Emerald Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Elizabethtown, Pennsylvania.
- Location
- 320 South Market Street, Elizabethtown, Pennsylvania 17022
- CMS Provider Number
- 395469
- Inspections on file
- 31
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Emerald Nursing And Rehabilitation during CMS and state inspections, most recent first.
Three residents experienced deficiencies in care when staff did not follow physician orders for medications, weight monitoring, and wound care. One resident with chronic diastolic CHF received significantly lower doses of torsemide than ordered and did not have weights monitored as prescribed, despite cardiology instructions for higher dosing and daily weights, and later developed increased edema and weight gain before being sent to the ED for fluid overload. A second resident missed multiple ordered oxycodone doses without documented rationale or provider notification and had bilateral leg cellulitis wounds for which ordered treatments were not properly transcribed into the TAR or consistently applied, with no clear documentation of replacement dressings when the resident removed them. A third resident with a left calf wound and lymphedema had a change from wound vac to dressing and compression therapy, but weekly wound assessments were not documented for several weeks, leaving the wound unassessed during that period.
Surveyors found that a resident’s bathroom was not maintained in a clean and homelike condition. During an observation with an LPN, they noted dried brown substances in and around the toilet, used towels left in the sink, a used drawsheet, a used gown, and a wet washcloth with brown stains on the floor, and a trash can overflowing with used incontinent briefs. The LPN confirmed the bathroom smelled of urine, demonstrating a failure to maintain a safe, clean, and comfortable environment as required by facility management regulations.
A resident with an indwelling urinary catheter, which under facility policy required enhanced barrier precautions (EBP) when contact precautions did not otherwise apply, was observed without any EBP signage on or outside the room and without PPE available as required. The facility’s EBP policy specified that residents with wounds and/or indwelling medical devices require EBP regardless of MDRO status, and that signage and PPE must be placed outside resident rooms. During the survey, an LPN confirmed the absence of the required signage, and the findings were later reported to the NHA and DON.
A resident with moderate cognitive impairment and multiple diagnoses was incorrectly assessed as low risk for elopement. Despite repeated exit-seeking behaviors observed by staff, these were not reported to supervisors. The resident was able to leave the facility unaccompanied and was only discovered missing when a family member called to report the resident's arrival at their home.
A resident with dementia eloped from the facility due to the failure of the NHA and DON to ensure proper completion of elopement assessments and to supervise residents exhibiting elopement behaviors. This resulted in an Immediate Jeopardy situation, as the facility did not maintain effective systems or oversight to safeguard residents at risk.
Multiple residents' rooms and common areas were found with overflowing trash, soiled items, food crumbs, and visible dirt, with residents reporting that housekeeping had not cleaned their rooms for several days. The Nursing Home Administrator confirmed these environmental concerns during walkthroughs, and previous grievances about cleanliness were documented.
Two residents did not receive care according to professional standards: one with diabetes had blood glucose readings above 400 mg/dl without required physician notification or proper documentation, and another with muscle weakness and a fall-related skin tear did not have timely wound care or physician notification, with no treatment orders documented.
Staff failed to provide timely incontinence care and respond to call bells for two residents dependent on assistance, resulting in prolonged periods in soiled briefs and unmet toileting needs. Multiple residents reported excessive wait times, and observations confirmed staff inattentiveness and use of personal devices during shifts, despite care plans requiring regular assistance.
A resident with ESRD who required regular dialysis did not consistently receive care according to physician orders and care plan directives, as blood pressure was documented as being taken from the restricted arm multiple times. Additionally, required dialysis communication forms were missing from the clinical record for several treatment dates, and the DON confirmed these forms were not available as expected.
Annual performance evaluations for nurse aides were not completed as required for four out of five aides reviewed. The DON confirmed that the evaluations were missing from employee files and should have been present.
The facility did not ensure that monthly medication regimen reviews were completed by a pharmacist and that recommendations were addressed by prescribers for several residents with complex medical conditions, including those with heart disease, kidney disease, diabetes, depression, and dementia. Required pharmacy reviews were missing for multiple months, and some pharmacy recommendations were not responded to by staff or prescribers.
Surveyors found that food and beverages were not stored or labeled according to professional standards, with expired items, open and unlabeled food packages, and improper storage of scoops in food containers. The milk refrigerator contained expired milk, personal staff beverages, and was heavily soiled, all in violation of facility policy.
The required members of the Quality Assurance Committee, including the MD or designee, NHA, and DON, did not meet together on a quarterly basis for two consecutive quarters, as confirmed by review of meeting signatory pages and staff interview.
A resident with heart failure and chronic kidney disease, who was assessed as continent, experienced multiple incontinence episodes and embarrassment due to delayed call bell responses and lack of timely assistance to use the bed pan. Staff did not accurately document the resident's continence status, despite frequent requests for help, and concerns about long call bell wait times were noted in Resident Council Meeting Minutes.
The facility did not complete criminal background checks at the time of hire for an LPN and a nurse aide, as required by its abuse prevention policy. This failure was confirmed through personnel file reviews and administrator interview.
A resident with multiple chronic conditions was transferred to the hospital on two occasions without receiving required written notices about bed-hold and transfer policies. Facility policy required these notifications and documentation, but they were not provided due to a misunderstanding by the administrator in training responsible for this task.
