Elizabethtown Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Elizabethtown, Pennsylvania.
- Location
- 141 Heisey Avenue, Elizabethtown, Pennsylvania 17022
- CMS Provider Number
- 395844
- Inspections on file
- 24
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Elizabethtown Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not provide required written transfer and bed-hold notices to residents or their representatives during hospitalizations. Several residents with complex medical conditions were transferred without receiving documentation outlining the reason for transfer, appeal rights, or bed-hold policy, as confirmed by clinical record review and DON interviews.
The facility did not update care plans for several residents to reflect changes in their medical conditions, treatments, or physician orders. Examples include a resident admitted to hospice without hospice care planning, a resident no longer needing a sling or extensive transfer assistance, and care plans listing outdated interventions or medications. The DON confirmed that care plans should have been revised to match current needs.
The facility did not ensure that annual written performance evaluations were completed for nurse aides who had been employed for over a year, as required by facility policy and state regulations. The DON confirmed that although staff performance was discussed informally, a formal evaluation process was not in place.
Surveyors identified that three residents' assessments were not accurately coded, including errors in documenting medication use, weight loss, and medication dose reductions. The DON confirmed that these MDS assessments did not reflect the residents' actual clinical status.
A resident with a history of venous thrombosis, embolism, and hypertension was admitted and received medications for pain and anticoagulation, but the baseline care plan did not address pain management or anticoagulant use as required by facility policy. The DON confirmed these omissions during an interview.
A resident with a history of falls and mobility issues experienced multiple incidents where staff did not use the required sit-to-stand lift during transfers, as outlined in the care plan. Additionally, after these falls, proper investigation protocols were not followed, including failure to notify the DON and collect witness statements, and a new fall intervention was not added to the care plan as required.
The facility did not consistently provide physician-ordered nutritional supplements to two residents and failed to notify the physician of significant weight loss for two residents. Documentation showed that supplements were often unavailable and not administered as ordered, and there was no evidence that the physician was informed of missed doses or significant weight changes, despite facility policy requiring such notifications.
A resident with PTSD did not receive a timely trauma assessment or have an individualized, person-centered care plan developed and implemented for trauma-informed care. Despite facility policy requiring universal trauma screening and care planning, the resident's records lacked documentation of trauma history, symptoms, or triggers, and staff confirmed that trauma assessments were not being completed.
Surveyors observed that two opened vials of tuberculosis PPD solution in the medication storage room were not labeled with the date they were first accessed, as required by facility policy. An LPN and the DON both confirmed that the vials were opened and lacked the necessary labeling.
A resident admitted with hypertension and bilateral leg fractures did not have timely or complete physician progress notes in their medical record. Facility staff confirmed that the process for receiving and filing physician notes was unclear, and only a few notes were obtained after direct requests, with no assurance of regular or timely documentation as required by policy.
Elizabethtown Nursing and Rehabilitation failed to comply with infection control protocols when a Physical Therapist provided care to two residents under droplet precautions for COVID-19 without wearing the required PPE. Despite being educated on the facility's COVID-19 policies, the staff member neglected to wear an N95 mask, face shield or goggles, gloves, and gown, as mandated by the facility's updated protocols.
The facility did not maintain a data collection system for infection surveillance for 10 months, as required by its infection control policy. The infection control logs were blank for October 2023 through July 2024, and the Nursing Home Administrator confirmed the deficiency was due to the lack of a trained Infection Preventionist.
The facility failed to comply with regulations requiring a qualified Infection Preventionist (IP) for its Infection Prevention and Control Program (IPCP). The DON confirmed that the designated IP, a registered nurse, had not completed the necessary certification modules. Additionally, no infection control data had been tracked since September 2023, highlighting a lapse in infection control practices.
The facility did not offer residents the opportunity to formulate an advance directive, as required. A review of clinical records and interviews with staff revealed that four residents were not documented as having been informed about their right to create an advance directive or living will. The facility's admission packet required residents to provide an executed advance directive but did not indicate that they were offered the chance to formulate one.
