Elan Skilled Nursing And Rehab, A Jewish Senior Li
Inspection history, citations, penalties and survey trends for this long-term care facility in Scranton, Pennsylvania.
- Location
- 1101 Vine Street, Scranton, Pennsylvania 18510
- CMS Provider Number
- 395103
- Inspections on file
- 17
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Elan Skilled Nursing And Rehab, A Jewish Senior Li during CMS and state inspections, most recent first.
Surveyors found unsanitary conditions in the kitchen, including debris and rodent droppings on floors and under the dishwasher, along with used gloves, garbage, and utensils in food service areas. Multiple sticky traps in food prep and tray line areas contained live and dead cockroaches, indicating active infestation where food and utensils were handled. Although the facility had a pest control contract and was receiving rodent treatments, the Dietary Director and pest control provider confirmed that no targeted cockroach treatment was being performed, despite documented cockroach activity near the kitchen. There was no documentation that staff monitored for cockroaches or implemented increased sanitation or environmental controls to ensure food was stored, prepared, and served under sanitary, pest-free conditions for all residents.
The facility failed to maintain an effective pest control program on two nursing units and in the kitchen. Although a pest control contractor was providing regular services focused on mice on upper floors and general treatments elsewhere, surveyors observed a dead cockroach behind a resident’s bed and rodent droppings with food debris in a third-floor kitchenette. Pest control records noted prior roach activity and rodent droppings, but no additional targeted treatment was provided for roaches after the initial finding, and the Director of Maintenance acknowledged that no specific preventative measures for cockroach control were being implemented in the kitchen.
Surveyors found that the facility did not maintain an effective pest control program, as evidenced by ongoing fruit fly and mouse activity on two nursing units. Despite internal work orders and staff efforts to address pests, the pest management contractor was not informed of the issues, and pest activity was observed in resident areas. A resident with paraplegia reported repeated mouse sightings and evidence of food being eaten by rodents, with further observations confirming the presence of droppings and gnaw marks.
The facility did not accurately complete MDS assessments for three residents, omitting documentation of a surgical wound, a fall, and multiple falls with injury, despite these events being present in clinical records. These discrepancies were confirmed through record review and staff interviews.
A resident with cognitive impairment developed a persistent rash, and although a CRNP ordered a dermatology consult and diagnostic tests for suspected scabies, these were not completed. The resident was treated for other skin conditions until a wound physician later identified scabies, by which time multiple residents required treatment for exposure. Facility staff confirmed that the lack of timely diagnostic follow-through may have delayed identification and mitigation of the outbreak.
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon hospital transfer. This deficiency was identified through a review of clinical records and staff interviews, revealing that three residents were transferred to the hospital without receiving the necessary written information. The Clinical Operations Executive confirmed the absence of documented evidence of this provision.
The facility failed to follow physician orders for medication administration for three residents, resulting in a deficiency. Residents with hypertension and other conditions were given medications without documented evidence of required blood pressure and heart rate checks. This lack of adherence to physician-prescribed parameters was confirmed by the Clinical Operations Executive.
The consultant pharmacist failed to identify drug irregularities for two residents, including dual antidepressant therapy and lack of justification for antipsychotic use. Despite identifying a dosing discrepancy for Aricept, the pharmacist did not ensure timely physician action. The DON confirmed these failures, which violated Pennsylvania Code regulations.
The facility failed to maintain a clean and safe environment on the 5th floor. A Broda chair was heavily soiled with various substances, and a fall mat in a resident's room had large tears exposing the internal foam. These issues were confirmed by an LPN and acknowledged by the DON and Nursing Home Administrator, who stated that resident care equipment should be kept clean and sanitary.
A resident with a history of inappropriate behavior was not adequately monitored, leading to an incident of sexual abuse involving another resident who was unable to consent. Additionally, a resident requiring specific transfer assistance was neglected, resulting in a fall. The facility's delay in reporting and implementing safety measures contributed to these deficiencies.
A facility failed to follow its abuse prohibition procedures after an incident where a resident was observed holding another resident's hand on his genital region. The incident was not reported to the administration or authorities until two days later, despite policy requiring immediate reporting. The involved resident was severely cognitively impaired and unable to consent, and there was no documentation or protective measures implemented following the incident.
