervisor.
The facility was found to have smoke barrier deficiencies in two rooms. The main floor emergency stock room had loose and missing ceiling tiles, while the third floor roof access room had loose, missing, and unsealed ceiling tiles. These issues were confirmed by the maintenance supervisor during the survey.
The facility failed to maintain electrical system requirements as per NFPA standards. An observation revealed that oxygen cylinder carts were blocking access to electrical panels in the third floor electrical room. This deficiency was confirmed by the maintenance supervisor.
The facility failed to maintain emergency preparedness guidelines by not conducting a full-scale exercise, test, and evaluation of the emergency preparedness plan within the previous year. This deficiency was confirmed by the maintenance supervisor, who acknowledged the lack of documentation. The facility did not comply with regulations requiring at least two exercises per year to test their emergency plans.
The facility was found to exceed the height requirement for a three-story, Type II (000), unprotected, non-combustible building, as observed during a survey. The maintenance supervisor confirmed the building's height surpassed the allowable limit for its construction type.
The facility failed to maintain proper evacuation diagrams on all building levels. Observations revealed that the diagrams lacked a notation showing the viewer's location, which was confirmed by the maintenance supervisor. This deficiency violates NFPA 170-11.2.4 and 11.4.1 standards.
The facility did not maintain proper exit signage for one of over ten exits. A missing directional exit sign near the second-floor lounge, intended to guide individuals towards the stair towers, was observed. This was confirmed by the maintenance supervisor during the survey.
The facility did not ensure GFCI protection for electrical receptacles in two areas: the main floor employee lounge ice machine and the main floor kitchen dishwashing area. This deficiency was confirmed by the maintenance supervisor.
The facility failed to ensure residents' concerns were documented and addressed during Resident Council meetings. Despite residents expressing issues with call bell response times, snack availability, and housekeeping, these concerns were not followed up or resolved. The Activity Director and Social Services Director were unaware of these issues, indicating a breakdown in communication and documentation.
The facility failed to maintain a clean and sanitary environment, with 14 resident rooms and a dining room found unsanitary. Observations revealed dirty floors, medical waste, and a lack of essential supplies like toilet paper and soap. Residents expressed dissatisfaction with the cleanliness, and staff confirmed the absence of supplies. The Nursing Home Administrator acknowledged the unsanitary conditions.
The facility failed to provide sufficient nursing staff, resulting in delayed response times to call bells. Residents reported waiting up to an hour for assistance, with one resident left on a bedpan for an extended period. Staff were observed ignoring call bell alerts while seated at the nursing station. These issues were consistent across shifts, highlighting a deficiency in nursing services.
The facility did not follow its infection control policy for Enhanced Barrier Precautions (EBP) in two units. A CRNP failed to wear a gown during a wound assessment for a resident with a chronic pressure ulcer and foley catheter. Additionally, PPE was not available for residents requiring EBP, as confirmed by staff interviews.
A resident was admitted with a stage three pressure ulcer, but the facility inaccurately documented it as a stage two ulcer upon admission. The facility's policy requires comprehensive assessments, but the initial documentation lacked accuracy and detail, as confirmed by the ICLPN.
The facility failed to reorder and store medications properly for two residents, resulting in unavailable medications during administration. A resident with a history of falls and joint replacement therapy was unable to receive Oxycodone due to a lack of reordering, while another resident with multiple diagnoses, including Type 2 Diabetes and heart failure, did not receive Furosemide as it was not reordered. Both nursing staff and management confirmed the oversight.
The facility did not routinely offer nutritious evening snacks as desired by residents. Interviews with several residents revealed their preference for evening snacks, which were not being provided. Observations showed limited snack availability for 54 residents on one floor, with only a few items available. This deficiency was noted under nursing services regulations.
The facility was found deficient for not having a lavatory in the common bathing room on the second floor nursing unit. This was observed and confirmed by the Nursing Home Administrator during a survey.
The facility did not meet the required nurse aide (NA) staffing ratios on specific dates for both the evening and overnight shifts. On the evening shift, the facility failed to maintain the minimum of one NA per 11 residents on two occasions. For the overnight shift, the facility also failed to meet the minimum requirement of one NA per 15 residents on two occasions. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not meet the required LPN staffing levels on a day shift, with only 3.67 LPNs available for 101 residents, falling short of the 4.04 LPNs needed. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide the required 3.2 hours of direct resident care per day for twelve out of fourteen days reviewed. Staffing documents showed care hours per patient per day (PPD) ranged from 2.92 to 3.10, below the mandated minimum. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain a homelike environment due to a shortage of essential supplies, including wash cloths, towels, and toilet paper, on the Second and Third floor nursing care units. Observations and interviews revealed inadequate stock of clean linens and paper products, impacting the care of 91 residents. The DON confirmed the insufficiency of supplies, with residents and family members reporting the use of blankets for drying and purchasing personal wash cloths.
The facility failed to serve meals that were palatable and at a safe temperature, as reported by 17 residents. Meals were often cold due to trays sitting in hallways for long periods, and the food quality was poor. No policy was provided regarding meal service expectations.
The facility failed to honor the bathing preferences of six residents, as outlined in their policy and the RAI manual. Despite the policy requiring a minimum of two baths or showers per week, records and interviews revealed inconsistent bathing schedules for these residents, with some reporting hardly ever receiving a bath or shower. The Interim Nursing Home Administrator confirmed the lack of evidence supporting adherence to resident preferences and facility policy.