The facility did not promptly resolve resident grievances and failed to post complete contact information for the Grievance Official. Grievance forms lacked documentation of responses, and the bulletin board did not include the Grievance Official's full contact details.
The facility failed to follow food safety standards, with unlabeled food items and expired pH strips in the kitchen. During meal service, a cook did not perform hand hygiene after touching a trash lid, continuing to serve food with contaminated gloves. The Director of Dining confirmed the lapse in protocol.
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of a system to monitor antibiotic usage for two residents. Antibiotics were prescribed without proper justification or monitoring, and the facility lacked an infection preventionist and the required tracking form.
The facility did not ensure proper documentation of vaccine consents and education for two residents. One resident had no record of pneumococcal vaccination and lacked documentation of influenza vaccine education and consent. Another resident was offered the influenza vaccine, but there was no documentation of education or consent. The DON confirmed these documentation lapses.
The facility failed to offer and document current COVID-19 vaccinations for four residents, as required by policy. Clinical records lacked documentation of vaccine offers, education on risks and benefits, and consents or refusals. The DON confirmed the absence of necessary documentation.
The facility did not post required information about State agencies and advocacy groups on the bulletin board for resident review. An observation revealed the absence of this information, which was confirmed by the Nursing Home Administrator.
The facility did not ensure residents could access the most recent survey results. The survey results book was found in a locked area requiring a code for access, and no survey books were available in resident areas. The Nursing Home Administrator confirmed the book should not have been in a locked area.
The facility did not inform two residents of the costs for services not covered under Medicare at the end of their Medicare stay. One resident's Medicare A coverage ended without being informed of the estimated costs for non-covered services, and the same occurred for another resident. The Nursing Home Administrator acknowledged the residents' right to be informed of these costs.
The facility failed to provide written notifications to residents, their representatives, and the State Ombudsman regarding hospital transfers, lacking essential details such as reasons for transfer and appeal rights. This deficiency was noted in two residents' records, where verbal communication was used instead of documented written notices.
A facility failed to provide a written bed-hold notice to a resident and their representative during a hospital transfer. The resident, with a history of depression, diabetes, hemiparesis, stroke, and epilepsy, was transferred for blood in her stool. Interviews revealed that the facility's process involves nursing staff informing the resident's representative about the transfer and bed-hold options, but no documentation of this communication was found.
A facility failed to create a comprehensive care plan for a resident with COPD using oxygen therapy. Despite the facility's policy requiring individualized care plans, none was developed for the resident's oxygen use. The resident was observed using an oxygen concentrator, and the DON confirmed the absence of a specific care plan.
The facility failed to document medication administration and refusals for two residents. One resident's MAR showed missing documentation for multiple medications and treatments, with no record of refusal. Another resident's MAR indicated several medications were not administered, also lacking refusal documentation. The DON confirmed that refusals should be documented on the MAR.
A facility failed to ensure proper documentation for a resident receiving oxygen therapy. The resident, diagnosed with COPD and muscle weakness, was observed using an oxygen concentrator without any physician orders in her clinical records. The DON confirmed the absence of a physician's order for the oxygen use.
A facility failed to ensure that a licensed pharmacist's report of a medication irregularity was reviewed and acted upon for a resident. The facility's policy requires monthly reviews of each resident's medication regimen, but there was no documentation for Resident 24, who had multiple diagnoses and medications. Interviews revealed that reviews were conducted off-site, but documentation was missing, indicating a lapse in policy adherence.
A facility failed to properly label insulin pens in a resident's medication compartment, as observed during a medication cart review. A Novolog insulin pen lacked a resident identifier and the date it was removed from refrigeration, contrary to facility policy. Additionally, two Lantus insulin pens were found without proper labeling. The LPN confirmed the oversight, and the DON acknowledged the policy breach.
The facility failed to ensure the Medical Director and Infection Preventionist attended QAPI Committee meetings as required, with the Medical Director absent from one meeting and no credentialed IP present at any meetings. Additionally, a sign-in sheet for the first quarter was missing, indicating a lack of documentation. The Nursing Home Administrator confirmed these deficiencies.
Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notifications to residents or their representatives regarding transfers to the hospital, including the reason for transfer or discharge, date and location of transfer, statement of appeal rights, and contact information for the State Long Term Care Ombudsman. Additionally, the facility did not provide written notice of the bed-hold policy at the time of transfer for all residents reviewed who were hospitalized. This was confirmed through facility policy review, clinical record review, and staff interviews, which revealed that nursing staff were not completing or sending the necessary notices as required by facility policy. Specific examples included residents with diagnoses such as wedge compression fracture, hypertension, anxiety disorder, congestive heart failure, and acute respiratory failure, who were transferred to the hospital without the appropriate documentation being provided. In some cases, there was no evidence in the clinical record that the bed-hold policy or transfer notice was reviewed or given to the resident or their representative. Interviews with the DON confirmed that staff were unaware of the requirement to complete these notices, resulting in the deficiency.
Failure to Timely Review and Revise Resident Care Plans
Penalty
Summary
The facility failed to review and revise the care plans for five out of thirteen residents as required by policy and federal regulations. The care plans were not updated to reflect significant changes in residents' conditions or treatments. For example, one resident was admitted to hospice care, but the care plan was not updated to include hospice services. Another resident no longer required a sling or extensive assistance with transfers, yet the care plan still listed these interventions. Additionally, a resident's care plan included an active urinary tract infection, although the resident no longer had this condition. Further deficiencies were observed with residents whose care plans did not reflect current medication regimens or physical needs. One resident's care plan indicated a risk for adverse effects from antianxiety medication, despite the resident no longer receiving such medication. Another resident's care plan continued to list the use of a cervical collar, even though physician orders and progress notes indicated the collar had been discontinued following a surgical evaluation. Interviews with the DON confirmed that care plans should be updated promptly to reflect changes in residents' conditions, treatments, and physician orders. However, the care plans for these residents were not revised in a timely manner, resulting in discrepancies between the documented plan of care and the residents' actual needs and treatments.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual written performance evaluations for nurse aides as required by its Employee Handbook and state regulations. Documentation review showed that five nurse aides, all employed for over a year, did not have evidence of a formal annual evaluation. The Employee Handbook specifies that all employees must receive a written annual rating and evaluation by their department supervisor, to be reviewed and signed by the employee. During an interview, the DON stated that while staff performance is discussed informally, there was no formal process in place for conducting and documenting annual evaluations at the time of the survey.
Inaccurate Resident Assessments Documented in Multiple Cases
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' current status for three out of thirteen residents reviewed. For one resident with multiple diagnoses including depression, anxiety, intellectual disabilities, PTSD, cerebral palsy, and encephalopathy, the Minimum Data Set (MDS) assessment incorrectly indicated that the resident was still receiving an anticoagulant medication, even though it had been discontinued. The Director of Nursing (DON) confirmed that the MDS was inaccurate and the care plan was not updated to reflect the medication change. Another resident, who was at risk for malnutrition and had experienced significant weight loss, had an MDS assessment that failed to accurately document the weight loss, marking it as "No or unknown" despite clear evidence of an 11% loss in less than a month. A third resident with dementia, anxiety disorder, and delusional disorder had MDS assessments that inaccurately recorded the use of antipsychotic, antianxiety, and anticonvulsant medications, either omitting a documented dose reduction or indicating use of medications not actually administered. In each case, the DON acknowledged the MDS coding errors during interviews.
