Embassy Of Huntingdon Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntingdon, Pennsylvania.
- Location
- 1229 Warm Springs Avenue, Huntingdon, Pennsylvania 16652
- CMS Provider Number
- 395297
- Inspections on file
- 25
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Embassy Of Huntingdon Park during CMS and state inspections, most recent first.
A resident with cirrhosis on hospice care and a PleurX catheter experienced ongoing leakage from the liver catheter, prompting the resident’s spouse to request transfer to the ER for evaluation. Nursing staff contacted a CRNP, who consulted with hospice and determined the resident did not need ER care and could be seen by hospice in the facility. Despite the spouse’s continued insistence on ER transfer, staff informed her they could not provide an order and that leaving would be against medical advice, rather than facilitating the requested transfer. A Regional RN later confirmed that the resident should have been sent to the hospital when the responsible party requested it, demonstrating a failure to honor the resident representative’s right to make treatment decisions.
Surveyors found that a resident did not receive a full course of ordered Cipro when the facility failed to adjust the antibiotic schedule after two missed doses, resulting in only nine days of therapy instead of the prescribed ten. In addition, another resident, initially assessed with intact skin and placed on a preventive zinc oxide regimen, later developed non-intact skin with treatment in place to the buttocks and coccyx, but there was no documented assessment of the skin change or notification of the wound nurse at that time; a subsequent assessment documented a closed abrasion and blanchable redness.
A resident with confusion, extensive ADL needs, and a right heel pressure ulcer did not receive wound care consistent with updated provider orders. After a CRNP changed the treatment from Gentamicin to Calmoseptine and a corresponding physician order specified cleansing the right foot, applying Calmoseptine, and using a heel cup with daily changes, staff documentation on the TAR showed they continued to apply Gentamicin in the evenings while also using Calmoseptine in the mornings. The Regional Nurse confirmed Gentamicin should have been discontinued, but staff instead applied both ointments rather than following the current order.
Surveyors found a full portable oxygen tank lying unsecured on a metal stretcher parked in a hallway outside residents’ rooms, contrary to facility policy requiring portable oxygen tanks to be stored safely in an upright position. The stretcher and tank were within reach of residents. An LPN acknowledged the tank should not have been stored on the stretcher in the hallway and was unsure why the stretcher was there, and the Regional Nurse confirmed the tank should have been stored securely elsewhere.
A resident with heart failure and hypertension did not receive prescribed Metoprolol Succinate for several months after a physician's order to decrease the dosage was not entered into the MAR, resulting in the medication not being administered as required.
A resident who was cognitively impaired, incontinent, and at risk for pressure ulcers developed a fluid-filled blister on the abdomen. Physician orders required a protective barrier to be applied twice daily, but review of treatment records showed no documentation that these treatments were completed as ordered. The Nursing Home Administrator confirmed the absence of documentation.
The facility did not follow physician orders for insulin administration for a resident with diabetes, administered insulin to another resident outside the manufacturer's recommended time frame, and failed to provide wound care as recommended by a consultant for a resident with frostbite wounds. These deficiencies were confirmed through record review and staff interviews.
A resident with a Stage 3 pressure ulcer did not receive wound care treatments as recommended by a wound consultant, including missed applications of collagen and bacitracin ointment on multiple occasions, as confirmed by the DON.
Surveyors identified multiple deficiencies in food storage and labeling, with uncovered and undated food items in both the cooler and freezer, and improper storage of scoops in ingredient bins. Dietary staff were observed handling food without fully covered hair, and kitchen equipment and shelving were found to be dusty and unclean, all in violation of facility policy.
A nurse aide failed to promptly report an incident where another aide yelled at a cognitively impaired resident and made a demeaning comment during care. The delay in reporting the suspected verbal abuse was not in accordance with facility policy, which requires immediate notification to administration.
A resident receiving anticoagulation therapy did not have a physician-ordered INR blood test completed as required. Despite prior adjustments to the resident's medication following a critically high PT/INR, there was no documentation that the subsequent ordered lab was performed, as confirmed by facility administration.
