Ellen Memorial Rehabilitation And Healthcare Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Honesdale, Pennsylvania.
- Location
- 23 Ellen Memorial Lane, Honesdale, Pennsylvania 18431
- CMS Provider Number
- 395357
- Inspections on file
- 24
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Ellen Memorial Rehabilitation And Healthcare Cente during CMS and state inspections, most recent first.
A cognitively intact resident with right-sided hemiplegia and recent decline in mobility had an updated care plan and therapy recommendation requiring a stand-up lift and two-person assistance for transfers and ambulation with a rollator and gait belt. Despite this, the resident was assisted to ambulate to the bathroom by a single CNA using only a walker, after the resident reportedly insisted on walking and was told to prove herself by using the walker. While turning to sit on the toilet, the resident fell, was found with the left foot twisted backward, and was later diagnosed with a comminuted bimalleolar ankle fracture that required ORIF surgery. The facility’s investigation confirmed that staff did not follow the resident’s care plan, resulting in neglect.
A resident with multiple medical conditions was transferred to the hospital for evaluation and treatment, but the responsible party was not notified of this change in condition as required by facility policy. Review of records and staff interviews confirmed the lack of timely notification.
A resident with multiple medical conditions experienced a significant change in condition, including persistent fever and abnormal urinalysis results. The facility failed to ensure timely follow-up of ordered diagnostic tests, did not act promptly on abnormal findings, and did not identify or address the resident's consistently inadequate fluid intake. These failures led to the resident developing acute kidney injury and requiring hospitalization.
A resident with a history of cerebral vascular disease, anxiety, and hypertension developed fever and dysuria, leading to physician orders for urinalysis and urine C&S. Despite specimen collection, lab results were not received or reported in a timely manner, and the facility did not follow up with the lab regarding missing results. The resident's condition deteriorated, requiring additional labs that revealed infection and kidney impairment, resulting in hospitalization. The DON could not provide documentation of timely lab follow-up.
A resident with diabetes and malnutrition was found to have over 30 potassium chloride tablets impacted in the rectum after being transferred to the hospital for gastrointestinal symptoms. Despite facility policy requiring investigation of incidents of unknown origin as potential abuse, there was no documented evidence that staff who administered medications were interviewed or that the resident was questioned to determine the cause or rule out abuse, neglect, or mistreatment. The DON and NHA confirmed that a timely and comprehensive investigation was not conducted.
A facility failed to update a resident's care plan to reflect their POLST preferences, including DNR status, comfort care measures, and selective antibiotic use. Despite documentation in physician's orders and progress notes, the care plan did not align with the resident's updated medical treatment goals, as confirmed by the DON and Social Worker.
A facility failed to implement individualized continence care for a resident frequently incontinent of bowel and bladder. Despite a continence evaluation recommending routine toileting, the facility did not develop or implement a toileting retraining program as per its policy. The resident required assistance with daily living activities and had diagnoses including hypertension, anxiety, and recurrent UTIs.
The facility failed to coordinate care between the facility and hospice agency for two residents with end-stage dementia. Their care plans did not reflect necessary coordination to meet daily and terminal care needs, as confirmed by the DON.
The facility did not meet the required nurse aide to resident ratios on 13 out of 63 shifts, as revealed by staffing records. On several occasions, the number of nurse aides was below the required minimum for the day, evening, and night shifts based on the census. The Nursing Home Administrator confirmed the deficiency, and no additional staff were available to compensate for the shortfall.
The facility failed to meet the required LPN to resident ratios on 13 out of 63 shifts reviewed, with insufficient LPN staffing levels noted on several dates between October 2024 and January 2025. An interview with the Nursing Home Administrator confirmed the deficiency, and no additional higher-level staff were available to compensate for the shortfall.
The facility did not meet the required 3.2 hours of direct resident care per day on multiple occasions, providing between 2.90 and 3.17 hours instead. This was confirmed by the Nursing Home Administrator.
The facility failed to protect three residents from physical abuse. One resident with alcohol-induced dementia was scratched and bruised by another resident with Alzheimer's. Another resident with dementia was slapped by the same aggressive resident. A third resident with heart failure was shoved and hit by a resident with severe cognitive impairment.
The facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities of residents, including three residents with severe cognitive impairments. The residents' care plans included specific activity preferences, but there was no evidence that these activities were provided or that the residents participated in them. The facility also lacked consistent activities staff during crucial evening shifts.
The facility failed to accurately monitor and document fluid restrictions for two residents, leading to deficiencies in maintaining fluid balance and adequate hydration. The lack of proper documentation and monitoring resulted in non-compliance with physician orders and inadequate hydration management, as confirmed by the DON and NHA during the survey interviews.
The facility failed to provide individualized care for three residents with dementia, leading to repeated incidents of aggression, wandering, and inappropriate behaviors. Despite documented behavioral issues, the facility did not implement effective care plans based on the residents' histories and preferences.
A facility failed to implement procedures for investigating a resident's fractured leg, which was discovered after the resident exhibited pain and tenderness. The facility did not interview additional staff or investigate potential causes of the injury, violating their abuse prohibition policy. The Director of Nursing confirmed the lack of a thorough investigation.
The facility failed to provide necessary behavioral health care to a resident with PTSD, anxiety, and depression. The resident exhibited aggressive and inappropriate behaviors, and the care plan did not include effective interventions or follow-up psychiatric services. Despite frequent discussions, the facility did not provide evidence of necessary care and services to meet the resident's behavioral health needs.
Failure to Follow Updated Transfer Plan Resulting in Resident Ankle Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s updated care plan requiring two-person assistance and use of a mechanical stand-up lift for transfers. The resident had a history of right-sided hemiplegia/hemiparesis following a stroke but was documented as cognitively intact with a BIMS score of 15. A quarterly MDS showed the resident had previously been independent with ADLs, including transfers, ambulation, and toileting, and the initial care plan reflected independence with a rollator walker for transfers and ambulation. Subsequently, therapy documentation showed a decline in the resident’s functional mobility and increased left hip pain. On reevaluation, therapy noted the resident had recently refused attempts to stand and requested use of a standing lift for transfers. A therapy progress note documented that the resident remained in bed and declined to attempt standing, and the therapist downgraded the resident’s assistance level from independence with a rollator walker to requiring a stand-up lift due to the inability to assess safe ambulation and transfers. The care plan was updated to require use of a stand-up lift with assistance of two staff members for transfers and ambulation with a roller walker and gait belt with assistance of two staff members. Despite these updated care plan requirements, a nursing progress note documented that the resident experienced a witnessed fall in the bathroom while ambulating with one nurse aide using a roller walker. The resident fell while turning to sit on the toilet and was found sitting on the floor with the left foot twisted backward at the ankle, after which the resident complained of ankle and foot pain. Facility investigative documentation and staff statements indicated that the resident was transferred and ambulated without the required level of assistance and without use of the stand-up lift as specified in the care plan. As a result of this failure to follow the care plan interventions, the resident sustained a left ankle fracture that required evaluation, treatment, and subsequent surgical repair. Facility-provided statements further described the circumstances leading to the fall. One nurse aide reported responding to the resident’s call bell for bathroom assistance and documented that another aide had told the resident to prove herself by using the walker. The responding aide stated she told the resident that this was not the way the resident was supposed to transfer anymore, but the resident insisted on using the walker. The aide reported that the resident ambulated with the walker until turning to sit on the toilet, at which point the resident began to fall; the aide attempted to guide the resident to the floor but the resident landed sitting on her left foot. In a subsequent interview, this aide confirmed she was aware that the resident’s transfer status required assistance of two staff members with a stand-up lift for transfers and two-person assistance for ambulation with a roller walker, and acknowledged that the resident was ambulated and transferred without the required assistance, resulting in the fall and injury. Medical records from the hospital documented that imaging revealed a comminuted fracture of the medial malleolus and a laterally displaced oblique fracture of the lateral malleolus of the left ankle, with an impression of medial and lateral malleolar fractures. The resident received narcotic pain medication and a splint and wrap were applied. Subsequent orthopedic consultation records described the fracture as a closed, displaced lateral malleolus fracture and later as a left bimalleolar ankle fracture, characterized as unstable and requiring surgical intervention with ORIF. Nursing documentation confirmed the resident was transferred for surgery and returned following ORIF of the left ankle. The facility’s investigation, as confirmed by the Nursing Home Administrator, determined that the nurse aide did not follow the resident’s care plan requiring two-person assistance for ambulation and transfers, which constituted neglect under the facility’s abuse and neglect policy.