The facility failed to ensure residents receive necessary care and services for bathing, with water temperatures in the bathing rooms on the second and third floors being inconsistent and often too low. A resident reported uncomfortable shower experiences due to fluctuating water temperatures, and the Maintenance Director confirmed the ongoing issue.
The facility failed to provide medically related social services, particularly in the grievance process and psychosocial services. A resident's representative exhibited aggressive behavior, and the facility lacked a plan to address this, with no evidence of social, psychological, or emotional consultations provided.
The facility failed to follow physician orders for a resident with multiple diagnoses, including COPD, by not administering the prescribed Anoro Ellipta inhaler on two consecutive days. The LPN erroneously documented that the medication was given and did not inform the physician about its unavailability. The Director of Nursing confirmed the deficiency.
The facility failed to ensure nursing staff had the necessary training to care for residents' needs, as there was no RN Supervisor scheduled for a specific period, and an RN Med Nurse lacked the training to fulfill supervisory duties. This compromised the facility's ability to provide proper care.
A resident with COPD did not receive their prescribed Anoro Ellipta inhaler on two consecutive days due to unavailability. An LPN incorrectly documented that the medication was administered, which was later confirmed as an error by the DON.
Inadequate Linen Supply Resulting in Unmade and Improperly Made Beds
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment on two nursing care units due to inadequate availability of clean linens. On the second floor, observations showed that the clean linen stock had no wash cloths, no bed sheets, and no towels, and the clean storage room on that floor had no bedding supplies available. On the third floor, one clean linen cart contained only one sheet, three pillowcases, and no towels or wash cloths, and the third floor clean storage room also had no additional linens. Room observations on the third floor showed multiple beds that were not made, with some having no sheets at all and others having only a flat sheet and no fitted sheet. During an interview, the RN Supervisor stated that beds were not made because there were no linens available until they arrived from the laundry room. Observation of the laundry room revealed that only one washing machine was functioning, with a single employee responsible for sorting, washing, drying, folding, and redistributing all linens. At that time, there were only two wash cloths, three towels, four sheets, and four fitted sheets cleaned and ready for use, with one load in the washer and three to four bags of soiled laundry waiting to be processed. Observation of the clean linen cart at approximately the same time confirmed that there were not enough clean wash cloths, towels, fitted sheets, and flat sheets for the facility’s census of 103 residents. In an interview, the Nursing Home Administrator confirmed that there was not enough clean linen available for all residents at the time of observation.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to obtain ordered medications in a timely manner for two residents, resulting in multiple missed doses of prescribed drugs and supplements. For one resident with diagnoses including Type 2 Diabetes, lumbago with sciatica, depression, and difficulty walking, the electronic medication administration record (eMAR) showed missed doses of bupropion, CoQ-10, prednisone, Tresiba, adult multivitamin gummies, and baclofen, all due to the medications not being available. For another resident with respiratory failure, persistent vegetative state, tracheostomy, paranoid schizophrenia, and gastrostomy, the eMAR documented missed doses of atropine sulfate, ciprofloxacin, cefepime, and diazepam, also due to drug unavailability. The deficiency was attributed to delays in transmitting medication orders to the pharmacy, lack of clear instructions in the pharmacy policy for obtaining non-controlled medications before routine delivery times, and staff not requesting access to the emergency medication supply for controlled substances. Additionally, there was no alternate pharmacy listed for urgent medication needs. These issues were confirmed by the Nursing Home Administrator during interviews, who acknowledged the delays and gaps in the facility's processes for ensuring timely medication delivery.
Failure to Follow Physician Orders for Daily Wound Dressing Changes
Penalty
Summary
The facility failed to follow physician's orders for daily wound dressing changes for eight out of thirteen residents reviewed. During wound dressing observations, it was noted that daily wound dressings were absent for several residents, and a licensed nurse confirmed that the dressings were not changed or reapplied as ordered. Clinical record reviews showed that each affected resident had physician's orders for daily wound dressing changes, and interviews with cognitively intact residents further verified that staff rarely performed the dressing changes as required. One resident, who was cognitively intact, also confirmed that staff did not complete the daily wound dressing changes as ordered by the physician. These findings were based on direct observation, clinical record review, and resident interviews, all of which consistently indicated that the facility did not provide wound care in accordance with physician's orders and resident care plans.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system as required, which was evidenced by an observation and interview during a survey. On January 15, 2025, at 10:23 a.m., it was observed that the main floor laundry room corridor had three sprinkler heads that were dust-covered and dirty. This condition can potentially delay or limit the activation of the sprinklers during an emergency. The maintenance supervisor confirmed the existence of these deficiencies during an interview conducted on January 14, 2025, at 10:23 a.m.
Plan Of Correction
1. Nursing home administrator/designee cleaned the sprinkler heads in the main floor laundry room. 2. Nursing home administrator and/or designee will audit sprinkler heads weekly times 4 weeks and monthly times 2 months for cleanliness and debris.