A resident with an indwelling catheter, Stage 4 pressure ulcer, and wound infection did not have Enhanced Barrier Precautions (EBP) implemented upon admission, despite facility policy and federal guidelines requiring gown and glove use for residents with chronic wounds or indwelling devices. EBP was not documented or ordered until after contact precautions for an MDRO were discontinued, resulting in a failure to follow infection control protocols.
The facility did not submit required direct care staffing information for fiscal quarter one of 2024, as mandated by the ACA. The submission, due by the 45th day after the quarter's end, was confirmed missing during an interview with the Nursing Home Administrator.
The facility failed to update care plans for three residents, leading to discrepancies between documented care needs and actual care provided. A resident's care plan was not updated to reflect the discontinuation of a midline and antibiotic therapy. Another resident's care plan did not reflect the end of isolation precautions and antibiotic therapy. Additionally, a third resident's care plan lacked documentation for a wound vac requirement. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to follow physician orders for a resident's IV line care, including not flushing the midline catheter with saline before and after administering levofloxacin and neglecting to change IV line dressings and caps as required. The resident was receiving IV medications for a MRSA infection, and the lack of documentation confirmed these deficiencies.
The facility failed to maintain sanitary conditions for ice preparation and storage, with a dark substance found in the second-floor ice machine, and did not adhere to food storage standards, with unsealed cheese and expired rice in the kitchen. The Assistant Maintenance Director and Dietary Manager confirmed these deficiencies.
A resident with Alzheimer's and dementia, requiring extensive assistance, was found with unclean fingernails despite the facility's policy for regular nail care. Observations in May revealed the resident's nails extended beyond the fingertips with a dark substance underneath, indicating a failure in providing necessary personal grooming and hygiene services.
A resident with a history of sexually inappropriate behavior was involved in an incident due to the facility's failure to ensure functioning safety interventions. Despite a care plan revision to include a motion alarm on the resident's door, observations revealed the alarm was not functioning properly, and there was no documented evidence of monitoring its function.
The facility failed to maintain accountability for controlled medications for two residents. For one resident, doses of oxycodone were signed out but not documented as administered in the MAR. Similarly, another resident had doses signed out without documentation of administration. These discrepancies were confirmed by the Nursing Home Administrator, indicating a failure to adhere to the facility's medication administration policy.
The QAPI committee at the facility failed to effectively address recurring deficiencies related to care plan updates, grooming and hygiene, and accident hazard prevention. Despite previous plans of correction, the same issues persisted, indicating insufficient implementation of corrective measures.
Failure to Honor Resident Representative’s Request for Hospital Evaluation
Penalty
Summary
The facility failed to honor a resident and responsible party's right to make informed decisions regarding treatment when a request for hospital evaluation was not followed. Facility policy on residents' rights and advanced directives stated that residents have the right to request, refuse, and/or discontinue medical or surgical treatment. The resident involved was cognitively impaired, required staff assistance for daily care, had cirrhosis of the liver, was receiving hospice services, and had a PleurX catheter with a care plan directing nursing staff to monitor the dressing and observe for signs of infection or worsening condition. A nurse's note documented that the resident's wife, acting as responsible party, requested that the resident be sent to the emergency room due to continued leaking from the liver catheter and asked to speak with the provider. The nurse contacted the CRNP with an assessment, and the CRNP consulted with the hospice nurse. They agreed the resident did not need to go to the emergency room and that the hospice nurse could assess the resident at the facility. When informed of this, the resident's wife insisted on taking her husband to the emergency room and verbally rejected hospice and the facility's position. Staff told her she had the right to go to the emergency room but could not provide an order for transfer and that leaving would be against medical advice because the provider wanted the resident to remain for hospice assessment. An interview with the Regional RN confirmed that if the responsible party requested hospital evaluation, the resident should have been sent, indicating that the facility did not honor the responsible party's request for transfer for evaluation.
