Emmanuel Center For Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, Pennsylvania.
- Location
- 600 School House Road, Danville, Pennsylvania 17821
- CMS Provider Number
- 395824
- Inspections on file
- 19
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Emmanuel Center For Nursing during CMS and state inspections, most recent first.
The facility failed to provide adequate nursing staff in the Hospice Specialty Unit, resulting in periods where only one LPN or nurse aide was present to care for ten residents, most of whom required two-person assistance for transfers, feeding, and mobility. During staff breaks and absences, residents were left unsupervised, alarms went unanswered, and high-acuity care needs were unmet. Facility leadership confirmed that staffing assignments did not account for resident acuity, leading to insufficient care and supervision.
The facility failed to maintain sanitary food storage and service practices, increasing the risk of food-borne illness. Observations revealed unsanitary conditions in the dietary department, including improperly stored food and debris on equipment. Additionally, nutritional supplements in medication rooms were not labeled with thaw or use-by dates, as required by manufacturer instructions. Staff confirmed these deficiencies, and the NHA acknowledged the need for compliance with sanitary standards.
Residents in the facility experienced significant delays in receiving care after ringing their call bells, with staff often turning off the call lights without providing immediate assistance. This issue was reported by multiple residents, including those who are cognitively intact, and was exacerbated by the use of agency staff unfamiliar with the residents. The delays led to frustration and embarrassment among residents, impacting their dignity and quality of life.
The facility failed to maintain resident dignity during meal service and medication administration. A resident requiring assistance was left with her meal for 14 minutes without help, while another resident was served late, resulting in an undignified dining experience. Additionally, a resident received a topical medication in a public dining area, compromising privacy and dignity.
The facility failed to assess, document, and care for loop recorder implants for two residents, leading to inadequate care plans and potential risks. Despite having loop recorders, the devices were not documented in the residents' care plans or physician orders, and the implant sites were not assessed. This oversight was confirmed by interviews with the Nursing Home Administrator and DON.
A facility failed to provide appropriate bladder training for a resident with hydrocephalus, who was cognitively intact and required assistance for toileting. Despite the facility's policy on individualized treatment for incontinence, no bladder training or toileting schedule was attempted, resulting in 76 instances of urinary incontinence over a month. The DON confirmed the lack of implementation of a bladder training program.
The facility failed to provide prescribed oxygen therapy for a resident with respiratory failure and congestive heart failure, as their oxygen tank was found empty. Additionally, another resident's oxygen tubing was improperly stored on the floor. The DON confirmed the lack of documentation for hourly monitoring of oxygen equipment.
A resident with a spinal cord disease and a Foley catheter was given ceftriaxone despite not meeting criteria for a urinary tract infection. The resident's urine culture showed resistance to ceftriaxone, yet two doses were administered. The facility lacked documented evidence for the clinical rationale, as confirmed by the IP and DON.
The facility failed to coordinate hospice services for two residents with terminal illnesses, resulting in deficiencies in their comprehensive care plans. One resident with end-stage dementia and another with end-stage Parkinson's disease did not receive coordinated care between the facility and hospice agency, as confirmed by the NHA.
An LPN failed to follow infection control protocols while administering medications to a resident. The LPN used bare hands to handle pills and did not perform hand hygiene or wear gloves, even after pills spilled onto the medication cart. The Director of Nursing confirmed the breach in infection control measures.
The facility did not provide a resident or their representative with written information about the bed hold policy upon hospital transfer. A review of records and staff interviews confirmed the lack of documentation for this requirement.