Failure to Document Generator Load Test
Penalty
Summary
The facility failed to meet the electrical system requirements as outlined in NFPA 101 and related standards. During a document review on January 15, 2025, it was found that the facility could not provide documentation for the mandatory three-year, four-hour load test of their generator. This test is crucial to ensure that the generator can supply power within the required 10 seconds in case of an emergency. The absence of this documentation indicates a lapse in the facility's maintenance and testing protocols for their essential electrical systems. An interview with the maintenance supervisor on the same day confirmed that the documentation for the three-year load test was unavailable at the time of the survey. This deficiency highlights a failure in maintaining proper records of maintenance and testing, which are necessary to verify compliance with NFPA 110 and NFPA 111 standards. The lack of documentation raises concerns about the facility's ability to ensure the reliability of their emergency power systems, which are critical for the safety and well-being of the residents.
Plan Of Correction
1. Facility had third party Generator Specialist Inc. complete the 4 hour load test of the generator on 2/3/2025. 2. Facility contracts with Generator Specialist Inc to ensure that the 4 hour load test is completed every three years as required.
Deficiency in Kitchen Fire Safety Procedures
Penalty
Summary
The facility failed to maintain cooking equipment in the kitchen, as evidenced by observations and interviews conducted on January 15, 2025. During the inspection, kitchen staff members were found to be uncertain about the location and operation of the hood fire suppression system's manual activation. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the issue with the cooking equipment.
Plan Of Correction
1. Nursing home administrator and/or designee will educate dietary staff on the location of the hood fire suppression system's manual activation pull station. 2. Nursing home administrator and/or designee will educate all new dietary staff during orientation on the location of the hood fire suppression system's manual activation pull station. 3. Nursing home administrator and/or designee will audit 2 dietary staff weekly to ensure they are aware of the location of the hood fire suppression system's manual activation pull station.
Smoke Barrier Deficiencies in Facility
Penalty
Summary
The facility failed to maintain smoke barrier requirements in two of over ten rooms, as observed during a survey on January 15, 2025. Specifically, deficiencies were noted in the main floor emergency stock room, where ceiling tiles were found to be loose and missing. Additionally, the third floor roof access room had loose, missing, and unsealed ceiling tiles. These observations were confirmed through an interview with the maintenance supervisor conducted at the time of the survey.
Plan Of Correction
1. Missing ceiling tiles were replaced in the emergency stock room. 2. Third floor roof access room loose and ensealed ceiling tiles were replaced and repaired. 3. Facility maintenance/NHA will audit ceiling tiles weekly times 4 weeks then monthly times 2 months.
Electrical System Deficiency Due to Blocked Access
Penalty
Summary
The facility failed to maintain and inspect electrical system requirements as per NFPA 70 and NFPA 99 standards. During an observation on January 15, 2025, at 12:04 p.m., it was noted that the third floor electrical room had several oxygen cylinder carts obstructing access to the electrical panels. This deficiency was confirmed through an interview with the maintenance supervisor conducted at the same time.
Plan Of Correction
1. Oxygen cylinder carts have been removed from blocking the access to the electrical panels. 2. Nursing home administrator and/or designee will educate all facility staff on maintaining a clear pathway to the electrical panels. 3. Maintenance/nursing home administrator will audit access to the electrical panels is maintained daily times 5 days, weekly times 3 weeks, and monthly times 2 months.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to maintain proper emergency preparedness guidelines as required by regulations. During a document review conducted on January 15, 2025, it was discovered that the facility did not have records indicating that a full-scale exercise, test, and evaluation of the emergency preparedness plan had been performed within the previous year. This lack of documentation suggests that the facility did not conduct the necessary exercises to test their emergency plan, which is a critical component of ensuring readiness for potential emergencies. The deficiency was confirmed during an interview with the maintenance supervisor on the same day. The supervisor acknowledged the absence of documentation, which further substantiates the facility's failure to comply with the regulatory requirements for emergency preparedness. This oversight indicates a lapse in the facility's adherence to mandated protocols designed to ensure the safety and well-being of its residents and staff in the event of an emergency. The regulations require that long-term care facilities conduct at least two exercises per year to test their emergency plans, including a full-scale community-based exercise or an individual facility-based functional exercise. The facility's inability to provide evidence of such exercises being conducted within the specified timeframe highlights a significant gap in their emergency preparedness efforts.
Plan Of Correction
1. Nursing home administrator/designee immediately scheduled full scale exercise with outside community resources to be completed. 2. Regional Vice President of operations educated nursing home administrator on E0039 and the importance of yearly exercises to test the emergency plans. 3. Nursing Home Administrator will verify continued compliance with the EPP/tabletop exercises.
Building Height Exceeds Construction Type Limits
Penalty
Summary
The facility failed to maintain compliance with building construction type requirements as outlined in NFPA 101. During an observation on January 15, 2025, it was noted that the facility exceeded the height requirement for a three-story, Type II (000), unprotected, non-combustible building. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged that the building's height surpassed the allowable limit for its construction type. The report does not mention any specific patients or their conditions in relation to this deficiency.
Plan Of Correction
No adverse effects occurred from the facility exceeding the height requirement for this construction type. Life Safety Consultant Peters Rice Associates conducted an FSES on 3/20/2017, which is on file with the Department of Health. Edison Manor has been working with various vendors on a construction proposal that will minimize disturbance to the residents of the facility. Once a viable proposal has been acquired, the facility will submit architectural plans and determine the time frame to have the work completed to stay in compliance. TLW was submitted to the local department of health field office to be sent for approval. FSES is being requested to be updated.