Failure to Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
The facility failed to promptly notify a resident's responsible party of a significant change in condition, specifically the resident's transfer to the hospital. According to the facility's policy, notification of the resident, their physician, and their representative is required when there is a change in condition, including transfers or discharges. Review of the clinical record showed that the resident, who had diagnoses including cerebral vascular disease, anxiety, and high blood pressure, and was assessed as cognitively intact, was transferred to the hospital for evaluation and treatment. However, there was no documentation that the responsible party was notified of this transfer. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the responsible party was not informed of the hospital transfer. The deficiency was identified through review of clinical records, facility policy, and staff interviews, and was found to be in violation of both facility policy and state regulations regarding timely notification of changes in resident condition.
Failure to Provide Timely Assessment, Monitoring, and Intervention After Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services to a resident following a significant change in condition. The resident, who had a history of cerebral vascular disease, anxiety, and hypertension, experienced an elevated temperature and dysuria. Despite the physician ordering a urinalysis and urine culture, there was no evidence that the facility ensured timely receipt, review, or action on the test results. When the laboratory reported conflicting results and requested a new specimen, the facility did not ensure timely completion of the reordered testing. Abnormal urinalysis findings and persistent fevers were documented, but the facility did not ensure timely receipt of the culture and sensitivity results needed to guide treatment. The resident continued to experience elevated temperatures, and it was not until several days later that the physician was notified again and additional diagnostic tests were ordered. Ultimately, the resident was found to have a significant infection and impaired kidney function, requiring hospitalization for acute kidney injury. Additionally, the facility failed to identify and address the resident's inadequate fluid intake during this period. The resident's estimated daily fluid requirement was documented, but daily intake records showed that the resident consistently failed to meet these needs over a two-week period. There was no evidence that the facility reassessed the resident's hydration status, implemented interventions to increase fluid consumption, or notified the physician of the ongoing inadequate intake, even as the resident was experiencing infection and persistent fever. The combination of delayed follow-up on diagnostic testing, lack of timely intervention for abnormal findings, and failure to monitor and address inadequate fluid intake contributed to the resident's decline and subsequent hospitalization. The facility did not meet regulatory requirements for timely assessment, monitoring, and intervention in response to a significant change in condition, nor did it maintain accurate and complete records as required.
Failure to Ensure Timely Laboratory Services and Follow-Up
Penalty
Summary
The facility failed to provide timely laboratory services and appropriate follow-up for a resident who was admitted with diagnoses including cerebral vascular disease, anxiety, and hypertension. The resident developed an elevated temperature and dysuria, prompting a physician order for urinalysis and urine culture and sensitivity. Although the specimen was collected and sent to the laboratory, there was no evidence that the urinalysis results were received or reported to the facility. Subsequently, the laboratory reported conflicting results and requested a new specimen, which was collected and sent, but seven days later, the culture and sensitivity results had still not been completed or reported. The facility did not ensure follow-up with the laboratory regarding the missing results. During this period, the resident's condition worsened, with documentation of increased temperature and feeling unwell. Additional laboratory tests were ordered, including urinalysis, culture and sensitivity, CBC, and CMP. The results received indicated significant infection and impaired kidney function, leading to the initiation of IV fluids and transfer to the hospital for acute kidney injury. At the time of the survey, there was no documentation that the facility had followed up with the laboratory regarding the delayed results, and the Director of Nursing was unable to provide evidence of timely follow-up.
