Embassy Of Saxonburg

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the consistent services of a full-time Director of Nursing (40 or more hours a week). The DON job description stated the position was responsible for planning, organizing, developing, and directing the overall operation of the Nursing Service Department and included duties such as assisting the Infection Control Coordinator, monitoring in-service training, and ensuring sufficient licensed nurses and nurse aides were scheduled and working during all shifts. Information reported to the State Department of Health indicated the DON started at the facility on 12/22/26. During an interview, the DON stated she completed DON duties Monday through Friday during the daylight shift and could not be on a medication cart, but also said she acted as RN Supervisor and DON two to three times a week and sometimes was assigned a medication cart. She stated it was hard to do all the things and that she typically worked 12 to 16 hours, 6 to 7 days a week. The DON also confirmed she was responsible for nursing education and Infection Preventionist duties. On 4/23/26, the DON was observed working on the floor and stated she was assigned to work as an aide for the daylight shift. She was observed assisting surveyors while a resident called out for help, and she told the resident she would be right there. The DON confirmed she was assigned to the C Wing hallway and was providing direct resident care. An LPN confirmed the DON was working as the nurse aide and that the DON sometimes worked on the medication cart. The Nursing Home Administrator confirmed the facility failed to ensure the consistent services of a full-time DON in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly store, label, and date food items in the Main kitchen. Review of the facility policy on dating for food storage indicated that foods removed from original packaging were to be dated, and foods requiring time and temperature control were to be labeled with the common name of the food, the date made, and the use-by date. During observation of the Main Kitchen walk-in freezer, an opened bag of tater tots was found with no label or date, two bags of frozen noodles were not labeled or marked with a received date, three grocery bags of ice cream cups had no label or receive date, and a plastic container of kielbasa and sauerkraut had the lid off-center and was not sealed, with a use-by date of 4/10/26. During observation of the Main Kitchen stand-up freezer, a bag of potatoes was found with no label or receive date. The Kitchen Manager confirmed the findings and stated that the ice cream had been brought in by a resident's family and would not fit into the freezer in the nursing unit provided for resident use. The Kitchen Manager also stated that storing resident food in the freezer was not appropriate because chain of custody of the food and food safety were not guaranteed, and confirmed that the facility failed to properly label, date, and store food items.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete annual performance evaluations for four of five nursing staff personnel records, identified as Nurse Aides E10, E11, E12, and E13. Facility policy titled Employee Performance Evaluations, dated 3/16/26, stated that all employees receive timely, fair, and consistent performance evaluations, with evaluations conducted annually after 90 days. Review of personnel records showed that E10 was hired on 2/7/24 and had a last performance evaluation dated 6/20/24; E11 was hired on 10/30/23 and had a last evaluation dated 11/11/24; E12 was hired on 2/29/24 and had a last evaluation dated 8/7/24; and E13 was hired on 6/22/23 and had a last evaluation dated 6/24/24. The records did not include annual performance evaluations based on each employee’s date of hire. During interview, Human Resource Employee E4 stated the facility was behind in evaluations and trying to get caught up, and confirmed that annual performance evaluations had not been completed for these four nursing staff records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident representative had communication and access to persons and services inside the facility for one resident, R64. A resident representative reported receiving a bill on behalf of her mother and stated that when she called the facility, no one answered the phone; she also went in person, spoke with a young staff member, explained the billing concern, and left her name and phone number, but no one returned her call. During interview, the Nursing Home Administrator stated that the Business Office Manager who previously handled billing no longer worked at the facility and that the administrator was now handling these concerns, but she had not been made aware that the resident representative needed to speak with someone about the bill and had not addressed the concern. The administrator acknowledged that failure to return phone calls and answer questions failed to ensure ease of communication with persons inside the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive for two of three residents reviewed, Resident R4 and Resident R5. The facility policy dated 3/16/26 stated that on admission the facility would determine whether a resident had executed an advance directive and, if not, whether the resident would like to formulate one, and that the facility would provide residents or resident representatives information on formulating advance directives. Resident R4 was admitted to the facility and had an MDS dated 4/7/26 showing diagnoses of heart failure, high blood pressure, and anxiety. Review of the clinical record failed to reveal an advance directive or documentation that Resident R4 was given the opportunity to formulate one. Resident R5 was admitted to the facility and had an MDS dated 2/12/26 showing diagnoses of high blood pressure, COPD, and paraplegia. Review of the clinical record also failed to reveal an advance directive or documentation that Resident R5 was given the opportunity to formulate one. During an interview on 4/22/26 at 12:30 p.m., the Social Worker stated that it was not documented anywhere and confirmed the lack of documentation for both residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician of a change in condition for Resident R1, who was admitted with diagnoses including high blood pressure, diabetes, and chronic pain. A progress note documented that the resident’s daughter requested transfer to the emergency room because the resident was having difficulty breathing; the resident was found sitting in a wheelchair on oxygen with audible wheezing, and the daughter was updated on the resident’s condition before the resident was sent to the emergency room. Review of the clinical record did not show that the change in condition and hospital transfer were communicated to the physician, despite the facility policy requiring notification of the resident’s physician and family member when there is a significant change in condition or a transfer from the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that discharge documentation was on record for one closed resident record, Closed Resident Record R64. Facility policy on transfer and discharge required that, for transfer to another provider, the receiving provider be given the contact information of the practitioner responsible for the resident’s care, resident representative contact information, advance directive information, and other necessary information. However, review of R64’s clinical nurse notes, physician orders, and physician assessment documents did not include an order to discharge to Assisted Living/Personal care. Closed Resident Record R64’s admission record showed she was admitted to the facility, and her MDS dated 8/24/25 listed diagnoses of hyperlipidemia, hypertension, dysphagia, and macular degeneration. Her care plan dated 8/20/25 directed staff to notify the doctor of discharge plans and work with the resident to facilitate safe discharge. A clinical nurse note dated 9/12/25 stated that R64 was discharged with her son to an assisted living facility, that scripts were sent, and that discharge paperwork was sent with her son. During interview on 4/23/26, the NHA confirmed the facility failed to ensure discharge documentation was on record for R64, including a physician order to discharge to Assisted Living as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that required resident information was communicated to the receiving health care provider when Resident R1 was transferred to the hospital and later returned to the facility. The clinical record showed that Resident R1 was admitted to the facility, had an MDS dated 3/31/26 listing diagnoses of high blood pressure, diabetes, and chronic pain, and was transferred to the hospital on 3/19/26 before returning on 3/23/26. Review of the record found no documented evidence that the facility communicated the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, or other information needed to meet the resident’s needs at the receiving facility. The facility also failed to provide documented evidence that a written transfer notification was sent to the Office of the Long-Term Care Ombudsman for Resident R1’s hospitalization. Facility policy stated that transfer information must include practitioner contact information, resident representative contact information, advance directive information, and other information necessary to meet the resident’s needs. During interviews, the DON confirmed there was no evidence that the necessary information was communicated to the receiving health care institution or provider, and the NHA confirmed there was no documented evidence that the Ombudsman was notified of the transfer.