A resident with diabetes and CHF experienced significant weight loss, and the facility failed to implement and document planned nutritional interventions. Despite adjustments to dietary preferences and plans for supplements like Ensure pudding and ProStat, there was no evidence of their administration in the MAR. The RD confirmed the lack of implementation and documentation of these interventions.
The facility failed to ensure the availability of emergency supplies for two residents receiving hemodialysis, as required by physician orders and facility policy. Both residents were found to have only one fanny pack with emergency supplies on their wheelchairs, with the second required pack missing from their rooms. This deficiency was confirmed by staff and placed the residents at risk for delayed emergency intervention.
A facility failed to offer routine annual dental services to a Medicaid resident. The resident had been admitted to the facility, but there was no documented evidence of dental services being offered in the past year. This was confirmed by the Clinical Operations Executive during an interview.
The facility failed to maintain the automatic sprinkler system in three locations across three floors. Observations revealed missing components and obstructions, including a lack of a suspended ceiling assembly in the basement, a plastic bag affixed to a sprinkler head on the fifth floor, and a missing escutcheon plate on the first floor. These issues were confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain the smoke barrier separation doors on the fifth floor, as the Clay Street smoke barrier doors required adjustment to fully latch. This issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
The facility was found to have exceeded the maximum allowable story height for its construction type, classified as an unprotected, noncombustible building. The building was three stories higher than permitted, affecting all six floors. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain the required fire resistance rating for vertical enclosures, affecting all six floors. Observations revealed that HVAC shafts adjacent to exit stair towers lacked the necessary two-hour fire resistance. Additionally, the Clay Street exit stair tower on the fourth and fifth floors had inadequate construction, with insufficient drywall and unprotected steel beams. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
A resident with severe cognitive impairment was left unassisted for 25 minutes during a meal, despite needing supervision and assistance. Staff were occupied with other residents, and the unit was understaffed, leading to delays in providing necessary help. The DON acknowledged the facility's responsibility to ensure residents are treated with respect and dignity.
A facility failed to maintain accurate clinical records for a resident with cerebral infarction, who was receiving hospice services. Despite physician's orders, the resident's nutritional intake was not documented for 18 meals in August, and progress notes lacked this information. The DON confirmed the oversight but could not explain the lack of documentation.
Unsanitary Kitchen Conditions and Unaddressed Cockroach Infestation
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen in a sanitary condition and free of pest infestation while preparing, storing, and serving food for all residents. During a kitchen tour, surveyors observed debris and rodent droppings on the dishwashing area floor and along the perimeter floors throughout the kitchen. Under the dishwasher, the floor was soiled and contained used latex gloves, garbage, bottle caps, a fork, and rodent droppings. These conditions were present in active food service and dishwashing areas where food, utensils, and food-contact surfaces are handled. In the food preparation and tray line service area, surveyors observed seven sticky traps placed on the floor. One trap under the left side of the food preparation area contained five cockroaches, three of which were alive and moving. Another trap on the right side of the kitchen contained five cockroaches, with two alive and moving, and a third trap contained four cockroaches, two of which were alive and moving. These observations showed live and dead cockroaches present in food preparation and storage areas. The report notes that cockroaches are known vectors for disease-causing organisms such as Salmonella, E. coli, and Staphylococcus, and that their presence in these areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms, placing all 135 residents in a situation of Immediate Jeopardy to their health and safety. Interviews and record reviews showed that the facility had an ongoing pest control contract but did not ensure that cockroach activity in or near the kitchen was specifically addressed. The Director of Dietary Services stated that the outside pest control company had been treating the kitchen for rodents since December 2025, but the area was not being treated to prevent cockroaches. A dietary worker reported not seeing many cockroaches recently but acknowledged having seen them in the past. The Nursing Home Administrator confirmed that pest control services were requested in December 2025 in response to a rodent infestation and that remediation services twice weekly were recommended. Pest control inspection reports documented that on January 5, 2026, the pest management provider identified cockroaches at a coffee station located about 50 feet from the kitchen entrance and identified a potential rodent entry point in the dishwasher room, but there was no documentation that cockroach-specific treatment was initiated. The pest control provider confirmed observing German cockroach activity at the coffee station and stated that routine services consisted of perimeter spraying, with no targeted cockroach treatment areas identified. The facility did not provide documented evidence that staff were monitoring for cockroaches in the kitchen or that increased sanitation measures or environmental controls were implemented to ensure food was stored, prepared, distributed, and served under sanitary conditions and free of pest infestation.
