Fairview Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairview, Pennsylvania.
- Location
- 900 Manchester Road, Fairview, Pennsylvania 16415
- CMS Provider Number
- 395572
- Inspections on file
- 25
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Fairview Manor during CMS and state inspections, most recent first.
The facility failed to meet professional standards of nursing care by allowing LPNs, without RN oversight, to assess residents who experienced falls, changes in condition, or device dislodgement that led to emergency hospital transfers. Multiple residents with complex medical histories, including diabetes, heart failure, COPD, stroke, kidney stones with drainage tubes, and infections, were evaluated and sent to the hospital based solely on LPN assessments, with no RN assessments documented in the clinical records. LPNs reported they were expected to assess newly admitted residents, those with injuries, and those with changes in condition, and to obtain provider orders for hospital transfer, often when no RN was available. The DON confirmed that these assessments were completed by LPNs alone and stated unawareness that RN assessments were required for residents with changes in condition, contrary to state nursing practice standards and the facility’s own job descriptions.
A resident with renal dialysis dependence, existing right foot wounds, stage 3 kidney disease, and gout returned from dialysis in a wheelchair and was later found with heavy bleeding and abrasions on four toes of the left foot, including tissue loss and a missing toenail, requiring pressure dressings and rewrapping when bleeding recurred. The resident reported that transport staff had bumped into a curb, while the contracted transport driver stated being unaware of any injury. Despite facility policy requiring interviews of the resident, alleged involved parties, and witnesses, written statements, analysis of evidence, and documentation of the investigation and conclusions, the NHA could not locate any investigation notes or interview documentation related to this injury of unknown origin.
A resident with hemiplegia, hemiparesis, and other conditions was transferred using a mechanical lift by only one nurse aide, despite facility education and physician orders requiring two staff for such transfers. Both the nurse aide and an LPN confirmed the two-person protocol was not followed during the observed transfer.
Multiple residents reported long delays in call bell responses, missed showers, unchanged bed linens, and cold meals due to insufficient nursing staff and staff inattentiveness, including frequent cell phone use and loud conversations in hallways. These issues led to unmet care needs and dissatisfaction with the care provided.
A resident with multiple medical conditions had conflicting documentation regarding life-sustaining treatment: the physician's order and care plan indicated Full Code status, while the signed POLST specified DNR. The DON confirmed these documents were not consistent and should have reflected the resident's advance directive wishes.
A resident with an indwelling catheter was incorrectly coded on the MDS as 'occasionally incontinent' and 'always incontinent' instead of 'not rated,' despite having the catheter throughout the assessment period. This error was confirmed by the RN Assessment Coordinator, who acknowledged the MDS did not accurately reflect the resident's continence status.
A resident was readmitted from the hospital with multiple diagnoses and began receiving hospice services from an outside agency, as documented in the clinical record. However, there was no physician's order for these hospice services, a fact confirmed by the DON during staff interview.
A resident with a PICC line and indwelling urinary catheter did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy and CDC guidelines. Observations revealed the absence of EBP signage and readily available PPE such as gowns and gloves in the resident's room, and the clinical record lacked a physician's order for EBP. The DON confirmed these deficiencies during an interview.
The facility failed to meet the required RN staffing levels, with shortages observed over a 14-day period. The deficiency was confirmed through staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to meet the minimum RN ratios.
The facility failed to provide the services of an RN for at least 8 consecutive hours a day, 7 days a week, over a 21-day period. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home administrator, who acknowledged the absence of RN coverage for the required shifts.
A facility failed to maintain accurate documentation for a resident receiving enteral feeding and water flushes via a gastric tube. The MARs from January to May 2024 showed discrepancies, with documented intake often below the ordered amount, some entries left blank, and others marked incorrectly. The DON confirmed the incomplete and inaccurate documentation, violating professional standards.