Failure to Develop Baseline Care Plan for Pain and Anticoagulant Use
Penalty
Summary
The facility failed to develop a baseline plan of care within 48 hours of admission for a newly admitted resident, as required by facility policy. Specifically, the interdisciplinary team did not include care plans for pain management or anticoagulant use, despite the resident's documented medical history and current physician orders. The resident had a history of venous thrombosis, embolism, and hypertension, and was observed wearing a lidocaine patch for chronic right knee pain. Physician orders indicated the resident was receiving meloxicam and topical lidocaine for pain, as well as an anticoagulant medication. A review of the resident's baseline care plan revealed that neither pain management nor anticoagulant use was addressed. During an interview, the DON confirmed that these care needs should have been included in the baseline care plan. The deficiency was identified through clinical record review, observation, staff and resident interviews, and facility policy review.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, as well as to conduct thorough fall investigations. Review of the clinical record and fall reports for a resident with a history of wedge compression fracture, unspecified fall, and unsteadiness on feet revealed multiple incidents where staff did not follow the care plan interventions. Specifically, during two separate falls, staff did not utilize the sit-to-stand (sts) lift as required by the resident's care plan. Additionally, after one of these falls, the responsible RN did not notify the Director of Nursing (DON) as per facility protocol, resulting in an incomplete investigation and lack of witness statements. Further review showed that after another fall, a new intervention was documented in the fall report but was not added to the resident's comprehensive care plan. Interviews with the DON confirmed that expected procedures, such as updating the care plan and collecting witness statements, were not followed. These failures demonstrate lapses in both the implementation of fall prevention interventions and the facility's post-fall investigation process.
Failure to Provide Ordered Nutritional Supplements and Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to provide physician-ordered nutritional supplements as prescribed for two residents and did not notify the physician of significant weight changes for two residents. For one resident with multiple diagnoses including depression, anxiety, intellectual disabilities, cerebral palsy, and encephalopathy, there was a documented 10-pound weight loss over one month. Physician orders required a house supplement after meals, but the Medication Administration Record (MAR) showed multiple instances where the supplement was not administered due to unavailability. Progress notes confirmed the supplement was not available on several dates, and there was no documentation that the physician was notified of these missed doses. Another resident experienced a significant weight loss of over 10% in one month, but the clinical record did not show that the physician was notified of this change. The DON stated that the dietitian emails weight loss notifications to nursing leadership, but there was a misunderstanding about who was responsible for notifying the physician, resulting in a lack of physician notification. A third resident, at risk for malnutrition and with dysphagia, also had a significant weight loss and a physician order for a daily house supplement. The MAR indicated several days when the supplement was not available, and again, there was no documentation of physician notification regarding the missed supplement or the significant weight loss. Observations during the survey confirmed that the ordered supplements were not consistently available in medication carts, nourishment pantries, or central supply. Staff interviews corroborated that the supplement was sometimes unavailable and that the physician should have been notified when supplements could not be administered or when significant weight changes occurred. Facility policy required both the administration of supplements as ordered and physician notification of significant weight changes, but these procedures were not followed.
Failure to Complete Trauma Assessment and Care Planning for Resident with PTSD
Penalty
Summary
The facility failed to complete a timely trauma assessment and did not develop or implement an individualized, person-centered care plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Policy review indicated that nursing staff are to be trained on trauma screening tools, trauma assessment, and identification of triggers associated with re-traumatization, and that universal screening for trauma should be implemented. However, review of the resident's clinical record, hospital discharge summary, and the CMS 802 form confirmed the diagnosis of PTSD, but there was no evidence of a trauma history screening, documentation, or care planning related to trauma-informed care as required by facility policy. Further review of the resident's care plan did not include the resident's PTSD diagnosis, symptoms, or triggers. During an interview, the DON stated that the facility does not complete a trauma assessment because it is not available in the electronic record, although a form exists for this purpose. It was also revealed that the Social Worker would be responsible for completing the trauma-informed care assessment, but this had not been done at the time of the review.
Failure to Label Opened Multi-Dose Vials in Medication Room
Penalty
Summary
Surveyors found that the facility failed to comply with its own policy and accepted professional principles regarding the labeling of multi-dose vials. During an observation of the medication storage room, two vials of tuberculosis purified protein derivative (PPD) solution were found to have been opened, but neither vial nor their packaging was labeled with the date they were first accessed. A Licensed Practical Nurse confirmed that the vials appeared to have been accessed and lacked open dates. The Director of Nursing also confirmed that the open dates should have been documented on the PPD solution, as required by facility policy and professional standards.