Removal Plan
- Dispose of exposed food items
- Cease food preparation
- Transition dietary services to an outside vendor until pest mitigation was completed
- Activate pest control services for immediate treatment of source areas, including clean-out treatment, aerosol application, and gel treatments
- Place the kitchen under continuous monitoring by the Director of Dietary Services and the Nursing Home Administrator
- Schedule audits for each meal
- Conduct a comprehensive inspection of the kitchen by a licensed pest control inspector
- Implement aerosol treatment for immediate control and gel application for prevention
- Educate dietary staff on the facility's Pest Control and Kitchen Sanitation Policies and Protocols
- Review all residents for signs and symptoms of foodborne illness
- Initiate audits of pest control logs and environmental monitoring
- Implement inspection and monitoring by the pest control provider
Failure to Maintain Effective Pest and Rodent Control on Nursing Units and Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and rodents on Nursing Units 3 and 4 and in the kitchen. The facility’s own Preventative Maintenance Program policy required an ongoing pest control program to ensure the building was kept free of insects and rodents. Documentation showed that the facility contracted with a licensed pest control company to perform remediation services twice weekly, including mass trapping and baiting on upper floors and monitoring lower floors, and recommended that food in resident rooms be stored in plastic containers. Pest control service records documented several visits with interior perimeter inspections and treatments, including common areas, bathrooms, and hallways, and noted roach treatment at a first-floor coffee station and rodent droppings on the fourth floor. Despite these measures, surveyor observations and interviews showed ongoing pest activity that was not effectively addressed. On one observation date, a dead cockroach was found behind a resident’s bed in a resident room, and rodent droppings and significant food debris and crumbs were observed in drawers and throughout the third-floor kitchenette. The outside pest control provider reported being aware of roaches since an earlier visit and confirmed that no additional targeted treatment for roaches had been provided since that time, with efforts focused instead on mice activity on the fourth and fifth floors and only general treatment on other floors. The Director of Maintenance stated that construction on the first floor may have contributed to cockroaches moving toward the kitchen and acknowledged that the facility was not implementing preventative measures specific to cockroach control in the kitchen.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of insects, pests, and rodents on two out of four resident nursing units. Despite having a policy requiring ongoing pest control, documentation showed that while work orders were entered and completed for fruit fly issues on one unit, there was no evidence that these issues were communicated to the pest management contractor. Observations revealed the continued presence of small black flying insects in the resident dining area, and the pest management contractor confirmed he had not been informed of fruit fly problems nor treated for them in recent months. The Director of Maintenance reported that staff used cleaning agents and pesticides, but these actions were not coordinated with the pest management contractor. Additionally, a resident with paraplegia, who was cognitively intact, reported seeing mice in her room for over a month and discovered a partially eaten candy bar, which was a gift from a family member. Observations in her room and other resident rooms revealed multiple mouse-like droppings and evidence of gnawing. Pest management records did not document any mouse activity until surveyors made inquiries, indicating a lack of effective monitoring and communication regarding rodent issues. These findings were reviewed with facility leadership, confirming the deficiency in maintaining a pest-free environment.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with a history of Borderline Personality Disorder and Post Traumatic Stress Disorder, the quarterly MDS did not document the presence of a surgical wound on the left neck area, despite clinical records showing a wound evaluation by a specialty physician. For another resident admitted with a fractured clavicle and cellulitis, the quarterly MDS failed to record a fall that occurred during the assessment period, even though the clinical record documented the incident. Additionally, a third resident with a right artificial shoulder joint had three falls within the MDS assessment reference period, including one resulting in a forehead hematoma, but none of these falls were documented in the annual MDS. These inaccuracies were confirmed through clinical record reviews and staff interviews, where the Registered Nurse Assessment Coordinator acknowledged the omissions in the MDS documentation for all three residents.