A resident with dementia and chronic kidney disease was observed multiple times without hearing aids, despite a physician's order for daily application and removal. The care plan did not address hearing aid use, and the DON confirmed staff were expected to assist with them. This resulted in a failure to provide proper treatment and assistive devices to maintain hearing abilities.
A resident with dementia and severe malnutrition, identified as a fall risk, was observed with two fall mats stacked on one side of the bed instead of having a fall mat on each side as required by the care plan. The DON confirmed that the mats should have been placed on both sides.
A resident with dementia and severe protein-calorie malnutrition experienced significant unmonitored weight loss, with no physician notification or required reweigh completed. Monthly weights were not documented as ordered, and the DON confirmed missing records, indicating non-compliance with facility policy and physician orders.
A resident with heart failure and chronic kidney disease did not receive prescribed Furosemide for several days after admission because agency staff lacked access to the online system needed to obtain the medication, as confirmed by the DON.
A resident reported that coffee was never served hot, and a test tray confirmed the coffee was served at 110°F, below the facility's required 135°F. The Food Service Director indicated coffee was likely poured too early, resulting in it not being palatable or appealing at the time of service.
The facility did not post current daily nurse staffing information as required, with observations showing outdated postings and confirmation from the DON that the assigned staff member failed to update the information on multiple days.
The facility did not meet the required staffing levels for nurse aides during specific shifts from late January to early February 2025. The day shift was understaffed on four days, the evening shift on two days, and the night shift on two days, failing to meet the minimum nurse aide-to-resident ratios. These deficiencies were confirmed through staffing data and an interview with the Nursing Home Administrator.
The facility did not meet the required staffing levels, failing to provide one nurse aide per 10 residents during the day and one per 15 residents overnight. Specific deficiencies were noted on the day shift and night shifts on different days, as confirmed by the Nursing Home Administrator.
A resident with a high fall risk and multiple health issues was left unsupervised by a CNA during a care routine, resulting in a fall and a fracture to the right humerus. The resident's care plan required extensive assistance for bed mobility, but the CNA left the resident on their side without a protective pad to retrieve supplies. This led to the resident becoming unsteady and falling, necessitating hospital transfer and increased pain management.
The facility failed to honor the bathing preferences of three residents who preferred showers but were predominantly given bed baths. Records showed no evidence that the residents refused or were unable to tolerate showers, despite care plans suggesting otherwise. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain a clean and homelike environment on the 2nd floor nursing unit. Multiple rooms had air conditioners with a thin layer of dust, and one resident's bathroom had a clogged toilet with a dried brown substance on the seat, which remained unaddressed for at least two days. The Nursing Home Administrator could not provide evidence of when the air conditioners were last cleaned.
The facility failed to perform criminal background checks for three out of five personnel records reviewed, specifically for Employees E1, E2, and E5, as required by their policy. This was confirmed during an interview with the Nursing Home Administrator.
The facility failed to follow physician orders for three residents, leading to deficiencies in their care. One resident did not receive prescribed medications for constipation, another had missing documentation for fluid intake, and a third did not have bladder scans performed as ordered. These issues were confirmed by the Nursing Home Administrator.
The facility failed to monitor the nutritional status of five residents as per policy and physician orders, resulting in significant weight changes not being properly monitored or confirmed. Interviews with the Nursing Home Administrator confirmed the lapses in monitoring.
A resident was unable to access the bathroom due to the location and size of her wheelchair, forcing her to use a bed pan. The care plan included interventions for an unobstructed path and wheelchair transfers, but these were not effectively implemented.
The facility failed to update the care plan for a resident with Bipolar Disorder, Depression, and Anxiety to reflect her current status. Despite an incident where the resident attempted to harm herself with a call bell, and a subsequent safety contract allowing the call bell, the care plan was not updated. This was confirmed by the Nursing Home Administrator.
The facility failed to report critical lab results to the physician in a timely manner for a resident. A nurse received a call about a critical calcium level and faxed the results to the physician's office, but it took a week before the results were communicated via telephone. The Nursing Home Administrator confirmed the delay and improper faxing of critical values.
The facility failed to maintain accurate medical records for a resident. Initial evaluations showed no pressure ulcers, but subsequent notes documented a Stage 3 pressure ulcer, which was inconsistently recorded in later assessments. The Nursing Home Administrator confirmed the inaccuracies.
