Fair Acres Geriatric Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Pennsylvania.
- Location
- 340 N. Middletown Road, Lima, Pennsylvania 19037
- CMS Provider Number
- 395780
- Inspections on file
- 24
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Fair Acres Geriatric Center during CMS and state inspections, most recent first.
Surveyors found that residents were not educated on filing grievances and that grievance forms or boxes were not available or accessible on five nursing units. Staff interviews confirmed the absence of standardized grievance materials, and the DON stated there was no formal grievance policy. Resident council minutes showed no education on the grievance process.
The facility failed to maintain and inspect its emergency generator, lacking documentation for a 3-year, 4-hour load test, an annual 90-minute load bank test, and an annual fuel quality test. This deficiency was confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain and inspect the fire alarm system, as the annual inspection report noted that the kitchen's duct detector was missing and untested. The facility lacked documentation of remediation, confirmed by the Maintenance Director.
The facility failed to maintain and inspect its sprinkler system, as it could not provide documentation of a dry sprinkler full flow test within the past three years and had a missing sprinkler escutcheon above the ice machine on the fifth floor. These issues were confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain the door to a hazardous area on the first floor, as observed when the Clean Utility Room entry door was missing a strike plate. This deficiency was confirmed by the Maintenance Director.
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards. Observations revealed that doors on the first floor did not close smoke tight and had missing hardware, while a door on the second floor was obstructed by a bariatric chair. These deficiencies were confirmed during an exit interview with the Maintenance Director.
The facility failed to prevent the unauthorized use of electrical devices, as observed in a designated smoking room and Resident Room 118. A fan was powered by a surge protector in the smoking room, and a light duty extension cord was used for resident electronics in Room 118. Additionally, an oscillating fan was plugged into a power outlet multiplier in the same room. These actions were confirmed by the Maintenance Director, indicating non-compliance with NFPA 101 standards.
The facility failed to maintain proper oxygen storage and cylinder identification. On one floor, the Clean Utility Room lacked required precautionary signage for oxygen storage. Additionally, on another floor, full and empty oxygen cylinders were mixed, and on the ground floor, cylinders were not labeled. These deficiencies were confirmed during an exit interview with the Maintenance Director.
The facility failed to maintain portable fire extinguishers on two floors. A fire extinguisher was blocked by a laundry cart, and others were improperly mounted, affecting access. These issues were confirmed by the Maintenance Director.
The facility did not maintain the fire resistance rating of vertical openings on the tenth floor. An observation revealed that the rated access ceiling door in the Electrical Closet next to room 1020 failed to self-close and latch, as confirmed by the Maintenance Director.
A facility failed to maintain corridor doors to resist smoke passage and positively latch, as observed in resident room 211. The door did not latch properly, compromising safety standards. This was confirmed by the Maintenance Director during an exit interview.
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as observed on the eleventh floor above the smoke doors by room 1108. An unsealed penetration around electrical conduits was noted, which was confirmed by the Maintenance Director.
The facility did not maintain its HVAC system properly on one floor, as three portable air conditioning units were vented above the drop ceiling into the interstitial space, creating a plenum. This was confirmed by the Maintenance Director.
The facility failed to maintain the fire protection rating for linen chutes, with deficiencies observed on multiple floors. Chute doors in soiled utility rooms on the second, third, fourth, seventh, eighth, and tenth floors were found to be non-compliant, either failing to latch or being propped open. These issues were confirmed by the Maintenance Director, affecting six out of fifteen levels in the facility.
The facility failed to maintain electrical wiring protection on the tenth floor, where a junction box above the smoke doors at a resident's room was missing its cover plate, exposing the wiring. This was confirmed by the Maintenance Director.
A resident's drug regimen review at Fair Acres Geriatric Center revealed that the attending physician did not address several medication recommendations made by a pharmacist. These included discontinuing certain supplements and adjusting medication timing. The facility's Director of Nursing confirmed the absence of documented physician responses, indicating non-compliance with drug regimen review requirements.