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nutrition services met professional standards of quality for comprehensive care plan development for two months, March and April 2026. Review of the facility’s Nutritional Management policy dated 3/1/26 and previously dated 1/21/26 stated that monitoring of the resident’s condition and care plan interventions would occur on an ongoing basis, including interviewing the resident or resident representative, directly observing the resident, and interviewing direct care staff about the resident’s interventions and reporting responsibilities. During a telephonic interview on 4/22/26 at 12:46 p.m., the RD confirmed that she had worked from home for the past two months, now worked in Ohio, and did not come into the building. She stated that she accessed records remotely and communicated needs to the DON by email, but did not observe residents or conduct interviews with staff, residents, or families, and confirmed that current practices failed to meet professional standards of quality for comprehensive care plan development.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of Resident R15. The facility policy stated that residents would be provided an ongoing program of activities based on their comprehensive assessment, care plan, and preferences, with facility-sponsored group, individual, and independent activities designed to meet each resident’s interests. Review of the April 2026 activity calendar showed bingo scheduled only twice that month during the reviewed period, and Resident R15’s care plan and quarterly activity participation review identified bingo, trivia, and socials as preferred activities. Resident R15 was admitted and readmitted with diagnoses including paraplegia, insomnia, and muscle weakness. During interview, the resident stated the facility usually had bingo three times a week, but bingo was only offered once the prior week. Documentation showed the resident participated in a social activity for only one of 21 days, and the facility failed to document activities provided for the resident. The Director of Activities confirmed bingo was cancelled on one scheduled day, stated bingo was scheduled every Monday and Wednesday with residents calling bingo on Saturdays, and stated it was difficult to document activities. The Director of Activities also stated she was the only employee in the activity department and helped on the floor as a nurse aide. During resident council interview, two of seven residents voiced concerns about insufficient activity staff and missing bingo activities for a week.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an environment free of potential accident hazards and provide safe bed mobility for one resident. Resident R32 had diagnoses including anxiety disorder, hyperlipidemia, and diabetes, and her care plan indicated she was occasionally incontinent of bowel and bladder and required assistance with toileting needs. During the incident, she reported that a nurse aide moved her roughly while providing care, told her to roll to the left, and that she hit her head on the dresser. The resident’s dresser was observed near her window, and no bruising or pain was noted on observation. The resident stated that she rang the bell twice and that the aide was “like a gazelle” and “like a wild woman.” She said the aide was hysterical with her, changed her instead of taking her to the bathroom, and was pretty rough during the process. The nurse aide stated she checked residents who stayed in bed, asked Resident R32 if she needed the bedpan, rolled her over, placed her on the bedpan, washed her up, and gave morning care. The aide stated the resident did not say she was hurt and did not show signs of pain, but acknowledged that the resident was rolled twice during care and that she may have been moved toward the dresser. The facility also failed to ensure leg rests were applied to another resident’s wheelchair before transport. Resident R53 had diagnoses including adult failure to thrive, unsteadiness on feet, and muscle wasting and atrophy, and used a wheelchair. During observation, the resident was sitting in the wheelchair without leg rests, and EMS transport began pushing the resident down the hallway without them. The EMS transport employee confirmed he failed to apply the leg rests and failed to ensure the resident’s environment remained free of accident hazards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident R10, who had diagnoses of stroke, difficulty swallowing, and high blood pressure and was receiving nutrition through an enteral feeding tube, received appropriate treatment and services related to the tube feeding. The resident’s MDS indicated tube feeding use, and the clinical record showed a Medical Nutrition and Hydration Evaluation on 3/26/26 stating the resident was NPO and receiving Jevity 1.2 at 30 mL per hour continuously, with a recommendation to increase the rate to 65 mL per hour for 20 hours per day to meet estimated calorie needs. A physician order dated 4/1/26 directed Glucerna at 30 mL continuously, but the order did not specify the type or strength of Glucerna to be provided. A later RD evaluation on 4/9/26 documented the resident was receiving Glucerna at 30 mL per hour continuously and stated the current tube feed provided 720 calories, with a recommendation to continue the tube feeding as ordered, even though the report states the resident was receiving 830 to 1,140 calories less than estimated needs. During observation on 4/22/26, the resident was receiving Glucerna 1.5 at 30 mL per hour. The DON stated the physician did not want the rate increased because the resident had trouble tolerating the feeding in the hospital, but there was no documentation of that decision in the clinical record. The RD later confirmed the resident was not receiving the required calories, that this was based on advice from a community RD, and that the facility failed to document this. The community RD also confirmed she intended Glucerna 1.2, not 1.5, and acknowledged the facility failed to provide the correct formula because the order was not written correctly.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Safe and appropriate respiratory care was not provided for two residents who were receiving oxygen therapy. Resident R14 had diagnoses of heart failure, respiratory failure, and morbid obesity with alveolar hypoventilation, and had physician orders for one liter of oxygen every shift and BIPAP at bedtime and naps. During an observation, R14 was found lying in bed with oxygen on, with undated nasal cannula tubing and an empty humidification bottle dated 4/13/26. The resident’s care plan did not include a care plan for oxygenation use, and the RN Supervisor confirmed the facility failed to implement a care plan for R14’s oxygen use. Resident R44 had diagnoses of heart failure, diabetes, and COPD, and had physician orders for oxygen at two liters per minute via nasal cannula every shift and to change the humidifier and tubing weekly on Sundays. During an observation, R44 was lying in bed with oxygen on, and the oxygen nasal cannula and humidification bottle were not dated. The resident’s care plan intervention still reflected oxygen as needed for shortness of breath rather than the current plan of care, and staff confirmed the tubing and humidification bottle were missing dates and should be changed weekly. The RN also confirmed that R44’s oxygen care plan was not updated to reflect the current plan of care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe, appropriate pain management for a resident with low back pain, anxiety, and chronic pain. The resident’s care plan identified pain or risk for pain and discomfort and included interventions to administer pain medications as ordered, observe for side effects and effectiveness, complete pain assessments, and observe for pain each shift. Physician orders included Tylenol as needed and oxycodone for low back pain, with the oxycodone order later changed to scheduled dosing every 6 hours for pain. The clinical record did not include evidence that the resident’s pain was monitored and assessed each shift from 3/21/26 to 3/23/26, and the MAR showed the facility did not administer the ordered 5 mg oxycodone every 6 hours during that period. The resident later reported that after arriving at the facility she was in pain, did not receive any oxycodone until Tuesday after arriving on Friday evening, and spent the weekend in bed with increased pain. A progress note documented the resident lying in bed and stating she had a lot of pain in her hips, and the MDS indicated pain was present almost constantly, affected sleep and therapy participation, limited day-to-day activities, and was rated 8/10.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma informed care for Resident R43, who had a diagnosis of PTSD, high blood pressure, and insomnia. Review of the facility’s Trauma Informed Care policy showed that the facility was to identify triggers that may retraumatize residents with a history of trauma and add trigger-specific interventions to the care plan to decrease exposure to those triggers or mitigate their effects. However, review of Resident R43’s care plan for PTSD showed that it identified a traumatic event but did not identify any triggers related to PTSD. During an interview, the Social Worker confirmed that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization for Resident R43.