Evacuation Diagram Deficiency
Penalty
Summary
The facility was found to be deficient in maintaining proper evacuation diagrams across all three building levels. During an observation conducted on January 15, 2025, between 11:20 a.m. and 12:10 p.m., it was noted that the evacuation diagrams lacked a critical notation indicating the location of the viewer on the diagram. This deficiency was confirmed in an interview with the maintenance supervisor, who acknowledged that the diagrams did not show the viewer's location or the exit paths, as required by NFPA 170-11.2.4 and 11.4.1.
Plan Of Correction
1. Evacuation Diagrams have been updated to contain the notation showing the location of the viewer on the diagram.
Missing Exit Signage Near Second-Floor Lounge
Penalty
Summary
The facility failed to maintain proper exit signage for one of over ten exits. During an observation on January 15, 2025, at 12:06 p.m., it was noted that a directional exit sign was missing near the second-floor lounge, which was supposed to direct individuals towards the stair towers. This deficiency was confirmed through an interview with the maintenance supervisor at the time of the survey.
Plan Of Correction
1. Nursing home administrator and/or designee immediately changed the lightbulb in the exit sign to ensure the directional arrow was on. 2. Nursing home administrator and/or designee will audit facility exit signs to ensure all directional arrows are engaged weekly x 4 weeks and monthly times 2 months.
Failure to Maintain GFCI Protection in Electrical Receptacles
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with NFPA 101 standards in two specific areas. During an observation on January 15, 2025, it was noted that the ground fault circuit interrupter (GFCI) protection was not ensured for the receptacle used by the ice machine in the main floor employee lounge and the receptacle in the main floor kitchen dishwashing area. This deficiency was confirmed through an interview with the maintenance supervisor conducted on the same day.
Plan Of Correction
1. Facility immediately contacted a third-party contractor to evaluate outlets with need for GFCI and replace the outlets identified with GFCI outlets to include the employee lounge for the ice machine and the main floor dishwashing receptacle area. 2. GFCI receptacles have been replaced.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that residents could effectively voice their concerns during Resident Council meetings and that these concerns were documented and addressed in a timely manner. The facility's policy stated that the Life Enrichment Director or designee may attend the Resident Council Meeting to act as a liaison between the group and the facility if requested by the Council. However, the policy was not effectively implemented, as evidenced by the lack of documentation of resident concerns and follow-up actions in the meeting minutes from October, November, and December 2024. During a Resident Council meeting on January 7, 2025, seven residents expressed that their concerns were not being followed up by each department, and they never received feedback or saw resolutions to their issues. These concerns included call bell response times, snack availability, food quality, linen and care supplies availability, and housekeeping frequency. Despite these issues being raised, the Activity Director and Social Services Director were unaware of any concerns other than dietary issues, indicating a breakdown in communication and documentation. The review of the Resident Council meeting notes from the previous months revealed a lack of evidence of resident participation and facility responses to concerns. This deficiency highlights the facility's failure to adhere to its policy and ensure that resident concerns are properly documented, communicated, and addressed, leading to unresolved issues and dissatisfaction among the residents.
Plan Of Correction
a. Emergency Resident Council meeting held on January 21st to address all concerns. b. Nursing Home Administrator/designee educated Activity Director on resident council process and concern forms to be completed with each concern. c. Resident Council Concern form template updated and given to Activity Director to use with resident council concerns. d. Nursing Home Administrator/designee will meet with Resident Council president within 3 days of resident council meeting monthly (starting Jan 2025) times 3 months to verify completion of new concern forms are completed from the meeting and to discuss resolutions. Concerns will be reviewed in the old business of the next meeting. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Inadequate Housekeeping Services Lead to Unsanitary Conditions
Penalty
Summary
The facility failed to provide adequate housekeeping services, resulting in unsanitary conditions in 14 of 94 resident rooms and one of two dining rooms. Observations revealed dirty floors with dried stains, debris, trash, and food particles in several rooms. Additionally, some rooms lacked essential supplies such as toilet paper, soap, and paper towels. Interviews with residents indicated dissatisfaction with the cleanliness and frequency of cleaning in their rooms. The facility's policy on environmental cleaning and disinfection was not adhered to, as evidenced by the presence of medical waste and dried liquids in some rooms. Further observations on different dates confirmed that hand sanitizer dispensers in the hallways were empty, and several restrooms lacked necessary supplies. Interviews with staff members, including a Licensed Practical Nurse and a Registered Nurse, confirmed the absence of supplies in the restrooms and hallways. The Nursing Home Administrator acknowledged the unsanitary conditions and the failure to maintain a clean and sanitary environment as per the facility's policy.