Failure to Follow Medication, Weight Monitoring, and Wound Care Orders for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for medications, diagnostic monitoring, and wound care for three residents. For the first resident, who was cognitively intact, dependent for ADLs, and diagnosed with chronic diastolic CHF, the physician ordered torsemide 120 mg PO BID and later ordered weights three times weekly with specific parameters to notify the provider and the resident’s daughter of significant weight changes or refusals. After a hospitalization for CHF and discharge with instructions to continue torsemide 120 mg BID, the facility’s MAR showed an order for only 20 mg BID. A subsequent cardiology consult documented that the resident “should be on 120 mg of torsemide but since [they have] only been getting 20 BID, increase to 60 mg BID” and requested daily weights. The TAR documented only two weights over several days, and there were gaps in weight documentation despite orders for more frequent monitoring. Further documentation for the first resident showed ongoing weight fluctuations and edema consistent with fluid retention. Dietary notes identified significant weight changes and referenced increased torsemide per progress notes, while nursing notes described refusal of an outside IV diuresis appointment, abnormal BMP and magnesium results, and provider orders to encourage fluids and increase torsemide to 80 mg BID with BP monitoring. Cardiology later ordered torsemide 80 mg BID, daily pre-breakfast weights, and instructions to call for specified weight gains or worsening symptoms. Subsequent weights showed increases, and nursing notes documented weeping edema of the bilateral lower extremities, a 5‑pound weight gain, and 3+ pitting edema. The provider was notified and ordered BLE ultrasound and blood work, and the family arranged a cardiology appointment. The cardiology office later reported the resident was being sent to the ED for fluid volume overload, and hospital records confirmed admission for acute on chronic CHF. The surveyors concluded the facility failed to implement medication orders and failed to monitor the resident’s weight as ordered, resulting in increased CHF symptoms and actual harm. For the second resident, a physician ordered oxycodone 5 mg PO every eight hours for three days. The MAR showed missed doses on three occasions, with only one progress note indicating a dose was held because the resident was hard to arouse with low SpO2; there was no documentation explaining the other missed doses. The record also lacked evidence that the physician was notified of the resident’s change in condition or of the missed oxycodone doses. Wound consult documentation for this resident described bilateral lower leg cellulitis with detailed treatment orders, including Betadine to the left leg and acetic acid with Xeroform and bordered dressing to the right leg, and later an order for hydrogel with foam dressings and compression wraps to both legs. However, the right leg wound care order was not present in the physician orders, the Betadine order for the left leg was not transcribed to the TAR, and the hydrogel treatment ordered on March 20 was not completed as ordered from March 20 until March 26 because it was not transcribed into the TAR. Nursing notes recorded that the resident was removing leg dressings but did not document what replacement treatments or dressings were applied. The DON confirmed the wound orders were not followed as ordered, and a corporate nurse reported EMR changes with order transcription contributed to the issue. For the third resident, who had a history of a left lower leg wound with hematomas requiring incision and drainage, cellulitis, and lymphedema, a wound consult documented an unstageable left calf wound with tunneling and ordered NPWT (wound vac) at 125 mmHg continuous three times per week and as needed. A later nursing note indicated the wound vac was discontinued after a wound center appointment, and a new physician order directed cleansing the left lower leg with soap and water, applying Prisma and calcium alginate twice weekly, and applying Profore compression from toes to knees. Weekly skin assessments documented that the resident’s skin was not intact but did not include an assessment of the left calf wound on specified dates, and there was no documentation of weekly wound assessments on additional dates. The DON confirmed that the left calf wound was not assessed from December 31 until January 21. Overall, the surveyors determined the facility failed to ensure physician orders were followed and that ordered monitoring and treatments were completed for all three residents, in violation of 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Maintain Clean and Homelike Resident Bathroom Environment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, clean, and homelike environment in one resident’s bathroom. During an observation of Resident 2’s bathroom conducted in the presence of a licensed nurse (Employee E3), surveyors noted dried brown substances in front of the toilet bowl, brown substances in the toilet bowl, two used towels left in the sink, and a used drawsheet, a used gown, and a wet washcloth with brown stains on the bathroom floor. Additionally, the garbage can in the bathroom was overflowing with used incontinent briefs, and Employee E3 confirmed that the bathroom smelled of urine. These observed conditions demonstrated that the facility did not ensure Resident 2’s bathroom was maintained in a clean and sanitary state, as required by 28 Pa. Code 201.18(b)(1)(3)(e)(1) regarding management responsibilities for providing a safe, clean, and comfortable environment.
Failure to Provide PPE and Enhanced Barrier Precaution Signage for Resident With Indwelling Catheter
Penalty
Summary
The facility failed to implement its infection prevention and control program by not providing required personal protective equipment (PPE) and signage for a resident who met criteria for enhanced barrier precautions (EBP). The facility’s March 2024 policy on Enhanced Barrier Precautions states that EBP are indicated, when contact precautions do not otherwise apply, for residents with wounds and/or indwelling medical devices regardless of multi-drug resistant organism (MDRO) colonization status, and that signs must be posted on the door or wall outside the resident room indicating the type of precautions and PPE required, with PPE available outside resident rooms. During an observation on February 4, 2026, at approximately 12:05 p.m., a resident identified as having an indwelling urinary catheter was observed without any EBP signage on or outside the room and with no PPE available in the room. Two LPNs confirmed the lack of required signage later that afternoon, and these findings were reported to the Nursing Home Administrator and Director of Nursing the same day. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services. The resident involved had an indwelling urinary catheter, defined in the report as a flexible tube inserted into the bladder to continuously drain urine into an external bag, which under facility policy required EBP when contact precautions did not otherwise apply. Despite this condition and the clear policy requirements, there was no posted indication of EBP or required PPE and no PPE available as specified by the policy at the time of the surveyor’s observation.