Incomplete and Delayed Physician Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for one resident. According to facility policy, attending physicians are required to provide timely and pertinent documentation, including a progress note at each visit, which should be placed in the medical record within a week. However, review of the clinical record for a resident admitted with hypertension and bilateral fibula fractures revealed no physician progress notes since admission as of the date of review. Interviews with the DON and NHA confirmed that the process for receiving, printing, and placing physician notes on resident charts was unclear, and that the physician responsible for the resident was not timely in providing documentation. Only three progress notes were eventually obtained after the DON contacted the physician, and there was no evidence of additional notes or confirmation of when the resident was last seen by the physician. Both the DON and NHA acknowledged that physician progress notes were not consistently available within the expected timeframe outlined in facility policy.
Infection Control Breach by Staff
Penalty
Summary
Elizabethtown Nursing and Rehabilitation was found to be non-compliant with infection prevention and control requirements as outlined in 42 CFR Part 483.80. During an abbreviated survey, it was observed that the facility failed to maintain an effective infection prevention and control program. Specifically, a Physical Therapist, identified as Employee 4, was seen providing direct care to two residents who were under droplet precautions due to COVID-19 without wearing the required personal protective equipment (PPE). This included the absence of an N95 mask, face shield or goggles, gloves, and gown, which were mandated by the facility's updated COVID-19 infection control protocols. The deficiency was further confirmed through interviews with the Director of Nursing (DON), Nursing Home Administrator (NHA), and the Registered Nurse/Infection Preventionist. They acknowledged that Employee 4 had been educated on the facility's COVID-19 policy and procedures but neglected to adhere to them while providing care to the residents. The facility's policy required staff to don specific PPE when entering rooms of residents with COVID-19 exposure or positive tests, which was not followed in this instance, leading to a breach in infection control protocols.
Plan Of Correction
1. Residents 1 and 2 no longer on droplet precautions for Covid 19. Physical Therapist (employee 4) was educated after being identified as not donning proper PPE to enter resident 1 and 2's room and providing therapy services and expressed understanding of why it was important to follow isolation precautions including use of proper PPE when providing treatment for any residents on isolation. Employee 4 donned proper PPE for the remainder of their shift when entering any rooms designated as isolation rooms and providing therapy services. 2. Director of Nursing/designee will conduct a facility wide audit of current residents on isolation precautions to ensure staff are following infection control guidelines including proper donning of PPE prior to entering these identified rooms and for the care of residents on isolation. 3. Director of Nursing/designee will educate facility staff including therapy service staff on Ftag 880 and the importance of following infection control guidelines including donning PPE prior to entering isolation rooms and for care of residents on isolation precautions. 4. Director of Nursing/designee will conduct a random sample audit of 5 residents on isolation precautions to ensure staff are following infection control guidelines including donning appropriate PPE prior to entering isolation rooms and for the care of residents on isolation precautions. These audits will be conducted weekly for 4 weeks and monthly for two months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.
Inadequate Infection Surveillance System
Penalty
Summary
The facility failed to maintain a data collection system for infection surveillance for 10 out of 12 months reviewed. According to the facility's policy on infection control, a monthly line list of residents with infections should be maintained for trending and outbreak potential, with follow-up reviews of lab data and monthly reviews to identify trends. However, the infection control logs for the months of October 2023 through July 2024 were blank, indicating a lack of data entry. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the monthly infection control line list data was not being completed due to the absence of a trained or credentialed Infection Preventionist at the facility.
Inadequate Infection Preventionist Training and Data Tracking
Penalty
Summary
The facility was found to be non-compliant with the requirement to have a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP). According to the Centers for Medicare and Medicaid Services regulation S483.80(b)(4), the facility must designate one or more individuals as IPs who have completed specialized training in infection prevention and control. During an interview with the Director of Nursing (DON), it was revealed that the registered nurse designated as the IP, referred to as Employee 4, had not yet completed the necessary certification modules for the IP position. Furthermore, the DON admitted that no infection control data had been tracked since September 2023, indicating a lapse in the facility's infection control practices.