Failure to Complete Ordered Diagnostic Evaluation for Suspected Scabies
Penalty
Summary
The facility failed to follow physician-ordered diagnostic evaluation for suspected scabies in one resident, which contributed to a delay in identifying and mitigating the spread of scabies among residents. Specifically, a resident with dementia and major depressive disorder developed a raised papular rash, and the CRNP ordered a dermatology consultation, skin scraping, or biopsy to determine the cause. Although these diagnostic procedures were ordered, there was no documentation that they were completed, and the resident was instead treated for an allergic-type rash and later with various topical and oral medications for skin symptoms. Over the following weeks, the resident's symptoms persisted and worsened, with continued itching, scratching, and the development of additional lesions. Despite ongoing symptoms and further physician orders for different treatments, the facility did not obtain the required dermatology evaluation, skin scraping, or biopsy as initially ordered. Eventually, a wound physician identified the rash as consistent with a mite reaction on microscopic examination, and the resident was treated for scabies with permethrin cream and placed on contact precautions. The failure to promptly complete the ordered diagnostic evaluation potentially contributed to the spread of scabies within the facility. Another resident was confirmed positive for scabies on microscopic exam, and a total of thirty-six residents received treatment for exposure. Interviews with the Infection Preventionist and DON confirmed that the lack of timely diagnostic follow-through may have delayed identification and mitigation of the outbreak.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required by regulations. This deficiency was identified through a review of clinical records and staff interviews, which revealed that three residents, identified as Residents 27, 124, and 102, were transferred to the hospital without receiving the necessary written information about the facility's bed-hold policy. Resident 27 was transferred on November 27, 2024, Resident 124 on November 26, 2024, and Resident 102 on December 10, 2024. The Clinical Operations Executive confirmed the absence of documented evidence of the provision of this information during an interview conducted on January 23, 2025.
Plan Of Correction
1. Residents 27, 102, and 124 are MA or MAP residents and did not lose their assigned beds while out at the hospital. We are unable to correct those past occurrences. 2. All residents who transfer out to the hospital or on therapeutic leave have the potential to be affected by deficient practice. 3. All nursing staff will be educated regarding the bed hold policy and procedure. The business office and social services have been educated regarding the electronic completion of the bed hold notice. 4. Business Office Manager or designee will audit all transfers out of the building and therapeutic leaves daily during the business week for four (4) weeks then weekly until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for medication administration for three residents, resulting in a deficiency. Resident 121, who was diagnosed with hypertension and end-stage renal disease, had a physician order for Carvedilol with specific instructions to hold the medication if the systolic blood pressure was less than 100 mm Hg or the heart rate was less than 60 beats per minute. However, the Medication Administration Records for December 2024 and January 2025 showed that the medication was administered without documented evidence of blood pressure or heart rate checks prior to administration. Similarly, Resident 124, with diagnoses of hypertension and chronic atrial fibrillation, had a physician order for Atenolol with instructions to hold the medication under the same conditions. The records from November 2024 to January 2025 indicated a lack of consistent documentation of vital signs before administration. Resident 46, diagnosed with hypertension, depression, and dementia, had orders for Metoprolol and Norvasc with specific parameters for holding the medication. The records for December 2024 and January 2025 also lacked evidence of vital sign monitoring before administering these medications. An interview with the Clinical Operations Executive confirmed the failure to consistently obtain and document the necessary vital signs before medication administration for these residents.
Plan Of Correction
1. There is no way for the facility to retroactively address resident #121's supplemental documentation. Drug was discontinued on 01/16/2025. Resident #124's heartrate and blood pressure parameters, per physician order, were added to the physicians order effective 01/23/2025. Nursing staff is collecting this clinical information and administering based on parameters. Resident #46's heartrate and blood pressure parameters, per physician order, were added to the physicians' orders effective 01/23/2025. Nursing staff is collecting this clinical information and administering based on parameters. 2. A review was completed by the Director of Nursing on 02/05/2025 of vasoactive, antiarrhythmics, and antihypertensive orders for in-house residents to assure clinical parameters, as ordered by the physician, are in place and being utilized in the administration of the medications. 3. The Clinical Coordinator or designee will educate licensed nursing staff regarding the requirement to assure clinical parameters for medication, as ordered by the physician, are in place and being utilized in the administration of the medications. 4. The DON or designee will complete a weekly review of vasoactive, antiarrhythmics, and antihypertensives for newly admitted and current in-house residents to assure clinical parameters for medication, as ordered by the physician, are in place and being utilized in the administration of the medications. This review will continue weekly for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee monthly for three months to ensure continued compliance.