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Resident R50 received appropriate behavioral health management to maintain the highest practicable well-being. The facility policy stated residents should receive necessary behavioral health services to support their highest level of mental and psychosocial functioning. Resident R50’s record showed diagnoses of unspecified dementia with other behavioral disturbances, depression, and schizoaffective disorder, and the care plan directed staff to monitor, document, and report adverse reactions related to antidepressant therapy, including changes in behavior or mood such as insomnia. The MDS indicated the resident reported trouble falling asleep or staying asleep 12-14 days in the last two weeks, and a psych re-evaluation documented ongoing insomnia with no relief in four years and a request to increase melatonin. The psych note ordered melatonin to be discontinued and replaced with 6 mg nightly for sleep disorder, and the plan and education were reviewed with the resident and nursing staff. During interview and observation, Resident R50 stated he was shaky all the time, was not getting much sleep at night, and had not slept well for five years; the resident was also observed with visible tremors and later resting in bed with a sheet over his head. Review of physician orders failed to show the melatonin increase had been entered, and the Nurse Practitioner confirmed the facility had not increased the melatonin to 6 mg as ordered for nine days. The Regional Director of Clinical Operations confirmed the facility failed to ensure the resident received appropriate behavioral health management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide evidence that the licensed pharmacist’s monthly medication regimen review was reviewed and acted upon timely for one sampled resident, Resident R8. The facility’s Medication reconciliation policy stated that monthly reconciliation included pharmacy consultation access to all medication areas and records and required responses to medication irregularities reported by the pharmacy consultant. Resident R8 was admitted on [DATE] and, on the 4/8/26 MDS, was documented with hypertension, diabetes, dementia, and depression. His care plan dated 4/20/26 included depression, administering medications as ordered, and monitoring for side effects. Resident R8’s physician orders included lorazepam concentrate 0.5 ml sublingually every 4 hours as needed for anxiety, fentanyl patch 25 mcg transdermally every 72 hours for pain, and morphine 10 mg sublingually every 2 hours as needed for pain. The pharmacist medication review dated 2/9/26 showed a medication regimen review with a pharmacy recommendation requiring a response, but the medication and recommendation details were not documented. The clinical record did not include a physician response to the pharmacy recommendation. During interview, the NHA, Interim NHA, and Mobile DON confirmed the facility failed to provide evidence that the pharmacist’s medication regimen review was reviewed and acted upon timely for Resident R8 as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Drugs and biologicals were not stored securely in the facility’s Main Storage Room, and one resident’s medication was left unsecured. Resident R45, who was admitted with diagnoses including adult failure to thrive, urinary tract infection, and anxiety, had a physician order for 1% Fungicure External Solution to be applied to the fingernails topically twice a day for fungal treatment for four weeks. During observation, the resident’s bottle of Fungicure External Solution was found unsecured on the bedside table, and an LPN confirmed that the medication was not secured. In the Main Storage Room, multiple medical supplies were observed expired during a medication storage room review. The expired items included lavender, mint, and pink lab tubes, black foam wound dressing supplies, a black foam kit that was opened, [NAME] Foam Dressing, Drape File Dressing, wound vac canisters, and a large foam kit. An RN confirmed the expired supplies and stated they should have been disposed of after the expiration date.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent cross contamination and failed to implement appropriate transmission-based precautions for one resident with an open wound. Facility policy for Enhanced Barrier Precautions indicated that gown and glove use should be employed during high-contact resident care activities for residents with wounds, and the clean dressing change policy required gloves to be removed after the old dressing was taken off, followed by hand hygiene and clean gloves before continuing wound care. Resident R3 had diagnoses including high blood pressure, diabetes, and anxiety, and had a physician order for daily wound care to the area above the left knee using wound cleanser, xeroform, calcium alginate, and a super absorbent dressing. During observation of the resident’s room, there was no signage posted at the door indicating the resident was ordered Enhanced Barrier Precautions, and the resident’s physician orders did not include an order for EBP. During the dressing change, the RN failed to remove gloves and wash hands after removing the old dressing and before applying the clean dressing. The RN confirmed the failure to implement Enhanced Barrier Precautions and to prevent cross contamination during the dressing change, and the Nursing Home Administrator confirmed the resident should have been in Enhanced Barrier Precautions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to keep the Main Nursing Unit crash cart in safe operating condition. Facility documentation stated the emergency cart was to be checked daily by the night shift RN Supervisor for expiration dates and missing items, but the records reviewed showed missing signatures on multiple dates in January and February 2026. During an observation of the crash cart at the Main Nurses Station, the surveyor found an opened Ambu bag that had expired and an opened Suction Cath-N-Glove kit. During an interview, RN Employee E3 confirmed the missing signatures and the expired/open supplies on the crash cart.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a resident from verbal and mental abuse by facility leadership and nursing staff, resulting in severe psychosocial harm in the form of embarrassment and humiliation. The facility’s own abuse policy, reviewed with a date of 1/21/26, states that the facility will not tolerate abuse, neglect, or exploitation and defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including verbal and mental abuse. Despite this policy, a cognitively intact resident with bilateral above-knee amputations and opioid dependence, who had a physician’s order for oxycodone 10 mg every four hours, reported that when he requested his pain medication, an LPN refused to assist and told him she would not come into his room while he was screaming. The resident stated that this led him to yell and scream for help. The resident reported that the Nursing Home Administrator (NHA) then came to his room and verbally abused and threatened him. According to the resident, the NHA told him he sounded like an idiot and stated that if the resident had legs, he would beat his “a**,” and also yelled out the resident’s medical history, including calling him an addict, in a manner that could be heard by others. The resident stated that the Director of Maintenance had to pull the NHA out of his room twice. Another cognitively intact resident confirmed witnessing the altercation, stating that the NHA physically threatened the resident, referenced his medical information, and called him an addict, and that the Director of Maintenance had to carry the NHA away twice. Two additional residents reported hearing yelling and commotion lasting approximately 20 minutes, describing it as sounding like people fighting and exchanging words. The LPN involved acknowledged that the resident was screaming for his medications and that she told him his pain medication was scheduled every four hours and that she did not have to come into the room if he continued screaming, stating she would not enter until he calmed down. She reported going outside to cool down and smoke a cigarette while the resident continued to scream, and she admitted that she may have given the resident the middle finger. The resident reported that the LPN gave him the middle finger behind the curtain and then directly to his face when confronted, and he documented these events in a written letter given to an RN supervisor, stating he felt verbally and physically threatened by the NHA, unsafe with the NHA around, and that his personal information was being yelled in the hall. The RN supervisor confirmed receiving the written concern and hearing from several employees that the incident was “pretty bad.” The DON acknowledged that the NHA was asked to see the resident and confirmed that the facility failed to protect the resident from verbal abuse, which caused severe psychosocial harm. Surveyors determined that this failure created an Immediate Jeopardy situation for one of six residents reviewed.