Failure to Offer Advance Directive Formulation
Penalty
Summary
The facility failed to offer residents the opportunity to formulate an advance directive, as required by regulations. This deficiency was identified through a review of the facility's policy, clinical records, and staff interviews. The facility's admission packet indicated that residents must provide a valid executed original advance directive to the Nursing Home Administrator, but there was no indication that residents were offered the opportunity to create one. Specifically, the clinical records of four residents did not include any documentation of discussions regarding the formulation of an advance directive or living will. During an interview with the Nursing Home Administrator and Director of Nursing, it was revealed that the facility could not locate any additional documentation showing that these residents were informed about their right to formulate an advance directive or living will at the time of admission or during their stay. This lack of documentation and failure to offer the option to create an advance directive was noted for four out of 35 records reviewed.
Failure to Resolve Grievances and Incomplete Grievance Official Information
Penalty
Summary
The facility failed to promptly resolve resident grievances and did not adequately post the contact information of the Grievance Official. A review of the facility's grievance policy highlighted the requirement for a written Grievance Decision, which should include details such as the date the grievance was received, a summary of the grievance, steps taken to investigate, and any corrective actions. However, the facility's grievance forms revealed deficiencies in this process. One grievance form, filed by a resident requesting ginger ale, lacked a date and did not document any staff response or resolution. Another grievance form, dated May 31, 2024, concerning missing glasses, also lacked documentation of the facility's response. Additionally, an observation of the facility's bulletin board showed that while the name of the Grievance Official was posted, the required contact information, including the business address and email, was missing. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that only the name and phone number of the Grievance Official were displayed. These findings indicate a failure to adhere to the facility's grievance policy and to ensure residents have access to complete contact information for the Grievance Official.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in both the kitchen and nourishment pantry, as well as during meal service. Observations revealed that a plastic container with bulk thickener in the kitchen was not labeled with its contents or date, contrary to the facility's policy. Additionally, pH test strips were unavailable at the three-compartment sink, and the existing strips were expired. In the nourishment pantry, several food items, including ice cream and a sandwich, were not date-marked or labeled with a resident identifier, and personal food items were improperly stored. During a lunch meal service, a cook was observed handling food with gloves that had been contaminated by touching a trash lid, without performing hand hygiene before continuing to serve food. This was confirmed by the Director of Dining, who acknowledged that the cook should have changed gloves and completed hand hygiene after touching the garbage can lid. The Nursing Home Administrator and Director of Nursing were informed of these issues, but no further information was provided regarding the expired pH strips or food storage concerns.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of a system to monitor antibiotic usage for two residents. The facility's policy required the collection and documentation of antibiotic usage and outcomes using a facility-approved tracking form. However, during the survey, it was found that the facility had not implemented this system since September 2023. This deficiency was highlighted by the cases of two residents who were prescribed antibiotics without proper justification or monitoring. Resident 6 was prescribed Cipro for urinary symptoms before urinalysis results were available, and the facility could not provide these results. Similarly, Resident 23 was given Bactrim DS despite urinalysis results indicating no need for a culture, and there was no documented reason for the antibiotic use. The Director of Nursing and Nursing Home Administrator confirmed the absence of an infection preventionist and the required tracking form, indicating a lapse in the facility's antibiotic stewardship program.
Failure to Document Vaccine Consents and Education
Penalty
Summary
The facility failed to ensure that residents were offered influenza and pneumococcal vaccinations as required, specifically for two residents. The facility's policy mandates that residents or their legal representatives receive information about the risks and benefits of vaccines, with consents and refusals documented in the clinical record. However, for one resident, there was no record of pneumococcal vaccination, and no documentation of education on risks and benefits, or consent or refusal for the influenza vaccine. For another resident, although the influenza vaccine was offered, there was no documentation of education on risks and benefits, or consent or refusal. The Director of Nursing confirmed the lack of documentation and acknowledged that the policy should be followed.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered current COVID-19 vaccinations as required, affecting four out of five residents reviewed. The facility's policy, last reviewed in June 2024, mandates that residents or their legal representatives receive information about the risks and benefits of the vaccine before it is administered, and that consents and refusals be documented in the resident's clinical record. However, the clinical records for Residents 1, 12, 33, and 41 lacked documentation of vaccine offers, education on risks and benefits, and consents or refusals. Resident 1's record showed no documentation of any COVID-19 vaccine offer since admission. Resident 12 had a historical vaccine from 2021, but no current offer or documentation of education was present. Resident 33 refused the first dose, but there was no documentation of education or refusal in the clinical record. Similarly, Resident 41 had a historical vaccine from 2021, but no current offer or documentation of education was recorded. The Director of Nursing confirmed the absence of required documentation and acknowledged that the facility's policy should have been followed.