Failure to Investigate Incident of Unknown Origin Involving Medication Impaction
Penalty
Summary
The facility failed to thoroughly investigate an incident of unknown origin involving a resident who was found to have more than 30 potassium chloride tablets impacted in the rectum. The resident, who was cognitively intact and required staff assistance with activities of daily living, was transferred to the hospital after experiencing nausea and loose stools. Hospital evaluation revealed numerous circular foreign bodies in the rectum, identified as potassium chloride tablets, and the resident denied inserting the medications himself. Upon return to the facility, there was no documented evidence that an investigation was initiated to determine the root cause of the incident or to rule out abuse, neglect, or mistreatment. The facility's Abuse Policy required that incidents of unknown origin be investigated as potential abuse until a root cause could be identified. However, there was no documentation of interviews or witness statements from staff who administered medications to the resident during the relevant period, nor was there an interview or written statement from the resident to assess for possible mistreatment. Additionally, the facility did not document any attempt to determine how the resident became impacted with the pills or whether any staff had harmed him or administered medication inappropriately. Subsequent to the resident's return, another incident occurred where multiple pills were found on the floor at the resident's bedside, and a facility investigation report was completed for this later event. However, the initial incident involving the rectal impaction of pills was not investigated in accordance with facility policy or regulatory requirements. The Director of Nursing and Nursing Home Administrator confirmed that a timely and comprehensive investigation was not conducted for the original incident.
Failure to Update Resident's Care Plan with POLST Preferences
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan for a resident with Alzheimer's disease and muscle weakness. The resident's POLST form, completed with the responsible party, indicated a change to a do-not-resuscitate (DNR) status and elected comfort care measures, including selective antibiotic use and no artificial hydration or nutrition. Despite these updates being documented in the physician's orders and progress notes, the resident's care plan was not revised to reflect these specific medical treatment goals. The deficiency was confirmed by the Director of Nursing and the Social Worker, who acknowledged that the care plan did not incorporate the resident's preferences for comfort measures only, antibiotics for comfort, and the decision to forego artificial hydration and nutrition. This oversight was identified during a review of the resident's clinical records and staff interviews, highlighting a failure to align the care plan with the resident's updated medical treatment goals as outlined by the POLST form and the responsible party's instructions.
Plan Of Correction
1. Resident 67's comprehensive care plan has been updated to reflect the POLST, MD orders, progress notes and resident/representative instructions. 2. Residents POLST forms have been reviewed for conformity with MD orders, progress notes and resident/representative instructions. The care plans have the appropriate interventions and goals to meet their individual needs. 3. Facility procedures for developing comprehensive care plans have been reviewed/revised to assure MD orders, progress notes and resident/representative instructions represented on the POLST are included on the comprehensive care plan. The procedures have been in-serviced to the care planning team. 4. The NHA/designee will audit 5 random charts per week to assure MD orders, progress notes and resident/representative instructions represented on the POLST are included on the comprehensive care plan. The audit will be turned in to the QA team for review. 5. February 18, 2025
Failure to Implement Individualized Continence Care
Penalty
Summary
The facility failed to implement individualized approaches to prevent declines in bowel continency and restore normal bowel function for a resident. The facility's policy requires that residents with potential for improved continence be placed on a retraining program. Upon admission, re-admission, significant changes, or after urinary catheter removal, a bowel and bladder diary should be completed for at least three days to assess the resident's continence status. However, for one resident, who was frequently incontinent of both bowel and bladder, the facility did not evaluate the resident's bowel and bladder habits to develop an individualized toileting retraining program. The resident, admitted with diagnoses including hypertension, anxiety, and recurrent urinary tract infections, required partial/moderate assistance with activities of daily living, including toilet transfer and toileting hygiene. Despite a continence evaluation recommending routine toileting and checks, there was no evidence that the recommended program was implemented. This lack of action led to the deficiency, as the facility did not adhere to its policy of evaluating and implementing a toileting program to manage the resident's incontinence.
Plan Of Correction
1. Resident 65 has started a bowel/bladder diary to evaluate continence and provide a proper training program for bowel/bladder habits. Results of the program have been placed on the cardex and put on the comprehensive care plan. 2. Residents who are identified as having the potential to improve their continence will be placed on a retraining program. Residents will be assessed upon admission, readmission quarterly and annually. 3. The Bowel and bladder policy has been reviewed/revised to assure residents who are identified as having the potential to improve continence are placed on a retraining program. The policy has been in-serviced to licensed and direct care staff. 4. The DON/designee will audit 5 residents (admits, readmits, sig change, annual) to assure that residents that have the potential to improve continence are placed on a retraining program. The audit will be turned in to the QA team for review. 5. February 18, 2025
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to ensure proper coordination of care and services between the facility and the hospice agency for two residents. Resident 69, who was admitted with diagnoses including dementia and Alzheimer's disease, was placed into hospice care for end-stage Alzheimer's disease. However, the resident's care plan, last revised on November 25, 2024, did not reflect the necessary coordination of services between the facility and the hospice agency to meet the resident's daily and terminal care needs. Similarly, Resident 7, admitted with a diagnosis of dementia, was also placed into hospice care for end-stage dementia. The care plan for Resident 7, last revised on December 10, 2024, similarly failed to reflect coordination of services between the facility and the hospice agency. An interview with the director of nursing confirmed that the care plans for both residents were not coordinated with hospice services, indicating a deficiency in the facility's coordination of care.