Failure to Follow Antibiotic Orders and Inadequate Wound Assessment
Penalty
Summary
Surveyors identified that one resident did not receive antibiotic therapy as ordered and another resident did not receive appropriate wound assessment. For the first resident, the admission MDS showed cognitive impairment, dependence on staff for daily care, cirrhosis of the liver, and enrollment in Hospice services. Physician orders dated early January directed that 500 mg of Cipro be administered every morning and at bedtime for 10 days to treat purulent drainage. Review of the MAR showed that the first two scheduled doses of Cipro were documented as not administered, and the medication was then given twice daily from the evening of the following day through the morning of the tenth day, resulting in only nine days of therapy. The Regional RN confirmed that the Cipro order should have been adjusted when the first two doses were missed so that the resident would still receive the antibiotic for the full 10 days as ordered, but this was not done. For the second resident, the admission MDS indicated that the resident was cognitively intact, occasionally bowel incontinent, and had no wounds. A care plan required weekly skin assessments and direction for the charge nurse to notify the wound nurse, physician, and family of any new skin areas. An initial skin assessment documented intact skin, and physician orders were obtained for zinc oxide to be applied to both buttocks and the coccyx every shift for prevention. A subsequent skin assessment documented that the resident’s skin was no longer intact, with treatment in place to the buttocks and coccyx, but there was no documented assessment of the change from intact to not intact skin and no evidence that the wound nurse was notified. A later skin assessment described a closed abrasion on the right buttock and blanchable redness on both buttocks, and the Regional RN confirmed there was no assessment of the area at the time the skin first changed.
Failure to Follow Updated Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide pressure ulcer treatment according to current physician and CRNP orders for one resident with a right heel pressure ulcer. A quarterly MDS for this resident showed confusion, extensive assistance needs for daily care, and the presence of pressure ulcers. A CRNP wound nurse note documented that the treatment for the right heel pressure ulcer was changed from Gentamicin to Calmoseptine on February 3, 2026, and a physician’s order dated February 4, 2026, specified cleansing the right foot with soap and water, applying Calmoseptine, then a heel cup, with daily dressing changes. However, review of the February 2026 TAR showed that as of February 10, staff continued to apply Gentamicin ointment to the right heel pressure ulcer in the evenings while also applying Calmoseptine in the mornings, resulting in both ointments being used instead of only Calmoseptine as ordered. In an interview, the Regional Nurse confirmed that Gentamicin should have been discontinued when the treatment was changed, but it was not, and staff continued to apply both treatments.
Improper Storage of Portable Oxygen Tank on Hallway Stretcher
Penalty
Summary
Surveyors identified a deficiency related to accident hazards when a portable oxygen tank was found improperly stored on a metal stretcher in the 100 hall, short side. The facility’s oxygen policy dated December 10, 2025, required that portable oxygen tanks be stored safely in an upright position. However, during observation on February 10, 2026 at 1:45 p.m., a full portable oxygen tank was seen lying unsecured on the middle section of a metal stretcher parked in the hallway outside residents’ rooms and within residents’ reach. An interview with an LPN at the time of the observation confirmed that the oxygen tank should not have been stored on the stretcher in the hallway and that she did not know why the stretcher was there. In a subsequent interview, the Regional Nurse also confirmed that the oxygen tank should have been stored securely and not lying on a stretcher in the hallway, indicating the facility failed to maintain an environment free from accident hazards as required by policy and regulation. No specific resident medical histories or conditions were described in relation to this deficiency, only that the unsecured oxygen tank and stretcher were located within reach of residents’ rooms on the 100 hall.
Failure to Administer Medication per Physician's Orders
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders regarding medication administration for one resident. The facility's policy required that medications be administered by licensed nurses as ordered by the physician. The resident, who was cognitively intact and had a diagnosis of heart failure, had a physician's order to receive 50 mg of Metoprolol Succinate daily for hypertension. On March 6, 2025, the physician reviewed the resident's medications and ordered the Metoprolol dose to be decreased to 25 mg daily. However, the new order for 25 mg of Metoprolol was not added to the Medication Administration Record (MAR), resulting in the resident not receiving any Metoprolol Succinate from March 7, 2025, to July 28, 2025. This lapse was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the medication order change was not implemented and the resident did not receive the prescribed medication during this period.