Failure to Post Required State Agency and Advocacy Group Information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, as well as a statement that residents may file a complaint with the State Survey Agency. This deficiency was identified during an observation of the facility's bulletin board, which is intended for resident review. The observation, conducted on July 15, 2024, at 11:04 AM, revealed that the required information was not present. This omission was confirmed during an interview with the Nursing Home Administrator on July 17, 2024, at 1:40 PM, who acknowledged that the information was not posted at the time of the observation.
Survey Results Inaccessibility
Penalty
Summary
The facility failed to ensure that residents had the right to examine the results of the most recent survey, as required. An observation in the facility's lobby revealed that the survey results book was located in an area that required a code for access, making it inaccessible to residents. Further observations in resident areas, such as the dining area, common area, nurses' station, and designated activities area, showed no survey books available for resident review. An interview with the Nursing Home Administrator confirmed that the survey results book should not have been placed in a locked area, and it was later made accessible in resident areas.
Failure to Inform Residents of Non-Covered Service Costs
Penalty
Summary
The facility failed to ensure that residents were periodically informed of any charges for services not covered under Medicare, specifically at the end of a Medicare stay. This deficiency was identified for two residents. For Resident 1, the Skilled Nursing Facility Beneficiary Notification Review form indicated that Medicare A coverage ended on April 30, 2024. However, the facility did not provide an estimated cost of non-covered services to Resident 1 or her responsible party. Similarly, for Resident 148, the Medicare A coverage ended on February 17, 2024, and the facility again failed to provide the estimated cost of non-covered services to Resident 148 or her responsible party. The Nursing Home Administrator confirmed that residents and/or their representatives have the right to be informed of these costs.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents, their representatives, and the State Long-Term Care Ombudsman regarding hospital transfers, including essential details such as the reason for transfer, date, location, appeal rights, and contact information for the Ombudsman. This deficiency was identified in the records of two residents who were transferred to the hospital. Resident 19, with a medical history including depression, diabetes, hemiparesis, stroke, and epilepsy, was transferred to the hospital for blood in her stool but did not receive the required written notification. Similarly, Resident 46's record also lacked documentation of the transfer notice. Interviews with the Nursing Home Administrator (NHA) revealed that the facility's practice involved verbal communication of transfers to the responsible party by nursing staff and monthly email reports of transfers to the State Ombudsman by the Social Worker. However, there was no paper documentation of these notifications for the residents or their representatives, nor was there communication to the State Ombudsman or a bed hold notice for Resident 19. This lack of documentation and communication led to the identified deficiency.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident and their representative during a hospital transfer. Resident 19, who has a medical history including depression, diabetes mellitus, hemiparesis, stroke, and epilepsy, was transferred to the hospital due to blood in her stool. The clinical record did not document that the bed-hold notice was communicated to the resident or their representative at the time of transfer. Interviews with the Nursing Home Administrator and Business Office Manager revealed that the facility's process involves nursing staff calling the resident's representative to inform them of the transfer and discuss the bed-hold option and daily rate. However, there was no paper documentation of this communication or the bed-hold notice for Resident 19. The administrator confirmed that the bed-hold form should be completed by the nurse if requested, but this was not done in this case.
Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving oxygen therapy. The facility's policy, revised in September 2013, mandates the interdisciplinary team to create individualized care plans for each resident. However, a review of the resident's interdisciplinary plan of care showed no plan addressing the use of oxygen, goals, or interventions. The resident had diagnoses including chronic obstructive pulmonary disease (COPD) and muscle weakness and was observed using an oxygen concentrator in bed. An interview with the Director of Nursing confirmed that no specific care plan for the resident's oxygen use had been developed or implemented.