Failure to Supervise and Accurately Assess Elopement Risk Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident who was inaccurately assessed as low risk for elopement, despite having diagnoses including Parkinson's disease with dyskinesia, neurocognitive disorder with Lewy bodies, muscle weakness, and difficulty walking. The resident's admission assessment incorrectly indicated no dementia, resulting in a low-risk classification for wandering, even though the Minimum Data Set (MDS) showed moderate cognitive impairment. Multiple staff members observed the resident exhibiting exit-seeking behaviors, such as attempting to use the elevator, but none reported these behaviors to their supervisors. On the day of the incident, the resident was seen several times by different staff members attempting to access the elevator and was redirected to their room each time. However, these repeated exit-seeking behaviors were not communicated to supervisory staff. Later, the resident was observed by a staff member leaving the facility but was mistakenly believed to be on a leave of absence. The staff member did not report this observation, and the resident subsequently exited the building and walked out of the facility. The facility only became aware that the resident was missing when the resident's daughter called to report that the resident had arrived at her home after crossing multiple busy streets. The facility's failure to accurately assess the resident's elopement risk and to provide appropriate supervision for a resident actively exhibiting exit-seeking behaviors resulted in the resident leaving the facility without staff knowledge.
Removal Plan
- Nursing Administration reviewed all residents' electronic health records for accurate elopement/wandering evaluations.
- Elopement books at the reception desk and every unit were reviewed to ensure all residents identified as elopement risks were current and resident identifiers were available.
- Sign posted at reception notifying visitors of the Leave of Absence (LOA) process.
- Staff educated on routine resident checks, the wandering and elopement policy, and the wander management and elopement prevention policy.
- RN Supervisors/Unit managers educated on the completion of headcounts of all residents compared to the midnight census and the immediate reporting of any discrepancy to the Director of Nursing (DON).
- Staff educated on the LOA process.
- Reception staff educated on the facility visitor badge protocol, visitor badge process, resident leaves of absence, and signing residents out.
- Staff educated on the elopement/missing person policy and procedure including the elopement code announcement to notify staff in the center, search on the premises and the surrounding areas, and notification processes.
- Staff educated on elopement drills including the frequency of drills and expected responses.
- Training regarding elopement added to the general orientation schedule for new employees.
- Elopement drill completed.
- Elevator and keypads assessed. Elevator keypad code changed. Additional training provided to staff related to not providing keypad codes to visitors and/or residents.
- Elopement/wandering evaluation updated as needed.
Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
The facility failed to ensure the safety of a resident with dementia by not effectively managing elopement risks. Specifically, the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not establish or maintain systems to ensure that elopement assessments were completed correctly, nor did they prevent residents exhibiting elopement behaviors from leaving the facility without proper supervision. This lapse in management and oversight resulted in a resident eloping from the facility, creating an Immediate Jeopardy situation. Review of job descriptions and facility policies indicated that both the NHA and DON were responsible for developing and implementing operational policies and procedures to meet residents' needs and ensure their safety. However, documentation and staff interviews revealed that these responsibilities were not fulfilled, as evidenced by the failure to complete elopement assessments and to supervise residents at risk for elopement. The resident involved had a diagnosis of dementia, which increased their vulnerability, and the lack of appropriate interventions directly led to the elopement incident.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on one of its nursing units, as evidenced by multiple observations and resident interviews. Several rooms were found to have overflowing trash, food crumbs, soiled items, and visible dirt or stains on various surfaces, including nightstands, baseboards, privacy curtains, and bathroom fixtures. Residents reported that housekeeping had not cleaned their rooms for several days, and nursing staff had not emptied trash cans. These environmental concerns were confirmed by the Nursing Home Administrator during walkthroughs, who acknowledged that the rooms required cleaning. Additional observations included soiled clothing and briefs left on the floor, strong urine odors, lifted floor tiles, and non-operational air conditioning units in common areas. The chapel and surrounding hallways were noted to have black wheelchair marks, dried patches, and food crumbs, with no evidence of recent cleaning. The presence of a dead vine growing into the building through a window was also documented. The facility's grievance log had previously recorded complaints about cleanliness and overflowing trash, further substantiating the ongoing environmental deficiencies.
Failure to Follow Professional Standards in Medication Administration and Wound Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents. For one resident with multiple diagnoses including diabetes mellitus, metabolic encephalopathy, and congestive heart failure, clinical records showed that blood glucose levels exceeded 400 mg/dl on two occasions. On one occasion, 14 units of aspart insulin were administered and the supervisor was notified, but there was no documentation that the physician was notified as required by the sliding scale insulin order. On the second occasion, there was no documentation that insulin was administered or that the physician was notified. Progress notes did not reflect any physician notification for either event, despite the physician order specifying this action. For another resident with muscle weakness and gait abnormalities, after sustaining a fall and a skin tear on the left lower arm, there was no documentation that the physician was notified or that treatment orders were obtained. The resident reported that the wound was not cleaned for three days and only rebandaged upon her request. Clinical records did not include any physician orders for treatment of the wound, and the DON confirmed that a standard order for dressing and treatment should have been in place.