Failure to Provide and Document Pressure Ulcer Treatment as Ordered
Penalty
Summary
A review of facility policies, clinical records, and staff interviews revealed that the facility failed to provide pressure ulcer treatments as ordered by the physician for one resident. The facility's wound management policy required that wound treatments be administered according to physician orders, specifying the cleansing method, dressing type, and frequency. The resident in question was cognitively impaired, incontinent of bowel and bladder, and at risk for pressure ulcers. On assessment, the resident was found to have a fluid-filled blister on the right abdomen, with physician orders directing the application of a protective barrier every day and evening shift. The care plan also specified avoidance of tight clothing and adherence to the treatment orders. However, review of the Treatment Administration Records for the relevant month showed no documented evidence that the prescribed treatments were completed as ordered. This lack of documentation was confirmed by the Nursing Home Administrator.
Failure to Follow Physician Orders and Manufacturer Instructions for Medication and Wound Care
Penalty
Summary
The facility failed to follow physician's orders and manufacturer instructions for medication administration, as well as wound care recommendations, for three residents. One resident, who was cognitively intact and had diabetes, received Humalog insulin on multiple occasions despite blood sugar readings below the threshold specified in the physician's order, which required the insulin to be held if blood sugar was less than 100 mg/dL. Another resident, also cognitively intact and with diabetes, received Humalog insulin at times not aligned with the manufacturer's instructions, which state the medication should be administered within 15 minutes before or immediately after meals. The insulin was given at times that did not correspond with scheduled meal times. Additionally, a resident with cognitive impairment and frostbite wounds to the toes did not receive wound care as recommended by a wound consultant. The consultant recommended betadine be applied to the first and second toes of both feet twice daily, but physician's orders only included the right foot, and there was no documentation that the left toes received the recommended treatment. These deficiencies were confirmed through review of clinical records, medication and treatment administration records, and interviews with facility leadership.
Failure to Follow Wound Care Treatment Orders for Pressure Ulcer
Penalty
Summary
The facility failed to follow wound care treatment recommendations for a resident with a Stage 3 pressure ulcer on the coccyx. According to the facility's wound treatment policy, evidence-based treatments should be provided in accordance with physician orders. The resident, who was cognitively impaired and required assistance with care, had wound consultations that recommended daily application of collagen to the wound bed and zinc to the peri-wound area. However, review of the Treatment Administration Records showed that collagen was not applied daily as ordered from January 15 through February 5. Further, a subsequent wound consultation recommended daily application of bacitracin ointment and collagen to the wound bed, but records indicated that no treatment was applied to the coccyx from February 20 through 26. The DON confirmed that the recommended treatments were not completed as ordered on the specified dates.
Deficiencies in Food Storage, Staff Attire, and Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service as outlined in its own policies. During observations, multiple food items in the walk-in cooler and freezer were found either not labeled with preparation or opening dates or not properly secured, including trays of chicken and broccoli, as well as opened bags of vegetables and dinner rolls. Additionally, scoops for flour and rice were stored inside their respective bins, contrary to policy. The Dietary Manager confirmed that these practices did not comply with facility protocols. Further deficiencies were observed in staff compliance with uniform dress code and cleanliness of food service areas. Several dietary workers were seen with hair not fully covered by hair nets while handling and preparing food. Non-food contact surfaces, such as a blower fan and shelving unit used for storing pans and cookie sheets, were found to be coated with dust and debris. The Dietary Manager acknowledged that these conditions did not meet the facility's standards for cleanliness and staff attire.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner. According to the facility's abuse policy, staff are required to immediately report any suspected abuse to administration. In this incident, a nurse aide overheard another nurse aide yelling at a cognitively impaired resident who required assistance with daily care and had a diagnosis of hydrocephalous. The nurse aide told the resident that she did not deserve her shoes due to her behavior while getting ready. Despite witnessing this, the staff member did not immediately report the incident to administration, resulting in a delay of several days before the allegation was brought to the attention of facility management.