Removal Plan

• Identify root cause of the Immediate Jeopardy as staff failure to follow the facility abuse policy.
• Assess Resident R1 for adverse outcomes related to the abuse/neglect allegation.
• Offer Resident R1 coping and trauma support by RN Supervisor or designee.
• Ensure appropriate services are provided to Resident R1 if adverse outcomes occurred from abuse/neglect by Mobile DON or designee.
• Assess/interview all residents for abuse/neglect by Mobile DON or designee for indications of fear, trauma, or abuse/neglect.
• Notify physician/POA (if applicable) of any adverse findings and update the medical record.
• Review and update care plans as appropriate by Mobile DON or designee.
• Ensure appropriate services are provided to residents if adverse outcomes occurred from abuse/neglect.
• Report to appropriate agencies by Mobile DON or designee.
• Complete head-to-toe skin assessments for all residents, document findings in the medical record, notify attending physicians of any negative results, and ensure appropriate services are provided if adverse outcomes occurred.
• Interview staff by Regional Director of Operations or designee for allegations of abuse/neglect that have not been reported.
• Review incidents by Mobile DON or designee to ensure no incidents occurred that went unreported and immediately report any identified incidents that meet criteria.
• Review the Abuse/Neglect Policy for appropriateness and what to do if the alleged perpetrator is the DON or NHA and update if needed, including adding the corporate compliance number for staff to use if DON/NHA is involved or staff feel uncomfortable reporting to facility leadership.
• Re-educate all house staff by Regional Director of Operations or designee on the abuse/neglect policy, including the corporate compliance number for staff to use if DON/NHA is involved or staff feel uncomfortable reporting to facility leadership.
• Conduct audits to ensure no abuse or neglect is identified by reviewing residents.
• Review nursing documentation by Mobile DON or designee to ensure no incidents occurred that were unreported to administration.
• Review all audits and policy changes related to the Immediate Jeopardy at an Ad Hoc QA meeting.
• Have the QAPI committee review all findings upon completion of audits.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow its own abuse, neglect, and exploitation policy, including required criminal background checks and mandated reporting and investigation of abuse/neglect allegations. The facility’s written policy stated that all employees must have criminal background checks completed prior to hire and that records of such checks must be retained in employee files. Review of the social worker’s (Employee E1) personnel file showed a hire date of 1/27/26, but the criminal background check for this employee was not completed until 3/12/26. During an interview, the DON and NHA confirmed that this staff member began working without a completed background check, contrary to facility policy. The deficiency also includes the facility’s failure to identify, report, and investigate an allegation of abuse/neglect involving one resident, and failure to protect that resident from the alleged perpetrators. Resident R1, who had bilateral above-knee amputations and opioid dependence and was documented as cognitively intact with a BIMS score of 15, reported that on 3/11/26 he experienced verbal and attempted physical abuse from the NHA and felt unsafe when the NHA was in the facility. The resident stated he wrote a letter detailing the events and gave it the same day to an RN supervisor (Employee E3), whom he described as the only person he trusted. The resident reported that the facility did nothing, did not investigate, and allowed the alleged perpetrators to continue working. Multiple staff interviews corroborated that an incident occurred and that the NHA continued to work afterward. A COTA (Employee E5) stated he arrived about five minutes after the incident, described the NHA as intimidating with a short fuse, and confirmed the NHA worked the remainder of that day. The Director of Maintenance (Employee E4) confirmed he had to remove the NHA from the resident’s room to deescalate the situation and that the NHA continued to work that day. The resident’s written letter described verbal and attempted physical abuse by the NHA, a HIPAA violation involving personal information being yelled in the hall, and an LPN (Employee E2) making an obscene gesture behind a curtain and then directly to the resident when confronted. The RN supervisor (Employee E3) confirmed receiving the written concern on 3/11/26 and stated she was unsure to whom to give it because the allegation involved the NHA. The facility failed to document or process this allegation as an incident and did not report it to the State Agency or other required entities at the time it occurred. Review of facility incident logs and information submitted to the State Agency on 3/11/26 and 3/12/26 showed no inclusion of Resident R1’s abuse/neglect allegation. The DON acknowledged being aware of a verbal altercation on 3/11/26 and stated that the NHA was asked to see the resident and that corporate instructed them not to call the police. The DON confirmed that the NHA and LPN E2 were not suspended and continued to work in the facility, and that the facility failed to timely report, investigate, notify appropriate agencies, and protect residents from further abuse/neglect related to this event. The NHA was only suspended two days after the alleged abuse/neglect occurred. These failures, combined with the lack of a timely background check for Employee E1, resulted in an immediate jeopardy situation as cited by surveyors.