Plan Of Correction
Facility immediately addressed rooms 207, 209, 210, 217, 220, 223, 224, 226, 303, 307, 310, 319, 321, and 325 and cleaned all rooms to include the bathrooms and replenishing the toilet paper. Facility immediately implemented a cleaning schedule to include common areas/dining rooms and thorough cleans for each floor and patient rooms to protect residents in similar situations. Administrator/designee will educate all staff on F584, facility cleanliness and supplies. Administrator/designee will re-educate housekeeping staff on daily checklist which include replenishing supplies and cleaning compliance. Administrator/designee will begin daily audits of 2 rooms per floor verifying compliance/thorough cleans and replenishing supplies were completed using the housekeeping checklists for 5 days and then audit 2 rooms/areas 3x/week for 2 weeks and then audit 10 rooms/areas monthly x 2 months. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Delayed Response to Call Bells Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed response times to call bells. Residents expressed concerns about having to wait nearly an hour for assistance after activating their call bells. Specific instances included Resident R226, who was left on a bedpan for an extended period, causing discomfort, while staff were observed seated at the nursing station with the call bell system audibly and visually alerting them. During a Resident Council meeting, several residents reported similar issues with delayed responses to call bells, with wait times ranging from 30 to 45 minutes. These delays were consistent across different shifts, with some residents noting longer wait times during shift changes. The deficiency was identified under 28 Pa. Code 201.18(b)(1) Management and 28 Pa. Code 211.12(d)(4)(5) Nursing services, indicating a failure to provide adequate nursing services to ensure the well-being of residents.
Plan Of Correction
a. Facility completed a random audit of 15 residents to for call bell response times and to verify needs are being met with no adverse affects to any residents. b. Emergency Resident council meeting held on January 21st to address all concerns and nursing home administrator/designee will follow up with resident council president to ensure concerns are addressed and resolved. c. Nursing home Administrator/designee will educate facility staff of F725. d. Facility management team/designee will complete 6 random call bell audits over all 3 shifts for timeliness and resident satisfaction with needs being met daily times 5 days, weekly x 3 weeks, and monthly x 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its own infection control practices regarding Enhanced Barrier Precautions (EBP) for residents in two units. The facility's policy, dated September 2024, specifies that EBP are necessary to prevent the transmission of multi-drug resistant organisms (MDROs) through contaminated hands and clothing of healthcare workers. These precautions are particularly important for residents with chronic wounds, indwelling devices, or those colonized or infected with MDROs. However, observations revealed that a Certified Registered Nurse Practitioner (CRNP) did not don a gown while performing a wound assessment on a resident with a chronic stage four coccyx pressure ulcer and a foley catheter, who was under EBP. Additionally, it was observed that there was no Personal Protective Equipment (PPE) available at the doorways or in the hallways for several rooms housing residents requiring EBP. Interviews with staff, including a Nursing Assistant and the Director of Nursing, confirmed the absence of readily available PPE and acknowledged that staff should have been wearing appropriate PPE, such as gloves and gowns, when providing care to these residents. This lack of adherence to the facility's infection control policy was confirmed by the Director of Nursing.
Plan Of Correction
Resident 42 no longer resides in the facility. b. Director of nursing/designee completed a whole house audit to verify any resident requiring enhanced barrier precautions has personal protective equipment readily available outside of room. c. Nursing home administrator/designee educated all facility staff and wound nurse practitioner on personal protective equipment, enhanced barrier precautions and F880. d. Nursing home administrator/designee will audit personal protective equipment availability and use for 3 enhanced barrier precautions residents per floor daily x 5 days; weekly x 3 weeks; monthly x 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Inaccurate Pressure Ulcer Assessment on Admission
Penalty
Summary
The facility failed to comprehensively assess and document a pressure ulcer for a resident, identified as Resident R42, upon admission. The facility's policy requires that pressure injuries be assessed initially and at least weekly, including detailed documentation of the wound's characteristics. However, upon admission, Resident R42's pressure ulcer was inaccurately documented as a stage two ulcer, despite hospital records indicating it was a stage three ulcer with macerated, weeping skin and macules and papules around the edges. This discrepancy in documentation and assessment was confirmed by the Infection Control Licensed Practical Nurse (ICLPN). Resident R42 was admitted with a stage three pressure injury to the coccyx, as documented in hospital records, which included specific details about the wound's size, depth, and condition. However, the facility's initial assessment on the day of admission incorrectly documented the wound as a stage two ulcer, with different measurements and lacking a comprehensive assessment. This failure to accurately assess and document the pressure ulcer upon admission was identified during a review of the clinical records and confirmed through staff interviews.
Plan Of Correction
a. Resident 42 no longer resides in the facility. b. Director of Nursing/Designee will audit all residents with pressure ulcers to verify the last assessment and MDS are consistent for accuracy in a 90-day look back period. c. Director of Nursing/designee will educate nursing staff on pressure ulcer documentation, staging, and F686. d. Director of Nursing/designee will audit 5 random pressure ulcers to ensure documentation in assessments and MDS are consistent with the documentation from the wound nurse practitioner and accurate weekly times 4 weeks and monthly times 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Medication Reordering and Storage Deficiency
Penalty
Summary
The facility failed to properly reorder and store medications for two residents, leading to a deficiency in medication management. Resident R72, who had a history of falls, a fracture of the left femur, and was undergoing aftercare for joint replacement therapy, had a physician's order for Oxycodone 5 mg every 6 hours as needed for pain. However, during a medication pass observation, it was discovered that there was no medication card available in the cart to fulfill this order. The last administration of the medication was recorded on 11/04/24, and the order was not resubmitted to the pharmacy, resulting in the medication being unavailable when requested by the resident. Similarly, Resident R73, who had diagnoses including Type 2 Diabetes, depression, heart failure, and a history of cerebral infarction, had a physician's order for Furosemide 20 mg daily. During a medication pass, it was observed that the medication cart did not contain Furosemide, and the medication had not been reordered from the pharmacy after the last dose was administered. Both the LPN and RN involved confirmed the absence of the medications and the failure to reorder them. The Director of Nursing and Nurse Supervisor also acknowledged that the medications were not reordered as required, leading to their unavailability in the medication carts for the residents.