Failure to Provide Timely Incontinence Care and Call Bell Response
Penalty
Summary
Facility staff failed to provide timely and adequate assistance with activities of daily living, specifically incontinence care, for residents dependent on staff. Multiple residents reported excessive wait times for call bell responses, with some waiting over an hour or even up to two hours for assistance. Residents described instances where staff turned off call bells without providing help or stated they would return but did not. Observations confirmed that staff, including nursing assistants, were seen using personal cell phones at the nursing station instead of attending to resident needs. Resident council meeting minutes documented ongoing concerns about delayed call bell responses, staff inattentiveness, and the use of personal devices during shifts, particularly on the second and third shifts. Clinical record reviews for two residents revealed care plans requiring regular toileting assistance and incontinence care due to conditions such as dementia, urge incontinence, impaired mobility, and a history of falls. Despite these documented needs, observations and interviews showed that residents were left in soiled briefs for extended periods, sometimes overnight, and were not assisted in a timely manner. One resident reported being left in a soiled brief for three hours overnight, while another had to wait for over 20 minutes for help and sometimes attempted to manage toileting independently despite mobility challenges. These failures were observed and corroborated by both residents and facility leadership, with the expectation for call bells to be answered within 10 to 20 minutes not being met.
Failure to Provide Safe Dialysis Care and Maintain Required Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident with end stage renal disease (ESRD) who was dependent on renal dialysis. Despite having a physician order specifying dialysis three times per week at an outside facility and a clear directive for dialysis precautions—specifically, no blood draws, injections, or blood pressure measurements from the resident's left arm—documentation showed that blood pressure was recorded as being taken from the left arm on nine occasions. The resident's care plan also included instructions to avoid the left arm for these procedures and to coordinate care with the dialysis center. Additionally, the facility did not maintain complete records of dialysis communication forms, which are used to facilitate the exchange of assessment data between the dialysis center and the nursing facility. Multiple dates were identified where the resident attended dialysis, but no corresponding communication forms were available in the clinical record. The Director of Nursing confirmed the absence of these forms and acknowledged that they should have been completed and available for review.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for nurse aides as required. A review of facility documentation identified five nurse aides who had been employed for over a year, and the last annual performance evaluations for these employees were examined. It was found that four of the five nurse aides did not have documented performance evaluations completed within the past 12 months. During an interview, the Director of Nursing confirmed that she was unable to locate the required evaluations for these staff members and acknowledged that they should have been available in the employee files.
Failure to Complete and Respond to Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were completed by a consultant pharmacist and that recommendations were responded to in a timely manner by the attending physician or prescriber for four out of five residents reviewed for unnecessary medications. Specifically, for one resident with hypertensive heart disease and chronic kidney disease, there were no pharmacy reviews documented for August and November 2024. Another resident with type 2 diabetes, end stage renal disease, and dependence on dialysis did not have pharmacy reviews documented for July, August, and April, and pharmacy recommendations from September and December 2024 were not responded to by facility staff or a prescriber. Additionally, a resident with major depressive disorder, hypertension, and anxiety disorder did not have pharmacy reviews completed for July and August 2024. Another resident with dementia and severe protein-calorie malnutrition also lacked pharmacy reviews for July and August 2024. Interviews with the DON confirmed the expectation that pharmacy reviews should be completed monthly and responded to appropriately, but these expectations were not met for the residents identified.
Failure to Store and Handle Food According to Professional Standards
Penalty
Summary
The facility failed to store food and beverages and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Observations in the dry storage area revealed a bottle of honey thick orange juice with a past best by date, and in the reach-in freezer, multiple packs of waffles and fish patties were found open, unlabeled, and not dated as required by facility policy. Additionally, scoops were stored inside containers of flour and sugar, contrary to policy which requires scoops to be stored separately and cleaned regularly. Further inspection of the milk reach-in refrigerator showed two containers of milk with expired sell by dates, as well as personal water and soda bottles belonging to kitchen staff. The bottom of the refrigerator was heavily soiled with liquid and dried milk. An interview with the Nursing Home Administrator confirmed that the facility's expectation is for expired items to be discarded, food items to be labeled and dated, and for food and kitchen equipment to be stored, cleaned, and used according to professional standards.
Failure of Required QA Committee Members to Meet Quarterly
Penalty
Summary
The required members of the facility's Quality Assurance Committee, specifically the Medical Director (MD) or designee, the Nursing Home Administrator (NHA), and the Director of Nursing (DON), failed to meet together on a quarterly basis for two consecutive quarters. Review of the committee meeting signatory pages showed that there was no meeting attended by all required members during the last quarter of 2024 and the first quarter of 2025. This was confirmed during an interview with the NHA, who acknowledged that the facility's expectation was for the required members to meet at least once every quarter.
Failure to Ensure Dignity and Timely Assistance for Resident Needing Restroom Support
Penalty
Summary
A deficiency was identified when a resident with diagnoses of heart failure and chronic kidney disease, who was documented as being continent of bladder upon admission, experienced several episodes of incontinence due to long call bell wait times. The resident reported feeling embarrassed after not receiving timely assistance to use the bed pan, particularly when she first arrived at the facility. This was corroborated by the facility's Resident Council Meeting Minutes, which documented concerns about long call bell response times. Further review of the resident's clinical record showed that she was marked as incontinent for three consecutive days, despite her admission assessment indicating continence. The DON confirmed that staff reported the resident frequently rang the call bell for restroom assistance, but this was not accurately reflected in the clinical documentation. The DON also stated that staff are expected to document each episode of continence or incontinence, which was not done in this case.