Removal Plan

• Identify root cause of the Immediate Jeopardy as staff failure to follow the facility abuse policy.
• Assess Resident R1 for adverse outcomes related to the abuse/neglect allegation.
• Offer Resident R1 coping and trauma support by RN Supervisor or designee.
• Ensure appropriate services are provided to Resident R1 if adverse outcomes occurred from abuse/neglect by Mobile DON or designee.
• Assess/interview all residents for abuse/neglect for indications of fear, trauma, or abuse/neglect by Mobile DON or designee.
• Notify physician/POA (if applicable) of any adverse findings and update the medical record.
• Review and update care plans as appropriate by Mobile DON or designee.
• Complete head-to-toe skin assessments for all residents and document findings in the medical record.
• Notify attending physicians of any negative results from resident assessments.
• Report any adverse outcomes/findings to appropriate agencies.
• Interview staff for allegations of abuse/neglect that have not been reported in the last 30 days by Regional Director of Operations or designee.
• Review incidents to ensure no incidents occurred that went unreported and immediately report any that meet criteria by Mobile DON or designee.
• Review the Abuse/Neglect Policy for appropriateness, including what to do if the alleged perpetrator is the DON or NHA, and update if needed.
• Add the corporate compliance hotline number to the abuse/neglect policy for staff to use if DON/NHA are involved or staff are uncomfortable reporting to facility leadership.
• Re-educate all house staff on the abuse/neglect policy, including use of the corporate compliance hotline when leadership is involved, by Regional Director of Operations or designee.
• Educate HR (or designee) that criminal background checks must be completed prior to hire.
• Audit all staff HR files to ensure all background checks are present and do not allow any employee to return to work until a missing criminal background check is completed.
• Conduct audits to ensure all existing employee files contain criminal background checks and all new hires have checks completed prior to start date.
• Conduct audits of resident care needs to ensure no abuse/neglect is identified.
• Review nursing documentation to ensure no incidents occurred that were unreported to administration by Mobile DON or designee.
• Review all audits and policy changes related to the Immediate Jeopardy at an ad hoc QA meeting.
• Have the QAPI committee review all findings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure accurate staffing practices. The facility’s own policy dated 1/15/26 states it will maintain staffing practices consistent with federal regulations, state law, and professional standards while supporting safe and effective care. However, multiple residents reported that the facility was understaffed, resulting in missed showers, inadequate hygiene, and insufficient assistance with mobility and positioning. One resident stated they were not showered before a doctor’s appointment, did not have a buttocks wound dressed, and were left sitting on their buttocks all day. Another resident reported not getting out of bed for months due to lack of staff and not receiving regularly scheduled showers on Tuesdays and Fridays. Additional residents described similar issues related to inadequate staffing. One resident reported that when they get up during the day, there often are not enough staff to put them back to bed. Another resident stated that staff are “plugged into” nurse aide positions but do not provide care or remain on the floors. A resident with Lyme disease, whose skin becomes very itchy, reported receiving only five showers in six weeks despite being scheduled for two per week and stated there were days they were not cleaned up at all. Another resident reported waiting over an hour for staff to obtain a portable oxygen tank so they could leave their room. Staff interviews and staffing records further demonstrated insufficient and inaccurately represented staffing. A nurse aide reported there were not enough staff to turn and reposition residents and that it was hard to find help when two-person assistance was needed. Multiple staff members stated the facility “lies” on the staffing sheet by listing employees who are not actually providing resident care, including a cook and a social worker who were pulled to the floor without nurse aide job descriptions or orientation in their files, and a nurse aide who was scheduled but found folding linens in the laundry instead of providing care. On a shift with a census of 52 residents, an LPN reported having only two, possibly three aides, effectively leaving one aide per hallway. The interim administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the identified residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for a three‑month period from January 2026 through March 2026. Staff interviews and review of employee files showed that the individual functioning as the Kitchen Manager, Employee E21, had been hired on 1/21/26 and had worked as Kitchen Manager since 1/28/26, but was a Nurse Aide and not a Certified Dietary Manager. During an interview on 3/12/26, at 9:57 a.m., Employee E21 confirmed she was not a Certified Dietary Manager. In a subsequent interview on 7/21/24 at 1:40 p.m., the Interim NHA (Employee E12) and the DON confirmed that the facility could not provide documented evidence that Employee E21 met the qualifications required for the Food Service Director position, resulting in noncompliance with PA Code 201.18(e)(6) regarding management. No specific residents, medical histories, or clinical conditions were mentioned in relation to this deficiency in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the Nursing Home Administrator (NHA) failing to effectively manage the facility to ensure residents were free from abuse and to ensure the facility implemented its abuse policies, resulting in an immediate jeopardy situation. A review of the NHA’s job description showed that the primary purpose of the position was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations governing LTC facilities so that the highest degree of quality care could be provided to residents at all times. However, based on review of the job description, facility and clinical records, and staff interviews, surveyors determined that the NHA did not fulfill these responsibilities, as the facility failed to provide fundamental principles that apply to treatment and care, and failed to ensure that residents received treatment and care in accordance with professional standards of practice and facility policies. These failures were cited under 28 Pa Code 201.14(a) Responsibility of licensee and 28 Pa Code 201.18(b)(1)(e)(1) Management. The report does not provide specific resident identifiers, clinical histories, or detailed descriptions of individual abuse incidents, but it establishes that the facility’s administration and management, under the NHA’s direction, did not ensure implementation of abuse policies or adherence to professional standards and facility policies in the treatment and care of residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately complete and update its facility-wide assessment used to determine necessary resources for competent resident care during routine operations and emergencies. Review of the Facility Assessment dated 3/26/25 showed that the section listing key personnel still identified the previous Nursing Home Administrator, previous Director of Nursing, and previous Assistant Director of Nursing rather than current leadership. The census section referenced a time period of the 2025 year to date without current information, and the section titled “Information about our residents” had not been reviewed or updated since 3/26/25. During an interview on 3/14/26, the Interim Nursing Home Administrator (Employee E12) confirmed that the facility failed to accurately complete the Facility Assessment and that all information about the residents reflected the last time this employee had worked at the facility, rather than current resident data. These findings were cited under 28 Pa. Code 201.18(b)(3)(e)(2) related to management requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to put forth a good faith effort to correct deficient practices cited during the prior survey, including staffing, dietary management, employment process, and the Facility Assessment. Survey findings showed the facility did not provide adequate staffing to meet resident needs, did not provide qualifying coursework for the Dietary Manager, did not provide on-site oversight of daily dietary operations, did not train the Human Resources Director who was responsible for hiring qualified staff for the Dietary Manager position, hired an unqualified applicant to fill the vacant Dietary Manager role, and did not keep the Facility Assessment current and accurate as required. During interview, the DON confirmed the facility had failed to meet resident needs by not providing showers to residents. Review of April 2026 ETARs showed the facility also failed to provide showers, repositioning, skin protection care, assistance out of bed, and assistance with mechanical lift transfers. Staff interviews confirmed the facility was short staffed, resulting in staff failing to meet resident needs. The facility also failed to provide coursework for the current Dietary Manager to obtain the required qualifications and failed to provide on-site oversight of dietary operations, while the HR Director responsible for hiring was not included in the in-service training on Dietary Manager qualifications. The Facility Assessment was also not updated with current leadership information.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that a physician completed required initial comprehensive visits, as mandated by facility policy and state regulations. The facility’s “Physician Visits and Physician Delegation” policy, dated 6/1/24 and last reviewed 1/21/26, specifies that a PA, NP, or CNS may not perform initial comprehensive visits. Despite this, review of clinical records showed that initial visits for three residents were conducted by a Certified Registered Nurse Practitioner (CRNP), identified as Employee E20, rather than by a physician. For one resident admitted with anxiety, depression, and lung cancer, a late entry note dated 3/1/26 (effective 2/25/26) documented that the CRNP completed the initial admission visit. For another resident with gastroparesis, anemia, and esophagitis with bleeding, who had been discharged home and then readmitted, a late entry note entered on 2/25/26 (effective 2/23/26) showed that the CRNP assessed the resident following readmission, constituting the initial visit. For a third resident admitted with emphysema, oxygen dependence, and alcohol dependence with withdrawal, a late entry note entered on 6/26/26 (effective 6/25/26) documented that the CRNP performed the initial visit. During an interview, the DON and Interim Nursing Home Administrator acknowledged that the facility failed to ensure a physician completed the initial visits for these three residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the facility’s failure to appropriately and timely document progress notes in the clinical records for four residents. For one resident with anxiety, depression, and lung cancer, the initial admission visit was documented as a late entry on 3/1/26 for an encounter that occurred on 2/25/26, resulting in a four-day delay in documentation. Another resident with dementia, tremor, and a history of falling received a right shoulder injection on 3/5/26, but the corresponding progress note was not entered until 3/13/26, eight days later. A third resident with gastroparesis, anemia, and esophagitis with bleeding was seen for increased swelling in both lower extremities on 1/19/26, but the progress note was entered as a late entry on 1/23/26, four days later. A fourth resident with emphysema, oxygen dependence, and alcohol dependence with withdrawal was evaluated for nausea, vomiting, and diarrhea on 2/23/26, yet the related progress note was not entered until 2/25/26, two days later. During an interview, the Director of Nursing acknowledged that the facility failed to appropriately and timely document progress notes in the clinical records for all four residents, in violation of 28 Pa. Code 211.5(f)(g)(h) regarding clinical records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors determined that the facility failed to provide required training on effective communication for five of five sampled direct care staff members. Review of the facility’s employee listing showed that one RN and four NAs were hired on various dates between 10/30/23 and 12/4/24. Examination of facility-provided education documents and individual training records for these staff members revealed no evidence that they had received education on effective communication as required by facility policy and state regulations. During an interview on 3/14/26 at 1:00 p.m., the Interim Nursing Home Administrator confirmed that the facility had not provided effective communication training to these identified staff members. The deficiency was cited under 28 Pa Code: 201.14(a) Responsibility of licensee, 28 Pa Code: 201.18(b)(1) Management, and 28 Pa Code: 201.20(a)(6)(d) Staff development, based on the lack of documented training and the administrator’s acknowledgment of this omission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary treatment and services, consistent with professional standards of practice, for a resident with a pressure ulcer. Facility policy on Pressure Injury Prevention and Management required that treatment and services be provided to heal pressure injuries, that preventive interventions be implemented for all residents with pressure injuries, and that these interventions be documented in the care plan and communicated to staff. The resident, admitted with abnormal posture, paraplegia, and a right ankle pressure ulcer, had an MDS indicating a current Stage III pressure ulcer. The care plan and physician orders directed staff to encourage turning and repositioning every two hours and as needed, float heels while in bed, and apply offloading boots when in bed. However, review of the resident’s Documentation V2 Reports for February and March showed missing evidence of turning and repositioning each shift, with a total of 39 undocumented instances in February and 17 in March. During interview, the resident reported getting out of bed only once a day, needing assistance with turning and repositioning, and stated that staff turned and repositioned him maybe twice a shift. Observation found the resident lying in bed without the ordered offloading boots in place; the boots were seen in a chair, and the resident stated staff had not offered to put them on that day. An LPN confirmed the offloading boots were not on as ordered. The DON stated that for residents at risk for pressure ulcers or with wounds upon admission, interventions such as turning and repositioning, air mattress, wedges, or bunny boots are entered upon admission and are expected to be documented at least each shift, and confirmed the facility failed to document that the offloading boots were applied while the resident was in bed each shift. The Nursing Home Administrator and DON confirmed the facility failed to ensure necessary treatment and services were provided for the resident’s pressure ulcer, in violation of 28 Pa. Code 211.12(d)(5) Nursing services.