Plan Of Correction
a. R72 was assessed for adverse effects with no concerns and scripts were obtained for reorder of medication immediately. Facility completed an initial audit of all med carts to ensure that all medications were available as ordered which includes Furosemide with no issues or concerns. b. Director of Nursing/Designee completed a whole house audit to verify all ordered meds in facility are present for like residents-any medications not present will be addressed and resident will be assessed for adverse effects and physician/resident representative will be notified. c. Director of Nursing/designee will educate licensed nursing staff on F761 and obtaining new scripts and reordering of medications when needed. d. Director of Nursing/designee will audit 2 of 4 medication carts each week to verify medications ordered by the physician were not missed on the MAR and are readily available for each resident on the unit weekly x 4 weeks and monthly x 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Failure to Provide Routine Nutritious Evening Snacks
Penalty
Summary
The facility failed to routinely offer nutritious snacks as desired by residents, as evidenced by interviews with six alert and oriented residents who expressed that snacks were not routinely offered in the evening, despite their preference for an evening nutritious snack. The facility's policy, dated September 2024, states that there should be no more than 14 hours between dinner and breakfast unless a nourishing snack is provided at bedtime, allowing up to 16 hours between meals if agreed upon by a resident group. However, observations revealed limited snack availability, with only one fruit bar, five oatmeal cookies, one single-serve applesauce container, and one can of chicken soup available for 54 residents on the third floor, as confirmed by a nursing assistant. This deficiency was noted under 28 Pa. Code 211.12 (d)(1) Nursing services.
Plan Of Correction
a. Nursing home administrator/designee immediately audit nursing units to ensure nutritious snacks were available on the units for residents and there were no adverse effects to residents related to snacks. b. Nursing home administrator/designee educated dietary and nursing department staff on F809 and nutritious snack availability on the units and daily during the evening. c. Nursing home administrator/designee will randomly audit 3 residents on each unit daily x 5 days; weekly x3 weeks; monthly x2 months to ensure snacks are available/offered and that enough snacks are available on the unit. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Missing Lavatory in Second Floor Bathing Room
Penalty
Summary
The facility failed to meet the regulatory requirement of including a lavatory in each bathing room. During an observation on January 6, 2025, at 11:00 a.m., it was noted that the common bathing room on the second floor nursing unit did not have a lavatory. This deficiency was confirmed during an interview and further observation with the Nursing Home Administrator on January 8, 2025, at approximately 1:45 p.m., who acknowledged the absence of a lavatory in the specified bathing room.
Plan Of Correction
1. Facility is unable to retroactively correct not having a sink in the shower room. 2. Full house audit completed and all other shower rooms were assessed and are equipped with a sink and needed equipment. 3. Facility hired a contractor to come and evaluate the shower room for the installation of the sink. 4. Facility will install the sink in the second-floor shower room. 5. Sanitizer station placed directly outside of the shower room for use while waiting on installation. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on specific dates for both the evening and overnight shifts. On the evening shift, the facility did not maintain the minimum of one NA per 11 residents on two occasions: November 30, 2024, and January 6, 2025. Specifically, on November 30, 2024, with a census of 100 residents, only 8.63 NAs were available when 9.09 were required. Similarly, on January 3, 2025, with a census of 101 residents, 8.63 NAs were present when 9.18 were needed. For the overnight shift, the facility also failed to meet the minimum requirement of one NA per 15 residents on two occasions: November 26, 2024, and January 3, 2025. On November 26, 2024, with a census of 100 residents, 6.43 NAs were available when 6.73 were required. On January 6, 2025, with a census of 102 residents, 6.43 NAs were present when 6.80 were needed. The Nursing Home Administrator confirmed these staffing shortages during an interview on January 9, 2025.
Plan Of Correction
1. The facility is unable to retroactively correct the CNA staffing ratio for 11/26/24, 11/30/24, 1/3/25 and 1/6/25. 2. Nursing home administrator immediately audited future schedules for compliance with regulatory guidance for staffing of nurse aides. 3. Nursing home administrator/designee will schedule CNA's to meet state ratio. Call outs will be monitored by nursing home administrator/Director of Nursing and/or designee daily. Facility staff and staffing agencies will be utilized to facilitate replacement/procurement of staff. Facility has put into place sign on bonus' to increase applicants as well as pick up bonus' to increase retention. 4. Nursing home administrator/designee will educate the scheduling coordinator, director of nursing, assistant director of nursing, and human resources on the requirements of CNAs. 5. Nursing home administrator and/or designee will monitor staffing ratio weekly x4 weeks. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
LPN Staffing Shortfall on Day Shift
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on the day shift for one of the days reviewed. Specifically, on November 28, 2024, the facility had a census of 101 residents, which required 4.04 LPNs to meet the regulatory staffing ratio of one LPN per 25 residents. However, only 3.67 LPNs were on duty that day, resulting in a staffing shortfall. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 9, 2025, who acknowledged the failure to meet the minimum LPN ratio requirements for the specified shift and date.