Failure to Conduct Required Criminal Background Checks for New Hires
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the prevention of abuse, neglect, and misappropriation of resident property by not conducting criminal background checks upon hire for two employees. Review of the facility's policy indicated that background checks are required to ensure that no individual found guilty of abuse, neglect, exploitation, or misappropriation is employed. Personnel file reviews revealed that a Licensed Practical Nurse and a Nurse Aide, both hired in March 2025, did not have criminal background checks completed at the time of hire. An interview with the Nursing Home Administrator confirmed that these checks were not conducted as required by facility policy.
Failure to Provide Bed-Hold and Transfer Notices at Hospitalization
Penalty
Summary
The facility failed to provide required written notifications regarding transfer and bed-hold policies to a resident and/or their representative at the time of hospitalization. Facility policy mandates that before a resident is transferred to the hospital, written information about the facility's bed-hold and return policy must be given to the resident or their representative, and documentation of this notification must be included in the medical record. However, review of the clinical record for a resident with diagnoses including heart failure, anxiety disorder, and chronic kidney disease showed no evidence that bed-hold or transfer notices were provided during two separate hospitalizations. An interview with the Nursing Home Administrator confirmed that the responsibility for sending these notices was assigned to an administrator in training, who did not send them due to a misunderstanding. This resulted in the absence of required documentation and notification for the resident's transfers, as required by facility policy and state regulation.
Failure to Provide Hearing Aid Assistance as Ordered
Penalty
Summary
A deficiency was identified when a resident with dementia and chronic kidney disease did not receive proper assistance with hearing aids as ordered by the physician. Observations over several days showed the resident lying in bed without hearing aids, despite a physician's order to apply them each morning and remove them each evening. The resident's care plan did not address the use of hearing aids, and the Director of Nursing confirmed that the hearing aids were brought in by the family and that staff were expected to apply them daily. The lack of implementation of the physician's order and absence of a care plan for hearing aids led to the deficiency.
Failure to Properly Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that the environment remained as free from accident hazards as possible for a resident identified as being at risk for falls. Review of the resident's care plan indicated that fall mats were to be placed on each side of the bed as an intervention, but observations on multiple dates revealed that two fall mats were stacked on one side of the bed instead. The resident had diagnoses including dementia and severe protein-calorie malnutrition. During an interview, the Director of Nursing confirmed that the expectation was for fall mats to be on each side of the bed, in accordance with the care plan.
Failure to Monitor and Document Resident Weight and Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to properly monitor and document the nutritional status of a resident diagnosed with dementia and severe protein-calorie malnutrition. According to facility policy, residents' weights are to be measured on admission, weekly for two weeks, and then monthly if no concerns are noted, with any significant weight change (5% or more) requiring a reweigh for confirmation and physician notification. For this resident, there was a significant weight loss of 8.7% over a short period, but the clinical record did not show that the physician was notified of this change. Additionally, there was no documentation of a reweigh to confirm the significant weight loss as required by policy. Further review revealed that monthly weights were not obtained or recorded for the resident in the months following the significant weight loss, despite a standing physician order for monthly weights. The Registered Dietitian reported a change in the process for notifying physicians of significant weight losses but was unable to provide evidence of notification for this resident. The DON confirmed that the treatment administration records for the relevant months were blank for the resident's weight order, indicating non-compliance with both physician orders and facility policy.
Failure to Provide Prescribed Medication Due to Staff Access Issues
Penalty
Summary
The facility failed to ensure the availability and administration of prescribed medication for one resident. Clinical record review showed that a resident with diagnoses of heart failure and chronic kidney disease was admitted to the facility and had a physician's order for Furosemide 40 mg daily starting on May 15, 2025. However, the Medication Administration Record indicated that the resident did not receive the medication from May 15 to May 18, 2025. During an interview, the Director of Nursing confirmed the missed doses and explained that agency staff working at the time of admission did not have access to the online system required to obtain the medication as ordered.
Failure to Serve Coffee at Palatable Temperature
Penalty
Summary
The facility failed to provide coffee at a palatable and appealing temperature, as required by its Food and Nutrition Services Meal Assessment policy, which specifies that coffee should be served at 135°F or above. During an interview, a resident reported that the coffee is never served hot. A test tray conducted after lunch service confirmed that the coffee temperature was 110°F, which was not considered palatable or appealing. The Food Service Director acknowledged that coffee should be poured and lidded shortly before meal service to maintain the required temperature, but indicated that the coffee was likely poured too early on the day in question. The Nursing Home Administrator stated that she expects coffee to be served at a palatable and appealing temperature.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the facility name, date, census, and total hours of nursing staff directly responsible for resident care per shift, on multiple dates. Observations during entrance to the facility revealed that the posted staffing information was outdated, with the most recent posting dated May 16, 2025, when reviewed on May 19, 2025, and again on May 21, 2025, when the posting was still not current. During an interview, the Director of Nursing confirmed that the staff member responsible for posting the daily staffing, the Nursing Scheduler, did not complete this task on the specified dates, and acknowledged that daily posting is expected per federal regulation.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a period from January 28, 2025, to February 6, 2025. On the day shift, the facility did not maintain the minimum requirement of one nurse aide per 10 residents on four separate days. Similarly, the evening shift was understaffed on two days, lacking the required one nurse aide per 11 residents. Additionally, the night shift did not meet the standard of one nurse aide per 15 residents on two occasions. These deficiencies were confirmed through a review of facility staffing data and a telephone interview with the Nursing Home Administrator on February 11, 2025.