Penalty

Inspection fine: $270,889

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide the required number of Nurse Aides (NAs) per resident per shift as required by state regulations. Surveyors determined that, for the period from 1/25/26 through 2/13/26, the facility did not meet required NA staffing ratios for 40 of 63 shifts. A review of the facility’s staffing worksheet showed that the facility was using an outdated staffing hours calculator that did not reflect current NA ratio regulations, and the Nursing Home Administrator (NHA) confirmed that the incorrect calculator was being used. The documentation provided by the facility also lacked the assignment grids that were supposed to designate required NA ratios and be reviewed during labor meetings. Based on review of documents and staff interviews, surveyors concluded that the facility failed to make a good faith effort to correct and sustain improvement for a previously cited deficiency related to NA staffing ratios (Citation P5520). Despite prior education provided to the NHA and Director of Nursing (DON) on the required state Certified Nurse Aide ratios, the facility’s practices did not result in compliance with current staffing requirements. The failure to maintain required NA staffing levels and to use accurate tools to calculate staffing was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 28 Pa. Code: 201.18(b)(1) Management, and 28 Pa. Code: 211.12(d)(1)(2)(3)(4)(f.1)(i)(2) Nursing services.

Penalty

Inspection fine: $270,889

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet residents’ needs for activities of daily living (ADLs) and activities participation, resulting in unmet care needs for five of six interviewed residents. Facility policies dated 1/15/26 required staff to provide necessary services for bathing, dressing, grooming, oral care, transfers, ambulation, toileting, eating, and communication, and to assist residents to and from activities with accommodations in schedules and timing. Multiple residents reported that there were not enough aides, especially on the 2 p.m. to 10 p.m. shift, leading to missed showers on scheduled shower days, prolonged call light response times of up to an hour, and residents sometimes not being gotten out of bed at all because there was not enough staff to return them to bed. Residents also reported that activities, including Bingo and card games, were repeatedly cancelled or not attended because of insufficient staff to assist with transport and supervision. Several residents stated that Bingo, normally held three times a week, had not occurred for about a week, and that they were sometimes unable to go to the dining room to eat because there were not enough staff to supervise and help those who needed assistance. Staff reportedly informed residents that activities and dining room attendance were being limited or cancelled due to staffing shortages, particularly on specific shifts. The Nursing Home Administrator confirmed that the facility did not have sufficient nursing staff to provide nursing and related services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the affected residents.

Penalty

Inspection fine: $270,889

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to complete required neurological assessments following a resident fall. Facility policy on Fall Prevention and Management dated 1/15/26 states that in the event of a fall, a licensed nurse will assess the resident, the physician/NP and responsible party will be notified, and appropriate documentation and interventions will be completed. The 72-Hour Neurological Assessment Sheet further specifies that for all falls, neurological checks are to be completed at defined intervals (initial assessment, then every 15 minutes x4, every 30 minutes x4, every hour x2, and once per shift for 72 hours), and that unwitnessed falls or falls in which the head is struck require neuro checks and physician notification for any change in condition. The resident involved, identified as R1, had diagnoses including hypertension, seizure disorder, and hyponatremia, and experienced a fall on 1/18/26. A nursing progress note documented that at 4:15 p.m. the resident was found on the floor in his room, sitting on his buttocks, laughing, with the wheelchair at bedside and the bed on its side. The resident denied pain or discomfort, range of motion was within normal limits, no apparent injuries were noted, and vital signs were stable. The note stated that neuro checks were initiated per facility protocol. However, review of the 72-Hour Neurological Assessment Sheet dated 1/18/26 showed that only 8 neurological checks were completed out of 18 required opportunities. In an interview, the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure the resident received the neurological assessments after the fall, resulting in the cited deficiency under 28 Pa. Code 201.14(a), 211.10(d), and 211.12(d)(1)(5).