Plan Of Correction
1. Comprehensive care plans for Residents 69 and 7 have been revised so that the facility and hospice care plans are integrated to meet the resident's care needs. 2. Residents/Representatives electing the hospice benefit will have care plans integrated with hospice to meet the resident's care needs. 3. The coordination of hospice service policy has been reviewed/revised to assure that care and service between the facility and Hospice Agency is integrated. PCC will be contacted for care plan information to better our electronic care planning. The policy will be in-serviced to the IDT. 4. The NHA/designee will audit residents on hospice weekly to assure hospice and facility care plans are integrated and promote to meet the resident's care needs. 5. February 18, 2025
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on 13 out of 63 reviewed shifts. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts as per the regulation effective July 1, 2024. The deficiency was identified through a review of the facility's weekly staffing records, which showed that on multiple dates, the number of nurse aides on duty was below the required ratios based on the facility's census. For instance, on October 17, 2024, the night shift had 6.87 nurse aides instead of the required 6.93 for a census of 104 residents. Similarly, on November 23, 2024, the night shift had only 5.80 nurse aides, falling short of the required 6.93 for the same census. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility did not meet the required staffing ratios on the specified dates. No additional higher-level staff were available to compensate for the staffing shortfall.
Plan Of Correction
5520 1. The facility cannot retroactively correct nurse aide staffing ratios for the past. 2. The facility will review nurse aide ratios daily to provide care according to Pennsylvania regulation on staffing. (1-10; 1-11; 1-15) 3. Regulations for nurse aide ratios have been reviewed by facility management. Facility management will project ratios daily to have staff set according to guidelines. 4. Nursing will track ratios daily and provide a copy of the numbers to the administrator. The numbers will be provided to the QA team to track compliance. 5. February 18, 2025
Facility Fails to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on 13 out of 63 shifts reviewed. Specifically, the facility did not provide the minimum number of LPNs needed for the day, evening, and night shifts on several dates between October 2024 and January 2025. For instance, on October 17, 2024, the facility had 4.00 LPNs on the day shift, whereas 4.16 were required for a census of 104 residents. Similar deficiencies were noted on other dates, with the facility consistently falling short of the required LPN staffing levels. The report indicates that no additional higher-level staff were available to compensate for the deficiency in LPN staffing on the mentioned dates. An interview with the Nursing Home Administrator on January 9, 2025, confirmed the facility's failure to meet the required LPN to resident ratios. This deficiency was identified through a review of the facility's weekly staffing records and staff interviews, highlighting a pattern of inadequate staffing levels that persisted over several months.
Plan Of Correction
1. The facility cannot retroactively correct LPN staffing ratios for the past. 2. The facility will review LPN ratios daily to provide care according to Pennsylvania regulation on staffing. (1-25; 1-25; 1-40) 3. Regulations for LPN ratios have been reviewed by facility management. Facility management will project ratios daily to have staff set according to guidelines. 4. Nursing will track LPN ratios daily and provide a copy of the numbers to the administrator. The numbers will be provided to the QA team to track compliance. 5. February 18, 2025
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident per day. A review of the facility's staffing levels revealed multiple dates where the nursing care hours fell below the required minimum. Specifically, on several occasions between October 2024 and January 2025, the facility provided between 2.90 and 3.17 hours of direct care per resident, which is below the mandated 3.2 hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 9, 2025.