Plan Of Correction
Nursing Home Administrator/Designee will continue to audit nursing staffing schedules for the next two weeks to ensure schedules reflect at a minimum 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. Nursing Home Administrator/Designee will utilize the Staffing Calculator Tool Spreadsheet to calculate these staff ratios to ensure compliance. Nursing Home Administrator, Director of Nursing, and Scheduler/HR will continue to hold weekly meetings to discuss new opportunities to utilize local community resources for staffing including vocational schools that offer aide training programs. Facility will hold bi-weekly meetings with cooperate recruiting team to improve hiring process and discuss opportunities to contract with additional Staffing Agencies to ensure the facility remains in continued compliance with nurse staff ratios and PPD. Nursing Home Administrator will continue to have daily staffing meetings with Director of Nursing and Facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours. Scheduler/HR will discuss with staffing agencies any issues with their staff involving absenteeism and/or tardiness as it effects facility ratios. Nursing Home Administrator will continue to audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months utilizing the Staffing Calculator Tool Spreadsheet. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels as per the regulation effective July 1, 2024, which mandates a minimum of one nurse aide per 10 residents during the day and one nurse aide per 15 residents overnight. A review of the facility's staffing data from December 2 through December 11, 2024, revealed deficiencies on specific dates. On December 5, 2024, the day shift did not have the required number of nurse aides, and the night shift was understaffed on both December 5 and December 7, 2024. These findings were confirmed with the Nursing Home Administrator during a telephone interview on December 16, 2024.
Plan Of Correction
Nursing Home Administrator/designee will audit nursing staffing schedules for the next two weeks to ensure schedules reflect at a minimum 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. Nursing home administrator, Director of Nursing, and Scheduler/HR will hold weekly meetings to discuss new opportunities to utilize local community resources for staffing including vocational schools that offer aide training programs. Discussion to also include facility holding open interview times weekly for any walk-ins for immediate interviews. Nursing Home Administrator will have a daily staffing meeting with Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours. Scheduler/HR will discuss with staffing agencies any issues with their staff involving absenteeism and/or tardiness as it affects facility ratios. Nursing Home Administrator will audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in actual harm to a resident who sustained a fall and a fracture. The resident, who had a history of multiple health issues including renal cell cancer, muscle weakness, and a high risk for falls, was left unsupervised by a CNA during a care routine. The CNA left the resident on their side without a protective pad to retrieve supplies, during which time the resident became unsteady and fell, hitting their right elbow and sustaining a skin tear. The resident's care plan indicated a need for extensive assistance with bed mobility and required one staff member to assist with turning and repositioning in bed. Despite these requirements, the resident was left alone, leading to the fall. The resident's fall risk assessment had previously identified them as being at high risk for falls, and their MDS assessment confirmed they were cognitively intact, requiring significant assistance for mobility. Following the fall, the resident was diagnosed with a fracture to the neck of the right humerus, necessitating hospital transfer and subsequent orthopedic consultation. The incident led to increased pain management needs, as evidenced by the increased administration of Oxycodone for pain relief. Interviews with the resident and the Nursing Home Administrator confirmed that the staff's action of leaving the resident unsupervised was inappropriate and contributed to the incident.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the residents' preferences for their method of bathing, specifically for three residents who preferred showers but were predominantly given bed baths. During a Resident Council Meeting, it was revealed that these residents were not receiving showers as per their preferences. Resident 8's records indicated a strong preference for choosing between different bathing methods, yet the resident received only one shower in a 30-day period, with no documentation to support the need for bed baths. Similarly, Resident 29 and Resident 59 had care plans that included provisions for sponge baths when showers could not be tolerated, but their records showed no evidence that they were unable to tolerate showers during the review period. The clinical records for Residents 8, 29, and 59 lacked documentation indicating that they had refused showers or were unable to tolerate them, despite the care plans suggesting otherwise. The Nursing Home Administrator confirmed these findings during an interview. This failure to incorporate the residents' bathing preferences into their personal care routines constitutes a violation of their rights to self-determination and choice, as outlined in the relevant state codes.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the 2nd floor nursing unit. During an environmental tour, it was observed that multiple rooms had air conditioners with a thin layer of dust covering the units. This issue persisted over several days, as confirmed by observations on April 16, 17, 18, and 19, 2024. Interviews with residents revealed that they could not recall the last time their air conditioners were cleaned. Additionally, one resident's bathroom had a clogged toilet with a dried brown substance on the toilet seat, which remained unaddressed for at least two days. The Nursing Home Administrator was unable to provide evidence of when the air conditioners were last cleaned and confirmed the observations made by the surveyors. Housekeeping staff reported the clogged toilet to the maintenance director, but it was not resolved until April 18, 2024. The facility's failure to maintain a clean environment violates the residents' right to a safe, clean, comfortable, and homelike environment as required by regulations.