Failure to Document Medication Administration and Refusals
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards regarding medication and treatment administration for two residents. For Resident 24, the Medication Administration Record (MAR) for July 2024 showed missing documentation for several medications and treatments, including Atorvastatin, Famotidine, Humalog, Lantus, Haloperidol, Oxycontin, Gabapentin, and blood sugar monitoring (accu-checks) on specific dates. There was no documentation of medication refusal or treatment refusal in the progress notes for the period reviewed. Similarly, for Resident 40, the MAR for July 2024 indicated that several medications, including Melatonin, Omeprazole, Glimepiride, Magnesium Oxide, and Metformin, were not administered on a specific date. The progress notes for Resident 40 also lacked documentation of any refusal of medications. During an interview, the Director of Nursing confirmed that any medication refusals should be documented on the MAR, which was not done in these cases.
Failure to Document Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident receiving oxygen therapy. Resident 40, who has diagnoses including chronic obstructive pulmonary disease (COPD) and muscle weakness, was observed using an oxygen concentrator in her room. However, a review of her clinical records revealed no physician orders documenting the need and use of oxygen. An interview with the Director of Nursing confirmed that the facility could not locate a physician's order for the resident's oxygen use.
Failure to Document Monthly Pharmacy Medication Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's report of a medication irregularity was reviewed and acted upon for one of the residents reviewed for unnecessary medications. The facility's policy, revised in April 2007, mandates that a consultant pharmacist should review each resident's medication regimen monthly. However, for Resident 24, there was no documentation in the clinical record to confirm that these monthly pharmacy medication reviews were completed. Resident 24 had multiple diagnoses, including depression, diabetes mellitus, and schizoaffective disorder, and was prescribed several medications, including escitalopram, Humalog, Lantus, Haloperidol, and Oxycontin. Interviews with facility staff revealed that the monthly pharmacy medication reviews were not documented in the resident's hard chart or medical record. The Director of Nursing disclosed that these reviews are conducted off-site, and the pharmacy is supposed to send a list of residents reviewed along with any recommendations from the pharmacist. However, there was difficulty in locating documentation to verify that the monthly pharmacy reviews were completed, indicating a lapse in the facility's adherence to its medication therapy policy.
Medication Labeling Deficiency in Insulin Management
Penalty
Summary
The facility failed to adhere to appropriate labeling of medications, specifically insulin pens, as observed during a medication cart review. A Novolog insulin pen was found in a resident's medication compartment without a resident identifier or the date it was removed from the refrigerator. According to the facility's policy, insulin pens should be labeled with the resident's name and the date they are opened. The Licensed Practical Nurse confirmed the labeling oversight and discarded the improperly labeled insulin pen. Additionally, two Lantus insulin pens were found in the same resident's medication compartment without proper labeling, lacking both the resident's name and the date they were removed from refrigeration. The Director of Nursing acknowledged that the facility's policy was not followed, as both the Novolog and Lantus insulins should have been labeled correctly. This oversight was identified through observations, staff interviews, and a review of the facility's medication administration policy.
QAPI Committee Attendance and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure compliance with federal regulations regarding the composition and attendance of the Quality Assurance Process Improvement (QAPI) Committee. Specifically, the Medical Director was not present at the QAPI Committee meeting held on November 8, 2023, and there was no credentialed Infection Preventionist (IP) in attendance at any of the meetings reviewed. Additionally, the facility did not provide a sign-in sheet for the QAPI Committee meeting for the first quarter of the year, indicating a lack of documentation for that period. During an interview, the Nursing Home Administrator confirmed these deficiencies, acknowledging the absence of the Medical Director at one of the four meetings and the lack of an IP at any of the meetings. The facility's failure to maintain proper attendance and documentation for the QAPI Committee meetings is a violation of the Code of Federal Regulations, which mandates the presence of specific members, including the Medical Director and IP, at least quarterly to coordinate and evaluate activities under the QAPI program.
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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