Consultant Pharmacist Fails to Identify Drug Irregularities
Penalty
Summary
The consultant pharmacist at the facility failed to identify drug irregularities during monthly medication reviews for two residents. Resident 114, who was diagnosed with dementia with behavioral disturbances and major depressive disorder, was prescribed dual antidepressant therapy with Venlafaxine and Mirtazapine. Despite the presence of duplicate antidepressant therapy, the consultant pharmacist did not identify this irregularity or provide recommendations to assess the appropriateness of the therapy. Additionally, there was no documented clinical rationale justifying the prescribing of two antidepressants. Resident 130, diagnosed with dementia with severe agitation and depression, was prescribed Olanzapine, an antipsychotic, without documented justification for its use. The consultant pharmacist's new admission medication review failed to identify the lack of documented justification for the continued use of Olanzapine. Furthermore, the pharmacist identified a discrepancy in the dosing of Aricept, but the resident continued to receive the medication as prescribed without timely clarification or modification. The Director of Nursing confirmed that the consultant pharmacist failed to identify and address medication regimen irregularities for both residents. Additionally, Resident 130's attending physician did not timely act upon the pharmacist's recommendations and failed to provide a documented clinical rationale for the continued use of antipsychotic medication. These deficiencies were found to be in violation of specific Pennsylvania Code regulations related to pharmacy and nursing services.
Plan Of Correction
1. The facility cannot correct the untimely action to justify the prescribing of two antidepressants. However, Resident #114 has an active Gradual Dose Reduction (GDR) in place since 02/03/25 to discontinue his Venlafaxine, removing the antidepressant duplicate therapy. The facility cannot correct the delay in the physician response to pharmacist recommendation. Medication was discontinued on 01/08/2025. Resident #130 has documented clinical rationale for the continuation of Zyprexa as ordered. 2. The DON completed an audit of in-house residents presently on duplicate antidepressant medications on 02/07/2025. Listing reviewed with consulting pharmacist. Consulting pharmacist to issue medication regimen reviews to the appropriate physician to document the clinical rationale justifying the continued prescribing of duplicate antidepressant medication. 3. The DON or designee will re-educate the consulting pharmacist, attending physicians, and medical directors to Tag F 0756 and CMS 483.45(c)(1)(2)(4)(5) requirements, along with the facility's Monthly Medication Regimen Review Policy. 4. The DON or designee will review the monthly medication reviews sent to Elan Skilled by the consulting pharmacist and compare them to the listing of new residents receiving duplicate antidepressant therapy to ensure compliance with CMS 483.45(c)(1)(2)(4)(5) and facility policy. This review will take place for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee to determine compliance.
Facility Fails to Maintain Clean and Safe Environment on 5th Floor
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents on the 5th floor, as observed on January 23, 2024. A Broda chair located in the hallway outside a resident's room was found to be heavily soiled with a crusty orange substance on the seat, a dried white and brown substance on the footrest, and dirt and debris, including a significant amount of hair, entangled in the rear wheels. Additionally, a fall mat in the resident's room was observed to have large tears, exposing the internal foam. These observations were confirmed by a licensed practical nurse and later acknowledged by the Director of Nursing and the Nursing Home Administrator, who stated that resident care equipment should be maintained in a clean and sanitary manner.
Plan Of Correction
1. The immediate corrective action for the identified Broda chair: the seat, footrest, and wheels were cleaned. Also, the fall mat in room 504 was replaced. 2. EVS Director or designee will conduct an initial audit of all Broda chairs and floor mats to identify other residents who may have the potential to be affected by deficient practice. 3. All EVS staff will be educated regarding the scheduled cleaning of Broda chairs. All nursing staff will be educated to identify and rectify fall mats that are in poor condition. 4. EVS Director or designee will audit all Broda chairs and floor mats weekly for four (4) weeks, then monthly until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.
Failure to Prevent Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. Resident 102, who was moderately cognitively impaired, had a documented history of sexually inappropriate behavior. Despite this, the facility did not implement sufficient interventions to prevent an incident where Resident 102 was observed holding Resident 289's hand on his genital region. Resident 289, who was severely cognitively impaired and unable to consent to sexual contact, expressed discomfort and confusion about the incident. The facility delayed reporting and implementing safety measures for two days after the incident. Additionally, the facility failed to prevent neglect of another resident, Resident 25, who required assistance from two staff members and a sit-to-stand lift for transfers. Employee 6, a nurse aide, assisted Resident 25 to the bathroom without following the care plan, resulting in the resident falling. The aide attempted to support the resident with her arm, but the resident became unsteady and fell, landing on his bottom. The Director of Nursing confirmed that the aide did not adhere to the care plan, which led to the fall. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the incidents involving Residents 289 and 25. The failure to address Resident 102's inappropriate behavior and the neglect of Resident 25's care plan requirements resulted in deficiencies in resident safety and care. These incidents highlight the need for the facility to ensure that staff are adequately trained and that care plans are strictly followed to prevent abuse and neglect.