Failure to Ensure RN Assessments for Residents Transferred to Hospital
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not having a Registered Nurse (RN) conduct required assessments for residents who experienced falls, changes in condition, or device dislodgement that led to hospital transfers. Pennsylvania Code Title 49, Chapter 21, specifies that RNs are responsible for assessing human responses, planning, implementing, and evaluating nursing care, and collecting complete and ongoing data to determine nursing care needs. The facility’s own job descriptions state that LPNs administer resident care under RN and/or physician supervision and are to observe, evaluate, and report abnormal findings, while RNs are to observe, assess, and report abnormal findings and significant changes in condition. For seven sampled residents (R10–R16), the clinical records showed events requiring emergency transfer to the hospital, but lacked evidence of RN assessments prior to transfer. One resident with arthropathy, sacroiliitis, Type 2 diabetes, and stroke fell from bed, sustained injury, and was sent to the hospital. Another resident with irregular heartbeat, depression, heart disease, and fibromyalgia fell in the hallway, sustained injury, and was transferred for emergency evaluation. A resident with kidney stones, a displaced kidney drainage tube, UTI, and heart failure required emergency transfer when the kidney drainage tube became displaced. Additional residents with diagnoses including bacterial infection in the blood, heart failure, Type 2 diabetes, irregular heartbeat, high blood pressure, emphysema, COPD, stroke, heart attack, fainting, and heart disease experienced changes in condition that resulted in emergency hospital transfers. Interviews with LPN staff (E1–E5) confirmed that they were expected to complete their own assessments on newly admitted residents, residents with injuries, and residents with changes in condition, and that they were responsible for obtaining provider orders for emergency transfers based on their assessments. These LPNs also reported that there were many times when no RN was available to complete such assessments. Review of the clinical records for the seven residents confirmed the absence of RN assessments before hospital transfer. In an interview, the DON acknowledged that the assessments for these residents were conducted by LPNs without RN oversight or assistance and stated unawareness that an RN was required to perform assessments for residents experiencing a change in condition. The cited regulations included 28 Pa. Code 201.14(a), 201.18(b)(1)(3), 201.18(e)(1), 211.10(d), and 211.12(d)(1)(5).
Failure to Thoroughly Investigate Resident Toe Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an injury of unknown origin sustained by Resident R1. Facility policy on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property required the investigator to interview the resident, the accused, and all witnesses, obtain statements from each, document evidence of the investigation, analyze the evidence, determine whether the suspicion was substantiated or unsubstantiated, review and revise the resident’s plan of care as appropriate, consider policy or procedure modifications, and complete staff training if indicated. The Nursing Home Administrator later confirmed being unable to locate documentation of interviews or investigation notes related to the resident’s injuries, indicating that the required investigative steps and documentation were not completed as outlined in the policy. Resident R1 had an original admission date of 2/11/25 and a readmission date of 11/11/25, with diagnoses including dependence on renal dialysis, open wounds of the right foot, stage three kidney disease, and gout. Interdepartmental progress notes documented that the resident returned from dialysis in a wheelchair and, approximately 1.5 hours later, staff observed a large amount of blood on the floor and on the resident’s left foot, with a blood clot, blood-soaked sock, and heavy bleeding from abrasions on four toes. The great toe had an open area with tissue missing, the fourth toe was missing the toenail with a bleeding nail bed, and the second and third toes were also bleeding; staff were initially unable to stop the bleeding and applied a pressure dressing. Later that evening, removal of the pressure dressing resulted in renewed bleeding that required cleansing and rewrapping. An email between the NHA and the contracted transport company showed the driver reported being unaware of any injuries to the resident’s toes, but no further investigative documentation was found in the record.
Failure to Use Two Staff for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, hemiparesis, weakness, obesity, and vascular dementia was transferred using a mechanical lift by only one nurse aide, despite physician orders and facility education requiring two staff members for all mechanical lift transfers. The staff education materials and clinical records confirmed that two staff are necessary for safe transfers, and this requirement was acknowledged by both the nurse aide and the LPN during interviews. Observation revealed that the nurse aide performed the transfer alone, lowering the resident into bed without assistance. The nurse aide admitted to not following the two-person protocol, and the LPN and Nursing Home Administrator both confirmed that two staff are required for mechanical lift operations. No facility policy was provided for review.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of residents, as evidenced by multiple complaints documented in resident council minutes and resident interviews. Over a three-month period, residents reported persistent issues such as staff being on their cell phones, loud and inappropriate staff behavior in hallways, and delays in call bell responses, particularly during night shifts and weekends. Residents also noted that showers were not completed on designated days, bed sheets were not changed, and meal service was delayed, resulting in cold food and a non-homelike environment. During interviews, several residents described waiting 30 to 60 minutes for assistance after activating their call bells, with some requiring help for restroom use or ambulation that was not provided in a timely manner. Residents observed staff congregating in hallways or lounge areas, talking, watching TV, or using their phones while call lights remained unanswered. These actions and inactions directly contributed to unmet care needs, delays in assistance, and dissatisfaction with the quality of care provided.