Penalty

Inspection fine: $63,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with moderate cognitive impairment and a diagnosis of dementia and anxiety was subjected to mental abuse and intimidation by facility staff in a public hallway. The resident, who had a Power of Attorney (POA) assigned to handle financial matters, was confronted by the Nursing Home Administrator (NHA) and a sheriff's deputy regarding an outstanding facility bill of $26,827. The confrontation took place in a public area, with other residents and staff present, and involved repeated verbal statements about the resident owing money and threats of issuing 30-day notices. The resident became visibly distraught, tearful, and expressed confusion about the situation, stating they did not understand why they were being held or what the debt referred to. Multiple staff members witnessed the incident and expressed concern about the appropriateness of discussing private financial matters in a public space, especially given the resident's cognitive status. Written statements from staff described the resident as confused and tearful during and after the incident. Some staff members reported feeling pressured not to report the event as abuse, and there was a lack of a formal investigation into the incident. The facility's own policies required that such matters be handled privately and with the appropriate responsible party, in this case, the POA, rather than the resident. Interviews with staff and a representative from the sheriff's office confirmed that the resident's POA should have been the party served with legal or financial documents, not the resident with dementia. The NHA acknowledged that the situation was not handled appropriately and that the resident was not protected from mental/emotional abuse. The incident resulted in psychosocial harm and mental anguish to the resident, as evidenced by the resident's emotional response and the application of the reasonable person concept.

Penalty

Inspection fine: $63,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the responsible party signed financial papers for a resident with moderate cognitive impairment. According to facility policy, residents must be informed of their rights both orally and in writing, and information should be provided in a manner the resident can understand, taking into account any health or mental status limitations. The clinical record review showed that a resident with a BIMS score of 11, indicating moderate impairment, was admitted with diagnoses including Multiple Sclerosis, muscle wasting and atrophy, and hyperlipidemia. Despite this cognitive status, the resident personally signed a Notice of Medicare Non-Coverage (NOMNC) form. There was no documentation that the responsible party was informed or that they signed the necessary financial papers related to the ending of Medicare coverage. During staff interview, the Nursing Home Administrator confirmed that residents with moderate impairment should not sign NOMNC forms and acknowledged the failure to have the responsible party complete the required documentation. This deficiency was cited under 28 Pa. Code 201.18(b)(2) Management and 28 Pa. Code 201.29(a) Resident rights.

Penalty

Inspection fine: $63,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's legal surrogate, specifically the designated Power of Attorney (POA), was utilized for legal actions regarding non-payment of bills. The resident in question had a documented diagnosis of dementia with moderate cognitive impairment, as indicated by a BIMS score of 10, and her son was identified as her POA in the clinical record. Despite this, the facility sent invoices for a significant outstanding balance to both the resident and her POA, but when legal action was initiated for non-payment, the facility did not engage the POA and instead involved the resident directly. On one occasion, the Nursing Home Administrator (NHA), accompanied by a sheriff's deputy, confronted the resident in a public hallway about the unpaid balance, repeatedly informing her of the debt and the facility's practice of issuing 30-day notices. The resident, who was visibly distressed and expressed confusion about the situation, was not given the benefit of her POA's representation during this process. The NHA later confirmed that the facility failed to utilize the resident's POA for the legal action, despite being aware of the POA's authority and the resident's cognitive impairment.

Penalty

Inspection fine: $63,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of abuse involving a resident with dementia, high blood pressure, and anxiety. According to the facility's policy, all allegations of abuse, neglect, or exploitation must be reported to the Administrator and the Department of Health within 24 hours. On the date in question, the Nursing Home Administrator (NHA), accompanied by a sheriff's deputy, confronted the resident in a public hallway about an alleged debt, repeatedly stating the amount owed and referencing issuing 30-day notices. The resident became visibly distraught, crying and expressing confusion about the situation. Multiple staff members, including the Former Director of Nursing (FDON), Former Activities Director (FAD), and Former Social Worker (FSW), witnessed the incident and described it as emotional or mental abuse. Written statements were submitted by at least two staff members, detailing the resident's distress and the intimidating nature of the encounter. Despite these reports and the facility's policy, the incident was not reported to the state agency as required. The FDON acknowledged awareness of the situation but claimed not to have received any written statements, while other staff confirmed they submitted statements and were discouraged from pursuing the matter further. The NHA later confirmed that the facility failed to report the abuse allegation. A review of incidents submitted to the state agency showed no record of the staff-to-resident abuse allegation for the incident in question.

Penalty

Inspection fine: $63,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to identify and investigate an incident of possible abuse involving a resident with dementia, high blood pressure, and anxiety. The incident occurred when the Nursing Home Administrator (NHA), accompanied by a sheriff's deputy, confronted the resident in a public hallway about a significant outstanding balance, repeatedly stating the amount owed and referencing issuing 30-day notices. The resident became visibly distraught, was crying, and expressed confusion about the situation. Witnesses, including staff members, observed the resident's emotional distress and reported the event as potential verbal and psychological abuse. Despite the facility's policy requiring immediate reporting and investigation of all abuse allegations, the incident was not properly addressed. Staff members were instructed to submit written statements, and some did so, but the Director of Nursing (DON) reported receiving no statements. Witnesses later confirmed that they had submitted statements, which were not acknowledged or acted upon. The former NHA gave conflicting accounts regarding whether an investigation was conducted, at first stating that no investigation occurred and later claiming an investigation file existed but could not be located. Multiple staff interviews confirmed that the event was witnessed, statements were submitted, and concerns about abuse were raised. However, the facility did not follow its own procedures for investigating abuse allegations, failed to notify the Department of Health as required, and did not document or analyze the evidence. The NHA ultimately confirmed that the facility failed to identify and investigate the abuse allegation involving the resident.

Penalty

Inspection fine: $63,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ a qualified activities director as required by federal and state regulations. Review of facility documentation showed that the individual serving as Activity Director, Employee E8, previously worked as a Nurse Aide and did not have prior experience in an activity program. The personnel file for Employee E8 did not contain documentation demonstrating that they met the federal standards for the position. During interviews, both Employee E8 and the Nursing Home Administrator confirmed that the facility did not have a qualified activities director in place from October 6, 2025.

Penalty

Inspection fine: $63,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to make a good faith effort to correct and sustain improvement for two citations related to not providing the required number of NAs and LPNs per resident per shift. A review of the facility’s plan of correction, audit documents, and staff interviews showed that the audit used to measure compliance did not include corrective action or measurable data for continued deficient practice. Two audit forms were blank but were still initialed by the NHA as reviewed, and during an interview the NHA stated she was uncertain of the facility’s staffing compliance. The facility’s staffing worksheet showed that from 12/30/25 through 1/7/26, staffing ratios were not met for the NA position on 19 of 27 shifts and for the LPN position on 1 shift. During this period, the facility’s census increased from 50 to 57, but the staffing ratios were still not maintained according to the state agency requirements. The report also states that the facility failed to implement the use of outside resources to assist with improvement on staffing ratios, and during interviews the NHA confirmed that the facility did not employ a scheduler and that nurse staff schedules were completed by the DON and NHA.