Plan Of Correction
1. Resident 289 was discharged from the facility on 10/26/2024. A referral to psych services made for Resident 102 and an IDT approach continues. Resident 25 sustained no injury related to fall. Resident 25 was monitored for 72hrs and no change in condition was noted. Employee 6 was educated regarding reading residents' Kardex prior to providing care as well as abuse and neglect. 2. Residents of the facility have the potential to be affected by deficient practice. Staff records will be audited for Abuse/Neglect training over the past 12 months. Clinical Coordinator or designee will review new-hire CNA records for training in reading and adherence to the resident plan of care. 3. CNAs will be educated regarding adherence to the resident's plan of care. Facility staff will be educated regarding Abuse and Neglect upon hire and annually. 4. Director of Nursing or designee will audit all changes to the resident Kardex and Tasks five (5) times per week during the business week for two (2) weeks then weekly for four (4) weeks until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.
Failure to Implement Abuse Prohibition Procedures
Penalty
Summary
The facility failed to implement its abuse prohibition procedures in response to an alleged sexual abuse incident involving two residents. On October 7, 2024, Resident 102 was observed holding Resident 289's hand on his genital region in the lunchroom. Despite the facility's policy requiring immediate reporting of such incidents, the administration and relevant authorities were not notified until October 9, 2024, two days after the incident. The facility's policy mandates that all allegations of abuse be reported immediately to the Charge Nurse, Director of Nursing (DON), Administrator, and the resident's physician, and that the incident be reported to the Department of Health and local police within two hours. However, these procedures were not followed, resulting in a delay in reporting and investigation. Resident 289, who was severely cognitively impaired and unable to consent to sexual activity, was not protected according to the facility's policies. There was no documentation of the incident in the clinical records of either resident, and no evidence that the facility's administrator, DON, attending physician, or the resident's responsible party were notified at the time of the incident. Additionally, the facility did not develop or implement a plan to prevent future occurrences and protect Resident 289 and other female residents from Resident 102's inappropriate behavior. The facility's failure to follow its abuse reporting and investigation policies was confirmed by a Clinical Operations Executive.
Plan Of Correction
1. Resident 289 was discharged from the facility on 10/26/2024. A referral for psychological services made for Resident 102 and an interdisciplinary approach continues. 2. Facility residents have the potential to be affected by deficient practice. The facility will identify other residents on the affected unit to assess their ability to consent. Any resident without the ability to consent will be monitored for safety. The facility will continue to conduct sex offender checks for new admissions prior to facility acceptance with completion of the Trauma Informed Care evaluation upon admission, to determine resident history of and risk for abuse. 3. Facility staff will be educated regarding Abuse and Neglect policies and procedures, specifically, the reporting guidelines upon hire and annually, focusing on immediate identification, reporting of abuse, and initiating interventions for monitoring and preventing recurrence by the facility. 4. Documentation and concern forms will be reviewed daily during the business week for four (4) weeks to identify any potential areas of concern then weekly until substantial compliance is achieved. Audit results will be submitted and reviewed by the Quality Assurance Performance Improvement committee.
Failure to Implement and Document Nutritional Interventions for Weight Loss
Penalty
Summary
The facility failed to consistently implement and document interventions for significant weight loss for a resident, identified as Resident 67, who was at nutritional risk. The resident, diagnosed with diabetes and congestive heart failure, experienced a significant weight loss of 5.5% within one month, which was attributed to fluid loss from IV Lasix therapy. Despite the Registered Dietitian (RD) adjusting the resident's dietary preferences and planning for additional nutritional supplements, there was no documented evidence that these interventions were consistently implemented or communicated to the physician or responsible party in a timely manner. Further weight loss was noted, reaching an 8% loss within one month, prompting the RD to discuss and plan for the administration of Ensure pudding and ProStat as nutritional supplements. However, the Medication Administration Record (MAR) lacked documentation of the administration or consumption of these supplements. The RD confirmed that the facility failed to implement the planned nutritional interventions and did not document the physician-ordered nutritional interventions, which were crucial to maintaining the resident's nutritional parameters and preventing further weight loss.