Inadequate Staffing in Hospice Specialty Unit
Penalty
Summary
The facility failed to provide sufficient and appropriately deployed nursing staff to meet the needs of all residents in the designated Hospice Specialty Unit. Observations revealed that the unit was staffed with only one LPN and one nurse aide for ten residents, many of whom required high levels of care, including assistance with feeding, transfers, and mobility. During periods when the nurse aide was on break, the LPN was left alone to supervise and care for all residents, resulting in unsupervised common areas and delayed responses to call bells and alarms. On multiple occasions, residents identified as fall risks were observed attempting to stand unassisted while staff were occupied elsewhere. Interviews with staff confirmed that there was no system in place to provide relief coverage during staff breaks, leaving the unit understaffed and residents unsupervised. Staff reported that the acuity of the residents, including the need for two-person assistance for transfers and feeding, was not adequately considered in staffing assignments. There were instances when both staff members were required to assist a single resident, leaving other residents unattended and alarms unanswered. Additionally, there were times when only one staff member was present on the unit, and on one occasion, no LPN was assigned, requiring staff from another unit to cover both areas. The Director of Nursing and the Nursing Home Administrator acknowledged that staffing levels did not account for the high acuity of the hospice residents and were insufficient to meet their needs. Staff also reported that inadequate staffing during critical periods, such as when a resident was actively dying, prevented them from providing necessary emotional support to families, as they were occupied with routine care and responding to call bells. The facility's failure to ensure adequate staffing directly impacted the quality and timeliness of care, supervision, and services provided to the hospice residents.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an inspection of the dietary department, several unsanitary practices were observed. These included garbage cans with red splatter located near the tray line, a garbage can without a lid under a sink, and clean pitcher lids stored next to dirty cleaning rags. Additionally, uncovered Danish pastries were stored next to a bottle of cleaning solution and a staff member's personal drink. The bulk sugar and flour containers had visible debris, and the ice machine's tubing was dusty. The ice scoop was cracked, posing a contamination hazard. The ventilation hood over the cooking equipment was greasy, and the bulletin board and shelving had visible debris. In the dry food storage room, pasta was not securely sealed, and a case of bananas was stored improperly. In the medication rooms on the 100-Hall and 200-Hall, nutritional shakes and juice drinks were found without thaw dates or use-by dates, contrary to manufacturer instructions. Interviews with staff confirmed that all supplements should be labeled and dated as per manufacturer recommendations. The Nursing Home Administrator acknowledged that the dietary department is expected to meet sanitary standards to prevent contamination and foodborne illness, and that all nutritional supplements must be properly labeled and stored.
Delayed Response to Resident Call Bells
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, impacting their quality of life and dignity. Residents reported long wait times after ringing their call bells, with staff initially responding to turn off the call bell lights but delaying the provision of care. This issue was highlighted in Resident Council meeting minutes from October, November, and December 2024, where residents expressed concerns about insufficient staff to assist them, particularly after meals in the dining room. Resident 19, who is cognitively intact with a BIMS score of 15, reported waiting 20 minutes for care after ringing her call bell. She adapted to using the bathroom when staff were available due to the delays. Resident 21, also cognitively intact, experienced wait times of up to an hour when staffing was low, which occurred a few times a week. Both residents noted that the use of agency staff exacerbated the delays, as these staff members were less familiar with the residents. During a group interview, five out of six residents expressed frustration with the long wait times for care. Resident 12 reported waiting up to an hour and a half, especially when agency staff were present. Resident 5 experienced embarrassment due to soiling herself while waiting for assistance. Resident 42 faced delays in being escorted back to her room after meals, often waiting in the hallway for 20 to 30 minutes. The Nursing Home Administrator and Director of Nursing acknowledged the importance of treating residents with dignity but could not explain the untimely responses to residents' needs.
Failure to Maintain Resident Dignity During Meal and Medication Administration
Penalty
Summary
The facility failed to maintain the dignity of residents during meal service and medication administration. Resident 26, who was severely cognitively impaired and required total assistance for feeding, was left with her meal in front of her for 14 minutes without staff assistance, while her tablemate, Resident 44, was served and began eating. Similarly, Resident 58 was served her meal 13 minutes after her tablemate, Resident 57, had already started eating, resulting in an undignified dining experience. Additionally, Resident 31, who had diagnoses including generalized osteoarthritis and neuralgia, was administered Bio freeze gel to her left foot in the common area of the dining room during lunch service. This procedure was conducted publicly, without privacy, and at an inappropriate time, compromising the resident's dignity. The facility's policy on dignity and quality of life was not adhered to, as confirmed by the Nursing Home Administrator and Director of Nursing.
Failure to Document and Care for Loop Recorder Implants
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not thoroughly assessing, obtaining physician orders, and developing and implementing a person-centered comprehensive care plan for two residents. Resident 41, who was admitted with diagnoses including hypertension and cerebral infarction, had a loop recorder implant that was not documented in the admission assessment, physician orders, or care plan. Despite the potential for heart rhythm complications, the facility did not identify or include the care for the resident's implanted loop recorder in the current plan of care. Similarly, Resident 43, admitted with diagnoses including cerebral infarction and the presence of a cardiac and vascular implant, had a loop recorder implant that was not documented in the IDT care conference summary or physician orders. The facility also failed to assess the loop recorder implant site after the procedure. The care plan for Resident 43 did not identify the presence of or care for the loop recorder, despite the potential for complications with heart and circulation. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to assess and document the presence of the loop recorders, obtain appropriate physician orders, and include the devices in the residents' care plans. This oversight placed the residents at risk for undetected complications and inadequate care.