Failure to Provide Grievance Education and Accessible Grievance Materials
Penalty
Summary
The facility failed to provide evidence that residents were educated on the process of filing grievances and did not ensure that grievance forms or boxes were available and accessible on the nursing units across five floors. Observations on multiple floors revealed the absence of grievance forms and drop boxes, and staff interviews confirmed that these resources were not present. Instead, staff reported that residents could either call a posted phone number, write complaints on plain paper, or use blank envelopes to submit grievances, but no standardized forms or accessible boxes were available on the units. In the main lobby, a complaint box was observed, but no grievance forms were available for residents to use. Review of facility documentation, including resident council minutes, showed no evidence of education or discussion regarding the grievance process. Additionally, the Director of Nursing confirmed that the facility did not have a formal grievance policy in place. The facility's policy on resident rights referenced staff training but did not address resident education or the availability of grievance materials. These findings demonstrate a lack of compliance with requirements to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect its emergency generator as required by NFPA standards. During a document review on February 3, 2025, it was discovered that the facility could not provide documentation of a 3-year, 4-hour load test of the emergency generator. This test is crucial to ensure the generator's capability to supply service within 10 seconds, as stipulated by NFPA 101 and NFPA 110. Further investigation revealed additional deficiencies in the facility's maintenance and testing procedures. The facility was unable to provide documentation for an annual 90-minute load bank test and an annual fuel quality test. These tests are essential to verify the reliability and efficiency of the emergency power system, which is critical for the safety and well-being of the residents. An exit interview with the Maintenance Director on February 4, 2025, confirmed the lack of documentation for these required tests and inspections. The absence of these records indicates a failure to adhere to the necessary maintenance protocols, potentially compromising the facility's ability to provide essential power in emergencies.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Documentation will be provided by outside contractor for 3-year, 4-hour load test of emergency generator. Submission of Load test paper documentation will be checked quarterly to ensure all proper documentation is maintained. Documentation provided by outside contractor for 3-year, 4-hour load test of emergency generator. Documentation provided by outside contractor for Annual load bank test of. Documentation provided by outside contractor, Ferguson & McCann for fuel quality test. All paperwork needed for these items will be reviewed monthly by maintenance designee to ensure this issue does not reoccur.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect the fire alarm system as required, affecting the entire component. During a document review on February 3, 2025, it was discovered that the annual fire alarm inspection report dated May 2, 2024, indicated that the duct detector for the kitchen could not be found and was not tested. The facility was unable to provide documentation showing that this deficiency had been addressed. This was confirmed during an exit interview with the Maintenance Director on February 4, 2025.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0345 Johnson Controls Fire Protection was contacted and will provide information on the functionality of the duct detector. Annual fire alarm report will be reviewed by Maintenance designee to ensure this issue does not reoccur.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect its sprinkler system as required, affecting the entire component. During a document review on February 3, 2025, it was found that the facility could not provide documentation that a dry sprinkler full flow test had been conducted within the past three years. Additionally, an observation on February 4, 2025, revealed a missing sprinkler escutcheon above the ice machine on the fifth floor. These deficiencies were confirmed during an exit interview with the Maintenance Director on February 4, 2025.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0353 - 1 Sprinkler Company will be contracted to perform inspection. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0353 - 2 Escutcheon was replaced. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Deficiency in Door Maintenance to Hazardous Area
Penalty
Summary
The facility failed to maintain the integrity of doors to hazardous areas, specifically on the first floor. During an observation on February 3, 2025, at 10:35 a.m., it was noted that the entry door to the Clean Utility Room was missing a strike plate. This deficiency was confirmed during an exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m. The absence of the strike plate compromises the door's ability to function as a proper barrier in accordance with fire safety regulations.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal Law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any court proceedings. New strike plate was installed and will be monitored monthly for one quarter by a maintenance department designee to ensure condition is not replicated.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain smoke doors in compliance with NFPA 101 standards, affecting multiple areas across different floors. On February 3, 2025, observations revealed that the double doors to the Day Room on the first floor, next to rooms 129 and 118, did not close smoke tight when tested. Additionally, on the same day, the double smoke barrier doors next to the elevator on the first floor were found to have missing hardware on the push bar. These deficiencies were confirmed during an exit interview with the Maintenance Director on February 4, 2025. Further observations on February 4, 2025, indicated that on the second floor, next to room 208, one of the double smoke doors was obstructed by a bariatric chair, preventing it from closing smoke tight. This condition was also confirmed during the exit interview with the Maintenance Director. These findings demonstrate a failure to ensure that smoke barrier doors were maintained to resist the passage of smoke, as required by the NFPA 101 standards.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0374 A & B A. New door coordinator for double doors next to room 129 will be installed. Door will be monitored monthly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. B. New door coordinator for double doors next to room 118 will be installed. Door will be monitored monthly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0374 Missing Hardware on push bar was installed on door. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. 2/19/2025 Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Chair was removed from area blocking fire doors. Door was checked to ensure smoke tight closure. Fire and Safety or designee will monitor area weekly for 1 quarter to ensure this issue does not reoccur.