Plan Of Correction
1. Resident # 67 has Ensure Pudding once daily and ProStat twice daily added to his EMAR to now collect supplement administration and consumption to deter weight loss. 2. The Registered Dietitian completed an audit of current in-house resident supplements ordered to ensure that both supplement administration and consumption are being captured in the medical record. 3. The Clinical Coordinator or designee will re-educate licensed nursing staff and the Registered Dietitian regarding the facility's current Weighing of Residents Policy and the order entry process for supplements to ensure consistent implementation and documentation of physician-ordered nutritional interventions to maintain nutritional parameters and deter weight loss of a resident. 4. The Registered Dietitian or designee will review current in-house and new resident orders for supplementation weekly for three months to ensure consistent implementation and documentation of physician-ordered nutritional interventions to maintain nutritional parameters and deter weight loss of a resident. Audit results will be reported to the Quality Assurance Performance Improvement committee to determine compliance.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for two residents receiving hemodialysis, as required by physician orders and facility policy. Resident 121, who has end-stage renal disease and relies on hemodialysis, was observed to have only one fanny pack containing emergency supplies on her wheelchair, with the second required pack missing from her room. This was confirmed by both the resident and a licensed practical nurse. Similarly, Resident 187, who also depends on renal dialysis, was found to have only one fanny pack on the wheelchair, with the second pack missing from the room, as confirmed by another LPN. The facility's policy mandates that residents with temporary catheters for dialysis must have an emergency protocol kit available at all times, with staff required to check the presence of these kits every shift. The absence of the second fanny pack in the rooms of both residents was confirmed by the Clinical Operations Executive, indicating a failure to comply with physician orders and facility policy. This deficiency placed the residents at risk for delayed emergency intervention in the event of complications related to their dialysis access sites.
Plan Of Correction
1. For Residents #121 and #187, fanny packs with emergency supplies were placed in the resident room and on their wheelchair per National Kidney Foundation and the facility's Care of the Dialysis Resident Policy/Procedure. 2. The DON assessed current in-house hemodialysis residents on 02/05/2025. Current in-house hemodialysis residents had a fanny pack with emergency supplies located both in the resident room and on the resident wheelchair. 3. The Clinical Coordinator or designee will re-educate licensed facility staff regarding the facility's Care of the Dialysis Resident Policy/Procedure requirement for a fanny pack with emergency supplies to always be available in the resident room and on the resident wheelchair. 4. The DON or designee will continue to review current in-house hemodialysis residents weekly to assure compliance regarding the facility's Care of the Dialysis Resident Policy/Procedure requirement for a fanny pack with emergency supplies to be always located both in the resident room and on the resident wheelchair. This weekly review will continue for the next three months. Audit results will be reported to the Quality Assurance Performance Improvement committee monthly for three months to assure continued compliance.
Failure to Provide Routine Dental Services to a Medicaid Resident
Penalty
Summary
The facility failed to provide routine annual dental services to a resident whose payor source was Medicaid. The resident, identified as Resident 88, was admitted to the facility on an unspecified date, and there was no documented evidence that dental services had been offered to them in the past year. This deficiency was confirmed during an interview with the Clinical Operations Executive on January 23, 2025, who acknowledged that the facility had not offered the required dental services to Resident 88. The survey concluded on January 24, 2025, without any record of dental services being provided to the resident.
Plan Of Correction
1. Resident 88 was referred to in-house dental services. 2. All residents have the potential to be affected by deficient practice. Director of Nursing will audit all residents to identify any resident who may not have had dental services. 3. Social Services will be educated regarding the Dental Services Policy and Procedures. 4. All residents are offered dental services upon admission. All residents without dental services in the previous 12 months will be offered dental services. All residents will be scheduled for dental services per policy and procedure. Social Services or designee will audit Dental services monthly until substantial compliance is achieved. All results will be submitted and reviewed in QAPI.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in three specific locations, affecting three out of six floors. During an observation on January 7, 2025, several deficiencies were noted: the make-up air room in the basement lacked a suspended ceiling assembly with surface-mounted sprinkler heads; a plastic bag material was found affixed to an automatic sprinkler head in the fifth-floor Personal Laundry; and a sprinkler head assembly in the first-floor Dietary Office was missing an escutcheon plate. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
Observation 1: The make-up air room, located at the basement level, lacked a suspended ceiling assembly (surface-mounted sprinkler heads). 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? The current 2 sprinkler heads in the air make-up room are scheduled to be inverted to upright heads. The remainder of the drop ceiling will be removed. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the inspection findings to the QAPI committee. Observation 2: Plastic bag material was affixed to an automatic sprinkler head, located within the fifth floor Personal Laundry. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? Plastic bag material was removed from the automatic sprinkler head in the fifth floor personal laundry area. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the findings to the QAPI committee. Observation 3: A sprinkler head assembly, located within the first floor Dietary Office, lacked an escutcheon plate. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored? The escutcheon plate on the sprinkler assembly in the Dietary Office was replaced. Sprinkler head and in-house fire inspections will be completed quarterly. The Director of Facilities Management will report the findings to the QAPI committee.