Failure to Perform Criminal Background Checks for Employees
Penalty
Summary
The facility failed to perform criminal background checks for three out of five personnel records reviewed, specifically for Employees E1, E2, and E5. According to the facility's policy titled 'Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure' dated 2022, the facility is required not to employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. However, a review of the personnel records revealed that the facility did not obtain criminal background checks for these employees prior to their hire. This was confirmed during an interview with the Nursing Home Administrator on April 19, 2024, at 11:30 a.m. The deficiency was cited under 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(b)(1)(3)(e)(1), and 28 Pa. Code 201.29(a)(d).
Failure to Follow Physician Orders for Three Residents
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in their care. Resident 17, diagnosed with Irritable Bowel Syndrome and Diverticulitis, had physician orders for Milk of Magnesia, Dulcolax suppository, and a fleet enema if no bowel movement occurred. However, from January 24, 2024, to February 8, 2024, there was no documented evidence that these medications were administered despite the resident not having any bowel movements during this period. This was confirmed by the Nursing Home Administrator on April 18, 2024. Resident 30, diagnosed with Chronic Kidney Disease and Congestive Heart Failure, had a physician order for a 1500 ml fluid restriction, with specific amounts to be documented by nursing staff each shift. A review of the clinical record revealed multiple instances of missing documentation for fluid intake across various shifts from March 20, 2024, to April 17, 2024. Additionally, Resident 42, diagnosed with Benign Prostate Hyperplasia, had orders for bladder scans and straight catheterization if urine retention was detected. However, there was no documented evidence of bladder scans being performed on several shifts where no voiding was recorded. These deficiencies were confirmed with the Nursing Home Administrator on April 19, 2024.
Failure to Monitor Nutritional Status
Penalty
Summary
The facility failed to monitor the nutritional status of five residents as per their policy and physician orders. Resident 16 experienced an 11.48% increase in weight without a reweight for confirmation. Resident 17's weight was not obtained as ordered, delaying the assessment by the dietitian. Resident 35 did not have weights taken on the second day after admission or weekly for two weeks as required. Resident 42 experienced an 8.02% weight loss without a reweight for confirmation, and the facility failed to obtain weekly weights as ordered. Resident 47 had a 13.53% increase in weight without a reweight for confirmation. Interviews with the Nursing Home Administrator confirmed that the weights for Residents 16, 17, 35, 42, and 47 were not monitored according to the facility's policy or physician orders. The facility's failure to adhere to its weight assessment and intervention policy resulted in significant weight changes not being properly monitored or confirmed, potentially impacting the residents' nutritional status and overall health.
Bathroom Accessibility Issue for Resident
Penalty
Summary
The facility failed to ensure that a bathroom was accessible to Resident 56, who was unable to access the bathroom due to the location of the bathroom and the size of her wheelchair. The resident's wheelchair could not fit through the space between her roommate's bed and dresser, forcing her to use a bed pan instead. This issue was confirmed through an interview with the resident and her nurse aide, as well as an observation that measured the width of the wheelchair and the space available. The resident's care plan included interventions to ensure an unobstructed path to the bathroom and to use a wheelchair for bathroom transfers due to weakness. However, these interventions were not effectively implemented, as evidenced by the resident's continued inability to access the bathroom. The findings were confirmed with the Nursing Home Administrator, highlighting a failure to reasonably accommodate the resident's needs and preferences.
Failure to Update Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to update the care plan for a resident with Bipolar Disorder, Depression, and Anxiety to accurately reflect the resident's current status. A nurse's note from August 27, 2023, documented an incident where the resident attempted to use a call bell to harm herself. Consequently, the care plan was updated on August 28, 2023, to remove the call bell and provide a hand bell instead. However, an observation on April 17, 2024, revealed that the resident had a call bell in place on her bed. The resident had signed a safety contract in September 2023, allowing her to have a call bell again, but the care plan had not been updated to reflect this change. The Nursing Home Administrator confirmed on April 18, 2024, that the care plan was not updated accordingly.
Failure to Timely Report Critical Lab Results
Penalty
Summary
The facility failed to report critical laboratory results to the physician in a timely manner for one resident. Specifically, a nurse received a call from the laboratory on December 21, 2023, at 11:50 a.m. regarding a critical calcium level of 12.9 for Resident 56 and was instructed to fax the results to the unit. The results were faxed to the physician's office at 4:12 p.m. the same day. However, it was not until December 28, 2023, that the critical lab results were refaxed to the physician's office and a telephone call was made to communicate the results. The Nursing Home Administrator confirmed that critical lab values should not be faxed and acknowledged the week-long delay in relaying the lab results to the physician.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for one of the 24 residents reviewed. Resident 14's Admission Skin Evaluation indicated no pressure ulcers on April 1, 2024. However, the Wound Care Notes on April 2, 2024, documented a Stage 3 pressure ulcer on the sacrum. Subsequent Weekly Skin/Body Checks on April 3, 2024, again showed no pressure ulcers. The Admission Minimum Data Set (MDS) on April 6, 2024, inaccurately coded the resident as having a Stage 3 pressure ulcer on admission. By April 9, 2024, the Wound Care Notes only mentioned an area of Moisture Associated Skin Dermatitis (MASD) that had resolved, with no further documentation of the Stage 3 pressure ulcer. The Nursing Home Administrator confirmed the inaccurate documentation and coding during an interview on April 19, 2024.
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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