Plan Of Correction
5640 1. The facility cannot retroactively correct nursing PPDs for the past. 2. The facility will review nursing PPD daily to provide care according to Pennsylvania regulation on staffing (3.20 hours). 3. Regulations for nursing PPD have been reviewed by facility management. Facility management will project PPD daily to have staff set according to guidelines. 4. Nursing will track PPD daily and provide a copy of the numbers to the administrator. The numbers will be provided to the QA team to track compliance. 5. February 18, 2025
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that three residents were free from physical abuse. Resident 73, who was severely cognitively impaired due to alcohol-induced persisting dementia, was scratched and bruised by Resident 74. Resident 74, who had Alzheimer's disease and displayed aggressive behaviors, was noted to have physically attacked Resident 73 on multiple occasions. Despite interventions in place, Resident 74's aggressive behavior was not adequately managed, leading to physical abuse of Resident 73 on May 10, 2024, resulting in a scratch and bruising on her left forearm. Resident 65, who was severely cognitively impaired due to dementia, was slapped by Resident 74 in the hallway. The incident was witnessed by a nurse aide, and although Resident 65 did not sustain visible injuries or complain of pain, the facility failed to protect Resident 65 from physical abuse. Resident 74's aggressive behavior continued to be a problem, as evidenced by multiple documented incidents of physical aggression towards other residents. Resident 89, who was moderately cognitively impaired and had heart failure, was physically abused by Resident 80, who had severe cognitive impairment due to dementia. Resident 80 entered Resident 89's room, went through his belongings, shoved him, and hit him with a reaching-assistance device. Although Resident 89 did not initially report pain, he later complained of shoulder pain. The facility's failure to manage Resident 80's aggressive behavior resulted in physical abuse of Resident 89.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities of residents, including three residents out of 21 sampled. Resident 74, who was admitted with Alzheimer's disease and severe cognitive impairment, had a care plan that included preferences for activities such as gardening, watching specific TV shows, and crafting. However, there was no documented evidence that these preferred activities were provided or that the resident participated in them. The records showed minimal participation in reading activities and no indication of encouragement or prompting to participate in other activities, with the resident often wandering or in bed during activity opportunities. Resident 77, admitted with unspecified dementia and severe cognitive impairment, had a care plan addressing socially inappropriate behaviors and preferences for small group activities and sensory activities. Despite this, the activity participation logs revealed limited participation in activities, and observations showed that the resident was often wandering or in other residents' rooms instead of engaging in scheduled activities. The facility's activities calendar and staff schedules indicated a lack of consistent activities staff during evening shifts, which are crucial for managing dementia behaviors. Resident 80, also severely cognitively impaired, had a care plan that included preferences for music, reading, and outdoor activities. However, the activity participation records showed no evidence of participation in these preferred activities, with the resident often wandering, napping, or refusing activities. The facility failed to provide an individualized activities program and did not accurately monitor the residents' participation and response to activities, leading to inadequate and inappropriate activities programming for these residents.
Failure to Monitor and Document Fluid Restrictions
Penalty
Summary
The facility failed to accurately monitor and document fluid restrictions prescribed for two residents, leading to deficiencies in maintaining fluid balance and adequate hydration. Resident 35, diagnosed with heart failure and hyponatremia, had a physician's order for a 1500 ml per day fluid restriction. However, the facility's Medication Administration Record (MAR) and Documentation Survey Reports from February to mid-March 2024 did not show consistent documentation of the fluids provided by nursing staff, failing to ensure compliance with the physician's order and the resident's hydration needs. The Director of Nursing (DON) confirmed the lack of documentation during an interview on March 15, 2024, in the presence of the Nursing Home Administrator (NHA). This failure was acknowledged as a deficiency in maintaining the resident's clinical condition and hydration status as required by the physician's order and facility policy. Similarly, Resident 43, diagnosed with congestive heart failure, had a physician's order for a 2000 ml per day fluid restriction. The resident's care plan included specific fluid allocations for dietary and nursing staff, along with monitoring for signs of fluid overload. However, the facility's Documentation Survey Reports for February and March 2024 did not provide evidence of accurate recording and accounting of the resident's daily fluid intake. The Registered Dietitian's documentation from February 20 to March 7, 2024, also failed to show compliance with the prescribed fluid restriction and adequacy for hydration. The DON confirmed on March 15, 2024, that the facility did not total and calculate the resident's daily fluid intake, failing to meet the physician's prescribed fluid restriction and hydration needs. These deficiencies highlight the facility's failure to follow its own policy on fluid restrictions, which mandates that nursing staff obtain and verify physician's orders, document fluid intake accurately, and ensure compliance with the prescribed fluid restrictions. The lack of proper documentation and monitoring for both residents resulted in non-compliance with physician orders and inadequate hydration management, as confirmed by the DON and NHA during the survey interviews.