Smoke Barrier Door Deficiency on Fifth Floor
Penalty
Summary
The facility failed to maintain the smoke barrier separation doors on the fifth floor, specifically the Clay Street smoke barrier doors. During an observation on January 7, 2025, at 11:07 a.m., it was noted that these doors required adjustment to fully latch. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day, between 12:15 p.m. and 12:20 p.m.
Plan Of Correction
Observation 1: Observation revealed the fifth floor, Clay Street smoke barrier separation doors required adjustment to fully latch. 1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored: The Smoke Barrier Separation Door was adjusted to fully closed by the Assistant Director of Maintenance. All Barrier separation doors will be inspected to ensure proper closing during all fire drills by the members of our Maintenance team on their assigned floors during the fire drills. Barrier Separation door inspections will be submitted to QAPI Committee Quarterly by the Director of Maintenance and presented for review/discussion.
Excessive Building Height Deficiency
Penalty
Summary
The facility was found to have exceeded the maximum allowable story height for its type of construction, which is classified as an unprotected, noncombustible building. This deficiency was observed during a survey conducted on January 7, 2025, between 10:30 a.m. and 11:00 a.m. The building was noted to be three stories higher than permitted for its construction type, affecting all six floors of the facility. This finding was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day.
Inadequate Fire Resistance in Vertical Enclosures
Penalty
Summary
The facility failed to maintain the required fire resistance rating for multiple vertical enclosures, affecting all six floors. During an observation on January 7, 2025, it was noted that the vertical enclosures protecting the HVAC shafts adjacent to the exit stair towers did not meet the necessary two-hour fire resistance rating. Additionally, the construction of the Clay Street exit stair tower on the fourth and fifth floors was found to be inadequate, consisting of two sheets of drywall on the inside and one sheet on the corridor and resident room side of metal studs, with unprotected steel beams included as part of the enclosure. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Failure to Respect Resident Dignity During Meal Service
Penalty
Summary
The facility failed to conduct meal service in a manner respectful of each resident's personal dignity, specifically for one resident with severe cognitive impairment and dementia. This resident, who requires supervision and assistance when eating, was observed sitting with her meal in front of her for 25 minutes without any staff assistance or encouragement to eat. During this time, staff were assisting other residents, and the resident was left unassisted despite her care plan indicating the need for limited staff assistance and participation in the feeding assistance program. Interviews with staff revealed that the unit is often understaffed, leading to delays in providing necessary assistance to residents during meals. Staff acknowledged that the resident's meal should not have been placed in front of her until assistance was available. The Director of Nursing confirmed the high acuity of residents requiring meal assistance on the unit and acknowledged the facility's responsibility to ensure residents are treated with respect and dignity, which was not upheld in this instance.
Failure to Document Nutritional Intake for Resident Receiving Hospice Services
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, identified as Resident CR1, who was admitted with a diagnosis of cerebral infarction. Physician's orders indicated that hospice services were initiated for the resident on March 26, 2023, and monthly weight monitoring was discontinued on March 28, 2023. However, a documentation survey report for August 2024 revealed that there was no documented information regarding the resident's nutritional intake for 18 meals during that month. Additionally, the progress notes from August 1, 2024, through August 29, 2024, lacked documentation of the resident's nutritional intake. The resident was discharged to home with external hospice provider services on August 29, 2024. During an interview, the Director of Nursing confirmed the facility's responsibility to ensure accurate and complete clinical records and acknowledged the failure to document the resident's nutritional intake, without providing an explanation for the oversight.
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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