Penalty

Inspection fine: $63,990

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post complete and accessible contact information for the State Long-Term Care Ombudsman program and the State Survey Agency as required by regulations. Observations revealed that the posted Ombudsman information in the front hallway was missing the Ombudsman's name, address, and email. Additionally, the State Survey Agency contact information was posted at an inaccessible height, in small print, and did not include an email address, current address, or a required statement informing residents of their right to file a complaint regarding suspected violations, including abuse, neglect, exploitation, misappropriation of property, non-compliance with advanced directive requirements, and requests for information about returning to the community. The Nursing Home Administrator confirmed these deficiencies during an interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean, safe, comfortable, and homelike environment in two of five rooms, specifically C Hall and the Shower Room. Observations included two ceiling tiles with brown stains in one room and, in the shower room, walls with sections of missing paint, unpainted plaster repairs, and dark discoloration between tiles on the floor and lower walls. A resident reported that after showers, the towel under their feet became black, indicating a lack of cleanliness. The DON confirmed these findings during the survey. These deficiencies were identified through review of facility policy, direct observation, and staff and resident interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly label and date food products in the Main Kitchen, as required by facility policy. During an observation, surveyors found an opened bag of lettuce in the tray line refrigerator, two cans of tuna in the dry storage area, an open bag of garlic and a bag of celery in the walk-in refrigerator, and two apple pies in the walk-in freezer, all without appropriate labels or receive dates. The Assistant Dietary Manager confirmed that these food items were not labeled or dated according to policy. The deficiency was cited under relevant Pennsylvania Codes for responsibility of the licensee and management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. Specifically, there was no documented evidence that the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs were provided to the receiving facility upon transfer. This deficiency was confirmed by the DON during interviews and was evident in the clinical records of the affected residents, who had complex medical histories including diabetes, hypertension, chronic kidney disease, cerebral infarction, and muscle weakness. Additionally, the facility did not provide written notification of the bed-hold policy to the residents or their representatives at the time of hospital transfer for three residents. The clinical records lacked documentation of this required notification. Furthermore, the facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for these residents, as confirmed by the DON and a review of facility records. These failures were identified through policy review, clinical record review, and staff interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of a resident. According to the Resident Assessment Instrument (RAI) User's Manual, Section A2105 requires that the discharge status be coded to indicate the actual location to which a resident is discharged. In this case, a resident with diagnoses of anxiety, hyperlipidemia, and underweight was admitted and later discharged from the facility. The MDS assessment incorrectly coded the resident's discharge status as a transfer to a short-term general hospital, when in fact, the resident was discharged to home/community after the family decided to take the resident out of the facility against medical advice (AMA). Review of clinical records and staff interviews confirmed the error. Nursing progress notes detailed the events leading to the resident's discharge, including the family's decision to remove the resident and the completion of AMA paperwork. The Director of Nursing acknowledged that the MDS was completed incorrectly, with the discharge status and entrance status being flipped, resulting in inaccurate documentation of the resident's actual discharge location.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. One resident, admitted with diagnoses including high blood pressure, PTSD, and orthopedic aftercare, was observed wearing knee immobilizer braces on both legs. However, there was no physician's order or care plan documented for the use and management of the knee immobilizer. The Therapy Director stated that the resident was required to wear the immobilizers at all times except during bed rest for skin checks and showering, but this protocol was not supported by any documented order or care plan. The Director of Nursing confirmed the absence of these required documents. Another resident, admitted with diagnoses such as cerebral aneurysm, hypertension, and muscle weakness, had physician orders indicating an NPO (nothing by mouth) status and specific oral medications to be administered. Despite these orders, the Director of Nursing confirmed that the physician's orders were not followed as required. These findings demonstrate that the facility did not ensure residents received care and treatment in accordance with physician directives and established care policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma-informed care for a resident with a history of trauma, specifically Post Traumatic Stress Disorder (PTSD). According to the facility's own policy, triggers that may re-traumatize residents should be identified and addressed through specific interventions in the care plan. Resident R39, who had a documented history of being assaulted and expressed discomfort with male caregivers, had this trigger identified in the social service history. The resident reported feeling anxious and reliving the traumatic experience when cared for by male staff. Despite this information, a review of the resident's care plan showed that it did not fully address the PTSD diagnosis or specify the trigger of male caregivers, nor did it include interventions to eliminate or mitigate this trigger. The Nursing Home Administrator confirmed that the facility did not provide trauma-informed care to prevent re-traumatization for this resident, as required by policy and regulation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and showering, for three residents with significant physical disabilities. These residents had physician orders specifying regular showers, but due to ongoing renovations in the shower room, they were only receiving bed baths. The affected residents included individuals with multiple sclerosis, quadriplegia, paraplegia, diabetes, peripheral vascular disease, and spinal stenosis, all of whom required the use of a shower bed or specialized equipment for safe bathing. Interviews with the residents revealed that they had not received a proper shower for several weeks to months, and expressed dissatisfaction with the adequacy of bed baths as a substitute. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain hygiene, including showers or baths according to their preferences and needs. However, the shower room under renovation could not accommodate the required shower beds, and only two stalls were available, neither suitable for these residents. Staff and administrative interviews confirmed the lack of appropriate facilities and the inability to meet the residents' prescribed bathing schedules. Resident council minutes also documented ongoing bathroom remodeling over several months, further corroborating the prolonged lack of access to proper bathing facilities for these residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required staffing levels for nurse aides on two separate occasions. On the evening shift of April 20, 2025, the facility did not provide the mandated one nurse aide per 11 residents, as evidenced by staffing documents showing 45.69 actual hours against the required 48.75 hours for a census of 65 residents. Similarly, on the night shift of April 19, 2025, the facility did not meet the requirement of one nurse aide per 15 residents, with staffing documents indicating 36.43 actual hours against the required 42.95 hours for a census of 63 residents. This deficiency was confirmed by the Nursing Home Administrator during an interview on April 25, 2025.

Plan Of Correction

No residents were found to be negatively affected by the deficient practice of regulation. The facility will make every effort to meet minimum state regulation as required and calculated by PA DOH Minimum Staffing Ratios. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure the proper staff to resident ratios meet shift requirements according to current censuses. Census will be reviewed to ensure staff to resident ratio. 2. The facility will utilize administrative staff that have nursing or certified Nurse Aide certification to maintain the required ratios for the CNA, in the event of unforeseen shortage of CNA. 3. The Administrator and Assistant Administrator will be educated by Regional Support Personnel on staffing ratios, particularly as it pertains to CNAs. 4. The Facility will utilize Open Shift program to make the schedule accessible to staff to see open shifts and pick them up, advertisement of open positions and hiring incentives, and ongoing recruitment efforts. 5. Results of staffing meetings and recruitment efforts will be reviewed weekly by Administrator and DON and monthly by QAPI committee.