Failure to Obtain Ordered Laboratory Test for Anticoagulation Monitoring
Penalty
Summary
The facility failed to obtain a laboratory test as ordered by the physician for one resident who was receiving anticoagulation therapy. According to facility policy, the charge nurse is responsible for obtaining physician orders for pertinent labs and notifying the physician of results, specifically for residents on medications such as warfarin. The resident in question had a history of atrial fibrillation and cerebral infarction, was cognitively impaired, and required assistance with care needs. After a critically high PT/INR result, the resident's anticoagulation therapy was adjusted, and a repeat PT/INR was ordered and completed the following day. Subsequently, the physician ordered another INR blood test to be performed on a specific date. However, there was no documented evidence that this laboratory test was completed as ordered. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the test was not performed as required by the physician's order.
Failure to Implement Enhanced Barrier Precautions for High-Risk Resident
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC regarding Enhanced Barrier Precautions (EBP) for a resident with significant risk factors for multidrug-resistant organism (MDRO) transmission. Specifically, a resident who was admitted with an indwelling urinary catheter, a Stage 4 pressure ulcer, and a wound infection did not have EBP implemented upon admission, despite facility policy and federal guidance requiring gown and glove use during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of known MDRO status. Documentation showed that EBP was not initiated until after the resident was removed from contact precautions for an MDRO, and there was no evidence of an EBP order or care plan addressing these precautions at the time of admission. Interviews with the Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed that EBP was not documented or ordered when the resident was admitted, and the care plan was only updated after contact precautions were discontinued. The lack of timely implementation and documentation of EBP for this high-risk resident constituted a failure to adhere to both facility policy and current infection control standards, as required by regulatory guidelines.
Failure to Submit Direct Care Staffing Information
Penalty
Summary
The facility failed to electronically submit direct care staffing information for the first quarter of the fiscal year 2024, as required by Section 6106 of the Affordable Care Act (ACA). This requirement mandates that facilities submit staffing data, including agency and contract staff, based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS) by the end of the 45th calendar day after the last day of each fiscal quarter. For the first quarter, covering October 1st through December 31st, the submission was due by February 14th. A review of the Payroll Based Journal (PBJ) staffing data reports revealed that the facility did not submit the required data for this period. This deficiency was confirmed during an interview with the Nursing Home Administrator on May 21, 2024.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for three residents. For Resident 28, the care plan was not updated to reflect the discontinuation of a midline and antibiotic therapy, despite a nursing note indicating these changes. The Nursing Home Administrator confirmed that the care plan should have been resolved but was not. Similarly, Resident 39's care plan was not updated to reflect the discontinuation of contact isolation precautions and completion of antibiotic therapy, as noted in a nursing note. The care plan still indicated isolation/quarantine precautions for MRSA and VRE, which should have been resolved. Additionally, Resident 75's care plan did not include the need for a wound vac to the right knee, despite physician's orders and a nursing note indicating this requirement. The Nursing Home Administrator confirmed that the care plan was not updated accordingly.
Failure to Follow IV Line Care Protocols
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration and maintenance of intravenous (IV) lines for a resident. Specifically, the facility did not flush the resident's midline catheter with saline before and after administering levofloxacin, an antibiotic, on several occasions. The resident, who was cognitively intact, was receiving IV medications for a Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Despite physician orders to flush the central line with 5-10 mL of saline before and after medication administration and to perform a maintenance flush every shift, there was no documented evidence of these actions being completed on specified dates. Additionally, the facility did not change the resident's intravenous line dressing and caps as ordered by the physician. The Medication Administration Record (MAR) lacked documentation of the required dressing and cap changes on specific dates. An interview with the Nursing Home Administrator confirmed the absence of documentation for these essential care tasks, indicating a failure to comply with the facility's policy and physician orders for IV catheter care.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions for ice preparation and storage, as well as proper food storage in the main kitchen. Observations revealed a dark, removable substance inside the second-floor ice machine, indicating it had not been cleaned as per the facility's policy, which requires monthly cleaning with an approved sanitizing agent. The Assistant Maintenance Director confirmed that the second-floor ice machine was overdue for cleaning, and there was no documented evidence of it being cleaned for the month of May. Additionally, the facility did not adhere to professional standards for food storage. In the main kitchen's walk-in refrigerator, a large brick of cheese was found unsealed and exposed to air, and a large container of brown rice was observed with an expiration date of February 2022. The Dietary Manager confirmed that the cheese should have been sealed and the expired rice discarded, indicating a failure to follow the facility's policy for food storage based on Hazard Analysis Critical Control Point (HACCP) guidelines.