Plan Of Correction
1. The facility is unable to retroactively correct the staffing ratio for days: 11/28/2024. 2. Nursing home administrator immediately audited future schedules for compliance with regulatory guidance for staffing of LPN. 3. Nursing home administrator/designee will schedule LPNs to state ratio of 1 to 25 for day shift, 1 to 30 for afternoon shifts and 1 to 40 for midnight shifts. Call outs will be monitored by nursing home administrator/Director of Nursing and/or designee daily. Facility staff and staffing agencies will be utilized to facilitate replacement/procurement of staff. Facility has put into place sign on bonus' to increase applicants as well as pick up bonus' to increase retention. 4. Nursing home administrator/designee will educate the scheduling coordinator, director of nursing, assistant director of nursing, and human resources on the requirements of LPN ratios of 1 to 25 for day shift, 1 to 30 for afternoon shifts and 1 to 40 for midnight shifts. 5. Nursing home administrator and/or designee will monitor staffing ratio weekly x4 weeks. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
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 resident in a 24-hour period for twelve out of fourteen days reviewed. The deficiency was identified through a review of nursing staffing documents and confirmed during an interview with the Nursing Home Administrator. On specific dates, the facility's direct resident care hours per patient per day (PPD) fell below the required minimum, with recorded PPDs ranging from 2.92 to 3.10. This shortfall in staffing levels was acknowledged by the Nursing Home Administrator, indicating a consistent failure to meet the mandated care hours over the specified period.
Plan Of Correction
1. The facility is unable to retroactively correct the staffing PPD of 3.2 for 11/24/24, 11/25/24, 11/26/24, 11/27/24, 11/29/24, 11/30/24, 1/2/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25 and 1/7/25. 2. Nursing home administrator immediately audited future schedules for compliance with regulatory guidance for staffing to PPD. 3. Nursing home administrator/designee will schedule staff to meet state PPD of 3.2. Call outs will be monitored by nursing home administrator/Director of nursing and/or designee daily. Facility staff and staffing agencies will be utilized to facilitate replacement/procurement of staff. Facility has put into place sign on bonuses to increase applicants as well as pick up bonuses to increase retention. 4. Nursing home administrator/designee will educate the scheduling coordinator, director of nursing, assistant director of nursing, and human resources on the requirements of the minimum PPD of 3.2. 5. Nursing home administrator and/or designee will monitor staffing PPD weekly x4 weeks. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Deficiency in Providing Homelike Environment Due to Insufficient Supplies
Penalty
Summary
The facility failed to provide a homelike environment for residents on the Second and Third floor nursing care units. Observations revealed a significant shortage of clean linens, including wash cloths and towels, on both floors. The soiled linen rooms contained bagged linens that had not been sent to the laundry room for washing. The laundry room had clean linens ready for distribution, but the stock was insufficient to meet the needs of the 91 residents. Interviews with the Director of Laundry and Housekeeping Services and the Director of Nursing confirmed that the nursing staff had not sent the soiled linens for washing, and the available clean linens were inadequate for resident care. Residents and their family members reported a lack of wash cloths, towels, and toilet paper, with some residents using blankets to dry off after bathing. Observations of resident restrooms showed no backup rolls of toilet paper, and the kitchen area lacked paper towels. A housekeeping employee and the Central Supply Manager confirmed the absence of paper towels and toilet paper, with supplies ordered but not yet arrived. The DON acknowledged the insufficient stock of essential items, impacting the residents' care needs.
Failure to Serve Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable food at a safe and appetizing temperature, as determined through resident interviews. During a survey, 17 out of 18 alert and oriented residents expressed dissatisfaction with their meals, citing that the food was often cold upon delivery. This issue was attributed to meal trays being left in the hallways for extended periods before being served to residents. Additionally, residents reported that the overall quality and taste of the food were poor. The facility did not provide a policy outlining the expectations or requirements for meal service timeliness and food palatability, contributing to the deficiency.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the residents' preferences for bathing and showering, as outlined in their policy and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Six residents (R1, R2, R4, R5, R6, and R7) did not receive baths or showers according to their preferences. The facility's policy mandates that residents be bathed or showered according to their preferences to maintain hygiene and skin condition, with a minimum of two baths or showers per week unless otherwise preferred by the resident. However, the records and interviews revealed that this was not consistently followed for the six residents reviewed. For instance, Resident R1, who was alert and oriented with a BIMS score of 13/15, reported hardly ever receiving a bath or shower, despite the records indicating only a few bed baths over a two-month period. Similarly, Resident R2, with a BIMS score of 15/15, indicated not receiving showers as often as preferred, with records showing sporadic shower dates. Resident R4, also alert and oriented with a BIMS score of 15/15, mentioned receiving showers only when all staff were present, which was infrequent. Resident R5, with a BIMS score of 13/15, had inconsistent bathing records, including bed baths and showers. Resident R6, with severely impaired cognition, had a few recorded showers and a refusal of a bed bath. Resident R7, with a BIMS score of 15/15, had only one recorded bed bath over the review period. The Interim Nursing Home Administrator confirmed the lack of evidence indicating that these residents received baths or showers twice a week as per their preferences and facility policy. This deficiency highlights the facility's failure to promote and facilitate resident self-determination and choice in their care routines, specifically regarding bathing and showering preferences. The facility's policy and the RAI manual's guidelines were not adhered to, resulting in residents not receiving the care they preferred and were entitled to.