Failure to Implement Bladder Training for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to restore normal bladder function for a resident, identified as Resident 21, who was admitted with a diagnosis of hydrocephalus. The facility's policy on Bowel and Bladder Management requires that residents with bowel or bladder incontinence receive individualized treatment to maintain normal elimination function. However, a review of the resident's clinical records and interviews with staff revealed that no trial of toileting or bladder training was attempted for Resident 21, despite the resident being cognitively intact and requiring substantial assistance for transferring to the toilet. The care plan for Resident 21 identified the potential for complications with bowel and bladder but only included interventions for incontinence care and observation of symptoms. The urinary incontinence tracking showed that the resident was incontinent of urine on 76 occasions over a one-month period. During an interview, the Director of Nursing confirmed that the facility did not implement a bladder training or individualized toileting schedule for Resident 21, acknowledging the facility's responsibility to provide appropriate treatment and services to restore normal bladder function.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for one resident and did not store respiratory equipment in a sanitary manner for another resident. Specifically, Resident 2, who was admitted with diagnoses including respiratory failure with hypoxia and congestive heart failure, had a physician's order for continuous oxygen at 3 liters/min via nasal cannula. However, during an observation, it was found that the oxygen tank on the back of Resident 2's wheelchair was empty, indicating a failure to provide the prescribed oxygen therapy. This was confirmed by a licensed practical nurse. Additionally, during a facility tour, it was observed that the oxygen tubing and nasal cannula in Resident 41's room were lying on the floor, not stored in a sanitary manner. This improper storage was confirmed by a licensed practical nurse. The Director of Nursing acknowledged the facility's inability to provide documented evidence that oxygen tanks and concentrators were monitored hourly and recorded as required by the facility's policy, further confirming the deficiencies in respiratory care and equipment storage.
Unnecessary Antibiotic Administration to a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic drugs. Resident 19, who was admitted with a diagnosis of unspecified disease of the spinal cord and had a Foley catheter due to neuromuscular dysfunction of the bladder, was administered ceftriaxone, an antibiotic, despite not meeting the criteria for a urinary tract infection. The clinical records showed no symptoms of a urinary tract infection, such as fever, chills, or mental changes, from October 1 to October 2, 2024. A urine culture on October 2, 2024, revealed the presence of Escherichia coli, which was resistant to ceftriaxone. Despite the resistance, Resident 19 received two doses of ceftriaxone on October 3 and October 4, 2024. The McGeer Criteria checklist indicated that the resident did not meet the criteria for antibiotic use. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the resident did not have symptoms justifying the antibiotic treatment and that the facility failed to provide documented evidence for the clinical rationale behind administering ceftriaxone.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to coordinate hospice services effectively for two residents, leading to deficiencies in their comprehensive person-centered plans of care. Resident 34, who was admitted with end-stage dementia, required hospice care to manage symptoms such as severe cognitive decline, mobility issues, and increased anxiety. Despite the resident's need for hospice services to ensure comfort and quality of life, the facility did not demonstrate coordination with the hospice agency to meet the resident's daily care needs and specific requirements related to their terminal diagnosis. This lack of coordination was confirmed by the Nursing Home Administrator on the day of the resident's passing. Similarly, Resident 47, admitted with end-stage Parkinson's disease, also required hospice care to maintain comfort due to severe motor symptoms and cognitive issues. The resident's plan of care included hospice services and interventions to observe and optimize end-of-life needs. However, the facility again failed to demonstrate coordination and integration of services between the interdisciplinary team and the hospice agency. This deficiency was confirmed by the Nursing Home Administrator during the survey, indicating a systemic issue in coordinating hospice care for residents in need.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control techniques were followed during medication administration to a resident on the 200 Hall nursing unit. An LPN was observed administering morning medications without performing hand hygiene or wearing gloves. The LPN used her bare hand to block pills from a bottle, touched the pills, and placed them into the resident's medication cup. After knocking over the medication cup, the LPN picked up the spilled pills from the medication cart with an ungloved hand and placed them back into the cup without performing hand hygiene. The medications were then administered to the resident. The Director of Nursing confirmed the failure to follow proper infection control measures.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility failed to provide a resident or their representative with written information regarding the facility's bed hold policy upon the resident's transfer to a hospital. This deficiency was identified during a review of clinical records and staff interviews, which revealed that Resident 10 was transferred to the hospital on December 5, 2024, and returned to the facility on an unspecified date. However, there was no documented evidence that the facility provided the resident or their representative with the necessary written information about the bed hold policy at the time of transfer. An interview with the Nursing Home Administrator confirmed the absence of such documentation.
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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