Unauthorized Use of Electrical Devices in Facility
Penalty
Summary
The facility was found to have failed in prohibiting the improper and unauthorized use of electrical devices, as observed during a survey. On February 3, 2025, between 9:00 a.m. and 12:30 p.m., it was noted that a fan in the designated smoking room was powered using a surge protector, which is not compliant with the regulations. Additionally, in Resident Room 118, a brown light duty extension cord was used to power resident electronics, which is against the guidelines that prohibit the use of extension cords as a substitute for fixed wiring. Further observations on February 4, 2025, at 10:20 a.m., revealed another instance of non-compliance in Resident Room 118, where an oscillating fan was plugged into a power outlet multiplier. These findings were confirmed during an exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m. The use of these unauthorized electrical devices indicates a failure to adhere to the standards set by NFPA 101 and related codes, which are designed to ensure safety in the facility.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0920 a & b a. Fan power source was relocated to wall outlet. Smoking room will be monitored weekly for one quarter by maintenance designee to ensure this condition is not replicated. b. Extension cord was removed. Room 118 will be monitored weekly for one quarter by maintenance designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0920 Fan was plugged into wall outlet. Fire and Safety or designee will monitor room weekly for 1 quarter.
Deficiencies in Oxygen Storage and Cylinder Identification
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as evidenced by observations and interviews conducted during the survey. On the first level, the Clean Utility Room lacked the necessary precautionary signage for oxygen storage, which should include the wording: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING." This deficiency was confirmed during an exit interview with the Maintenance Director. Additionally, the facility did not properly store and identify medical gas cylinders on one of the three floors. On the second floor, full and empty oxygen cylinders were mixed in both racks, and on the ground floor, the cylinders were not labeled to distinguish between full and empty. These issues were also confirmed during the exit interview with the Maintenance Director.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. New signage was installed. First level clean utility room will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0923 a & b A. New signage will be installed on second floor inside oxygen storage to ensure there is no mixing of full versus empty cylinders. Area will be monitored weekly for 1 quarter by a maintenance department designee to ensure this condition is not replicated. B. New signage on ground floor will be installed to label/designate full versus empty cylinders. Area will be monitored weekly for 1 quarter by a maintenance department designee to ensure this condition is not replicated.
Deficiencies in Fire Extinguisher Maintenance
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards on two of fifteen floors. On February 3, 2025, a fire extinguisher in a corridor was obstructed by an unattended soiled laundry cart, as observed at 10:25 a.m. This was confirmed during an exit interview with the Maintenance Director on February 4, 2025. Further deficiencies were noted on February 4, 2025, between 9:40 a.m. and 10:30 a.m. On the thirteenth floor, next to stair tower #2, a fire extinguisher was improperly hung by its hose due to a missing mounting bracket. Additionally, on the tenth floor, fire extinguishers were mounted directly below handrails, impeding direct access. These issues were also confirmed in an exit interview with the Maintenance Director.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0355 Laundry cart was moved. Staff was in-serviced on the importance of not blocking fire extinguishers with laundry cart. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0355 a New extinguisher and bracket was installed. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. b Extinguishers will be remounted above handrail. Area will be monitored weekly for one quarter and by Fire & Safety Supervisor or designee for 1 quarter to ensure this condition is not replicated.
Failure to Maintain Fire Resistance Rating on Tenth Floor
Penalty
Summary
The facility failed to maintain the fire resistance rating of vertical openings, specifically affecting the tenth floor. During an observation on February 4, 2025, at 10:40 a.m., it was noted that the rated access ceiling door in the Electrical Closet next to room 1020 did not self-close and latch as required. This deficiency was confirmed during an exit interview with the Maintenance Director at 1:00 p.m. on the same day.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. Spring will be reset on ceiling door to ensure latching and ability to close. Ceiling door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Corridor Door Fails to Latch, Compromising Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch, as required by regulations. During an observation on February 4, 2025, at 10:50 a.m., it was noted that the door to resident room 211 on the second floor did not positively latch in the frame. This deficiency was identified as one of over three hundred corridor doors within the facility. The issue was confirmed during an exit interview with the Maintenance Director on the same day at 1:00 p.m. The report highlights that the door's inability to latch properly compromises its function to resist smoke passage, which is a critical safety requirement in long-term care facilities. The deficiency was observed and documented by surveyors, indicating a lapse in the facility's maintenance of safety standards for corridor doors.