Failure to Maintain Resident's Personal Grooming and Hygiene
Penalty
Summary
The facility failed to provide appropriate personal grooming and hygiene services for a resident who was dependent on care. The facility's policy, dated April 16, 2024, required that nail care, including cleaning and trimming, should be completed as needed unless contraindicated by conditions such as diabetes, in which case a nurse or podiatrist would provide care. A quarterly Minimum Data Set (MDS) assessment for the resident, dated February 19, 2024, indicated that the resident had Alzheimer's and dementia, and required extensive assistance with activities of daily living, including bathing. Observations on multiple occasions in May 2024 revealed that the resident's fingernails extended beyond the tips of her fingers and had a dark substance underneath them. The resident was scheduled to receive showers twice a week, with the last recorded shower on May 17, 2024. An interview with a nurse aide confirmed that the resident's fingernails were not cleaned as required, either during her scheduled showers or at any other time when staff noticed the need for such care. This failure to maintain the resident's personal grooming and hygiene was a deficiency in the facility's nursing services.
Failure to Ensure Functioning Safety Interventions
Penalty
Summary
The facility failed to ensure that interventions were in place and functioning to prevent inappropriate behaviors for a resident. The resident, who was cognitively intact but displayed sexually inappropriate behavior, was involved in an incident where he touched another resident inappropriately in the hallway. Following this incident, the resident's care plan was revised to include a motion alarm on his door frame and a requirement for supervision when out of his room. However, observations revealed that the motion alarm on the resident's door was not functioning properly. A Licensed Practical Nurse confirmed that the alarm was in the off position and should have been on. Despite attempts to fix it, the alarm continued to malfunction. The Nursing Home Administrator confirmed that there was no documented evidence of the alarm being monitored for function and placement, indicating a failure in ensuring the safety measures were operational.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents, leading to a deficiency in pharmaceutical services. For one resident, an admission MDS assessment indicated the resident had an unstageable pressure ulcer and required assistance with care needs. A physician's order was in place for the resident to receive oxycodone for pain management. However, the controlled drug accountability records showed that doses of oxycodone were signed out for administration on specific dates, but there was no documented evidence in the MAR that the medication was administered to the resident at those times. This discrepancy was confirmed by the Nursing Home Administrator. Similarly, another resident, who was alert and oriented and received as-needed pain medications, had physician's orders for oxycodone to be administered for pain relief. The controlled drug accountability records indicated that doses were signed out on several occasions, but again, there was no documented evidence in the MAR that the medication was administered. This lack of documentation was also confirmed by the Nursing Home Administrator. These findings indicate a failure to adhere to the facility's policy on medication administration and accountability for controlled substances.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as identified in the current survey. The deficiencies were related to care plan timing and revision, grooming and personal and oral hygiene, and ensuring that the resident's environment remained free from accident hazards. Despite having developed plans of correction following previous surveys, the facility continued to exhibit the same issues, indicating that the QAPI committee's efforts were insufficient in maintaining compliance with nursing home regulations. Specifically, the facility had previously developed plans of correction that included conducting audits and reporting the results to the QAPI committee. However, the current survey revealed that these plans were not successfully implemented. The deficiencies cited under F657, F677, and F689 showed that the QAPI committee was ineffective in ensuring ongoing compliance with regulations regarding updating residents' care plans, maintaining grooming and personal and oral hygiene, and keeping the resident environment free from accident hazards.
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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