Inconsistent Water Temperatures in Bathing Rooms
Penalty
Summary
The facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, specifically in relation to bathing. During an interview, a resident indicated that the water temperature during showers fluctuated from hot to cold, making the experience uncomfortable and leading the resident to request a bed bath instead. Observations with the Maintenance Director confirmed that water temperatures in the bathing rooms on the second and third floors were inconsistent and often too low, with the second floor reaching a maximum of 73 degrees and the third floor reaching a maximum of 94 degrees before dropping again. The Maintenance Director acknowledged that fluctuating water temperatures have been a consistent problem, resulting in residents often receiving cold showers. The Nursing Home Administrator confirmed that the water temperatures were too low for comfortable bathing experiences and acknowledged the facility's failure to ensure residents receive the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being related to bathing. The facility did not provide a water temperature policy for bathing, further highlighting the deficiency in maintaining appropriate water temperatures for resident showers.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide residents with medically related social services, specifically in relation to the grievance process and psychosocial services. The facility's documentation and policy review revealed that the Social Worker position, which is responsible for addressing residents' emotional and social needs, was vacant. The responsibilities were being handled by Registered Nurse Assessment Coordinators (RNACs), who were not consistently involved in the grievance process. Out of 36 grievances, only nine had involvement from the RNAC-Social Services designee, indicating a lack of consistent social services for residents. Resident R1's case highlighted the deficiency further. The resident had multiple chronic conditions, including Chronic Congestive Heart Failure and Type 2 Diabetes Mellitus. The resident's representative exhibited very aggressive behaviors, which were known to the facility. Despite this, there was no evidence of social, psychological, or emotional consultations to address the representative's aggressive behavior. The facility also lacked a plan to protect other residents and staff from this aggressive behavior. Interviews with the Nursing Home Administrator (NHA) and the Interim NHA confirmed the absence of a licensed Social Worker and the failure to provide necessary social services. The NHA attempted to fill the void but acknowledged the inconsistency in service provision. The facility did not provide evidence of medically related social services to Resident R1 and their representative, failing to meet the psychosocial needs and address the aggressive behavior pattern effectively.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow physician orders for Resident R3, who had multiple diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, diabetes mellitus, and chronic obstructive pulmonary disease (COPD). The Medication Administration Record (MAR) for Resident R3 indicated a physician order for Anoro Ellipta inhaler to be administered once daily for wheezing, starting on 5/18/23. However, during an observation on 1/09/24, it was found that the medication was not available in the medication cart, and Resident R3 did not receive the inhaler on 1/08/24 and 1/09/24 as prescribed. LPN Employee E1 confirmed the medication was not administered and had erroneously documented that it was given on 1/08/24. The LPN also failed to communicate to the physician that the medication was unavailable. The Director of Nursing confirmed that the Anoro Ellipta inhaler was not administered to Resident R3 on the specified dates as per the physician's order. This failure to follow physician orders and ensure the availability of prescribed medication constitutes a deficiency in nursing services as per 28 Pa. Code 211.12(d)(1) and 28 Pa. Code 211.12(d)(5). The incident highlights a lapse in medication management and communication within the facility, directly impacting the care provided to Resident R3.
Lack of RN Supervisor and Insufficient Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary training to properly care for residents' needs on 12/29/23. Specifically, the facility did not have an RN Supervisor scheduled from 7:00 p.m. on 12/29/23 to 7:30 a.m. on 12/30/23. The daily deployment sheet and employee punch reports confirmed the absence of an RN Supervisor during this period. Additionally, RN Med Nurse Employee E2, who was expected to fulfill the RN Supervisor responsibilities, confirmed that they had not received the specific training required for the RN Supervisor role and did not feel comfortable or safe performing those duties. The Interim Director of Nursing also confirmed the lack of an RN Supervisor and the insufficient training provided to the RN Med Nurse expected to take on those responsibilities. Observations on 1/09/24 and 1/10/24 revealed that the RN Supervisor was responsible for multiple critical tasks, including communicating with physicians, completing admissions, transferring residents to the hospital, reconciling narcotic medications, and supervising other nursing staff. The RN Med Nurses were observed administering medications and completing treatments for their assigned residents. The lack of an RN Supervisor and the insufficient training for the RN Med Nurse to perform supervisory duties compromised the facility's ability to ensure that nursing staff possessed the competencies required to maximize residents' well-being.
Failure to Administer and Document Medication Correctly
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for Resident R3. Resident R3, who was admitted with diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, diabetes mellitus, and chronic obstructive pulmonary disease (COPD), had a physician order for Anoro Ellipta inhaler to be administered once daily for wheezing. However, during an observation of the medication cart, it was found that the inhaler was not available, and Resident R3 did not receive the medication on two consecutive days as prescribed. This was confirmed by LPN Employee E1, who admitted to documenting in error that the inhaler was administered when it was not. Further interviews revealed that the Director of Nursing confirmed the medication was not administered per the physician's order and that the documentation was incorrect. This deficiency highlights a failure in the facility's medication administration and documentation process, leading to Resident R3 not receiving the necessary treatment for COPD as prescribed by the physician.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