Plan Of Correction
Exit Date: 02/04/25 0363 Scope/ Severity: E NFPA 101 STANDARD Corridor - Doors: Name - BLDG. 8 Component - 05 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. Observations: Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke and positively latch on one of over three hundred corridor doors within the facility. Findings include: Observation on February 4, 2025, at 10:50 a.m., revealed, on the second floor, resident room 211, failed to positively latch in the frame. Exit interview with the Maintenance Director on February 4, 2025, at 1:00 p.m., confirmed the door did not latch. Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0363 Door was repaired to latch in the frame. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Unsealed Penetration in Smoke Barrier Wall
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on February 4, 2025, at 10:00 a.m., it was noted that on the eleventh floor, above the smoke doors by room 1108, there was an unsealed penetration around electrical conduits. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day at 1:00 p.m.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0372 Penetration will be sealed with UL Rated Fire Stop. Fire safety supervisor or designee will monitor area weekly for 1 Quarter to ensure this condition is not replicated.
HVAC System Deficiency Due to Improper Venting
Penalty
Summary
The facility failed to maintain the heating, ventilating, and air conditioning (HVAC) system on one of its fifteen floors. During an observation on the ground floor inside the office therapy department, it was found that three portable air conditioning units were vented above the drop ceiling into the interstitial space, creating a plenum. This observation was confirmed during an exit interview with the Maintenance Director.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0521 Temporary AC units were removed from the building. Maintenance Department or designee will monitor are weekly for one quarter to ensure this issue does not reoccur.
Fire Protection Deficiencies in Linen Chutes
Penalty
Summary
The facility failed to maintain the fire protection rating for linen chutes, as evidenced by several deficiencies observed during a survey. On multiple floors, including the second, third, fourth, seventh, eighth, and tenth, the rubbish and laundry chute doors in the soiled utility rooms were found to be non-compliant. Specifically, the chute doors on the second and third floors failed to positively latch, while the chute door on the fourth floor was propped open by a lining cart. Additionally, the chute doors on the seventh, eighth, and tenth floors failed to close and latch properly. These deficiencies were confirmed during an exit interview with the Maintenance Director, who acknowledged the issues with the chute doors. The failure to maintain the fire protection rating for these chutes affects six out of fifteen levels in the facility, indicating a significant lapse in maintaining fire safety standards as required by NFPA 101. The report does not mention any corrective actions or plans to address these deficiencies.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0541-a Door was repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-b Door was repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-c Linen chute door was closed and Facility staff will be educated about the hazards of propping doors open. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-d Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-e Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0541-f Door will be repaired to positive latch. Door will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.
Electrical Wiring Protection Deficiency
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, as observed on the tenth floor. Specifically, a junction box located above the double smoke doors at resident room 1008 was missing its cover plate, which exposed the inner wiring. This deficiency was identified during an observation conducted on February 4, 2025, at 10:15 a.m. The Maintenance Director confirmed the missing cover plate during an exit interview later that day at 1:00 p.m.
Plan Of Correction
Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0911 Junction box cover was replaced. Facilities Director or designee will monitor weekly for 1 Quarter to ensure this issue does not reoccur.
Failure to Act on Pharmacist's Recommendations
Penalty
Summary
Fair Acres Geriatric Center was found to be non-compliant with the requirements for drug regimen review as per 42 CFR 483.45(c). The facility failed to ensure that medication irregularities identified by a licensed pharmacist were acted upon by a physician for one of the residents reviewed. Specifically, the pharmacist's recommendations to discontinue certain medications and adjust the timing of another were not addressed by the attending physician. These recommendations included discontinuing D-Mannose due to ongoing urinary tract infections and potential effects on blood sugar, Melatonin due to concurrent use with Trazadone for insomnia, Glucosamine-Chondroitin due to uncontrolled pain, and PreserVision AREDS 2 due to duplication with another multivitamin. Additionally, a recommendation was made to change the timing of Omeprazole to optimize its effectiveness. The clinical record of the resident in question did not contain any documentation from the attending physician acknowledging or addressing these recommendations. During an interview, the Director of Nursing confirmed the absence of documented evidence of a physician's response to the pharmacist's recommendations. This lack of action and documentation constitutes a failure to comply with the federal and state regulations regarding drug regimen reviews and the necessary follow-up actions by the attending physician.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court finding. All residents receiving a Drug Regimen Review have the potential to be affected. Resident R134 was seen by the physician following the pharmacy recommendation that was reviewed by the physician on 10/9/24 on 10/21/24, 11/21/24, 12/20/2024, and 1/22/25. Resident R134 had drug regimen reviews completed on 11/6/24, 12/6/24, and 1/8/24 which did not have any additional recommendations for the physician. Medication Regimen Review Policy and Procedure was reviewed. The physicians were re-educated on the Medication Regimen Review Policy and Procedure. DON, or designee, will audit for documented evidence of a response to Drug Regimen Reviews. Audits will occur monthly x3. If trends are identified, corrective action, including a Root Cause Analysis, will be reported to the QA Committee.
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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