Failure to Provide Individualized Dementia Care
Penalty
Summary
The facility failed to provide the necessary treatment and services to maintain the highest practicable level of mental, physical, and psychosocial well-being for three residents diagnosed with dementia. Resident 74 exhibited socially inappropriate behaviors such as hitting, punching, and swinging at staff. Despite documented incidents of increased aggression and wandering, the facility did not implement an individualized care plan that included purposeful and meaningful activities based on the resident's past history and preferences. This lack of individualized care led to repeated incidents of aggression and wandering, impacting both the resident and others in the facility. Resident 80 also displayed significant behavioral issues, including verbal aggression, cursing, and wandering into other residents' rooms. Despite multiple progress notes documenting these behaviors and the ineffectiveness of redirection and other interventions, the facility did not develop an individualized care plan that incorporated the resident's interests, such as music and car magazines. The resident's behavior continued to escalate, leading to frequent disruptions and safety concerns for both the resident and others. Resident 77 exhibited behaviors such as rummaging through other residents' belongings, disrobing in public, and physical and verbal aggression. Despite these documented behaviors and an incident involving inappropriate physical contact with another resident, the facility did not implement effective individualized interventions. The resident continued to display escalating dementia-related behaviors, and the facility's interventions were not fully effective in preventing these behaviors. The Director of Nursing confirmed that the interventions developed were not effective in addressing the residents' needs.
Failure to Investigate Resident's Injury
Penalty
Summary
The facility failed to implement their established procedures for thoroughly investigating an injury of known source, a fractured leg, sustained by one resident. The facility's abuse prohibition policy mandates that incidents of unknown origin be investigated as abuse until the root cause is identified. However, the facility did not follow these procedures. The resident, who was severely cognitively impaired and required staff assistance for daily activities, was found to have a fractured leg after exhibiting pain and tenderness in the right ankle. Despite the severity of the injury, the facility did not conduct a thorough investigation to rule out abuse, neglect, or mistreatment as potential causes. The clinical records and witness statements revealed that the resident was fine during the shift on the day before the injury was discovered. However, there was no documented evidence that the facility interviewed additional staff members, including those from other shifts that cared for the resident prior to the injury. The facility also did not investigate potential causes of the injury that may have occurred during the day of the injury. This lack of thorough investigation is a direct violation of the facility's abuse prohibition policy. The Director of Nursing confirmed that the facility planned to educate staff on the use of the mechanical lift to rule out potential staff technique as a cause of the injury. However, there was no documented evidence that this education was provided. The failure to conduct a thorough investigation into the resident's serious injury of unknown origin to rule out abuse, neglect, or mistreatment was confirmed by the Director of Nursing.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care to Resident 5, who had diagnoses including PTSD, anxiety, and depression. The resident's care plan identified potential for verbal and physical aggression and included various interventions. However, the care plan did not identify interventions to determine the root cause of the behaviors or effective strategies for staff to employ when the resident exhibited these symptoms. The care plan was not reviewed for continued adequacy and effectiveness in meeting the resident's mental health care needs. The resident's clinical records revealed multiple instances of aggressive and inappropriate behavior, including refusing care, damaging another resident's property, and making derogatory gestures towards staff. Despite these behaviors, there was no documented evidence of follow-up psychiatric services or effective interventions. The facility's documentation showed repeated behaviors with unchanged or ineffective interventions, and no revisions were made to address the resident's needs. Interviews with staff and the resident indicated that the resident's behaviors were frequently discussed but not adequately addressed. The facility was unable to provide evidence that necessary care and services were provided to meet the resident's behavioral health needs. The lack of an interdisciplinary approach and timely behavioral health care contributed to the deficiency in promoting the resident's highest practicable physical and psychosocial well-being.
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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