Inconsistent Advance Directive Documentation for Life-Sustaining Treatment
Penalty
Summary
The facility failed to ensure that a resident's physician orders, POLST (Pennsylvania Order for Life Sustaining Treatment), and care plan were consistent with each other and accurately reflected the resident's advance directive wishes. Specifically, a review of the clinical record for a resident with diagnoses including kidney failure, GERD, and high blood pressure showed a physician's order and care plan indicating Full Code status, which directs staff to perform CPR in the event of cardiac arrest. However, the resident's POLST, signed by both the resident and physician, indicated DNR (Do Not Attempt Resuscitation), which is a directive to allow natural death and not perform CPR. During an interview, the Director of Nursing confirmed that the physician's orders, POLST, and care plan for this resident were not consistent and acknowledged that all documents should reflect the resident's advance directive wishes. The facility's policy states that a POLST will be honored and should guide care according to the resident or surrogate's wishes, but this was not followed in this case.
Inaccurate MDS Coding for Urinary Continence
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the urinary continence status of a resident. According to the MDS instructions, urinary continence should be coded as 'not rated' if the resident had an indwelling catheter during the entire seven-day look-back period. The clinical record for a resident admitted with kidney failure, GERD, and high blood pressure showed that the resident had an indwelling catheter at the time of admission and throughout the assessment period. Despite this, the resident's admission and Medicare-5 day MDS assessments were incorrectly coded, with urinary continence marked as 'occasionally incontinent' and 'always incontinent' instead of 'not rated.' This coding error was confirmed by the Registered Nurse Assessment Coordinator during an interview, who acknowledged that the MDS assessments did not accurately reflect the resident's continence status as required.
Failure to Obtain Physician's Order for Hospice Services
Penalty
Summary
The facility failed to obtain a physician's order for hospice services for a resident who was readmitted from the hospital with a diagnosis of cerebral infarction, atrial fibrillation, and constipation. Upon readmission, the resident was receiving hospice services from an outside agency, as documented in both hospital records and hospice agency documentation within the clinical record. However, a review of the resident's clinical record revealed that there was no physician's order authorizing hospice services. This absence was confirmed by the Director of Nursing during an interview, who acknowledged that there was no documented evidence of a physician's order for the hospice care being provided since the resident's return.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Devices
Penalty
Summary
The facility failed to follow its own infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC line) and an indwelling urinary catheter. According to the facility's policy and CDC guidelines, EBP, including the use of isolation gowns and gloves during high-contact care, should be implemented for residents with indwelling medical devices to prevent the transmission of multidrug-resistant organisms (MDROs). However, during observations, there was no signage posted in the resident's room to alert staff or visitors of EBP requirements, and no personal protective equipment (PPE) such as gloves or gowns was available inside or outside the room. The resident involved had a history of kidney failure, GERD, and high blood pressure, and was admitted with both a PICC line and an indwelling catheter. The clinical record did not include a physician's order for EBP. The Director of Nursing confirmed during an interview that the required signage and PPE were not present, acknowledging that these measures should have been in place for residents with indwelling devices. These findings were based on policy review, clinical record review, direct observation, and staff interview.
RN Staffing Deficiency
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Registered Nurse (RN) per 250 residents during all shifts. This deficiency was observed over a 14-day period from December 30, 2024, to January 12, 2025. During this time, the facility did not meet the required RN staffing levels for the day shift on 12 out of 14 days, for the evening shift on 13 out of 14 days, and for the overnight shift on 13 out of 14 days. Specific instances included days where no RNs were present despite a resident census that necessitated at least one RN, such as on January 1, 2025, when the census was 102 residents, but no RNs were on duty. The deficiency was confirmed through a review of the facility's nursing staffing documents and a telephone interview with the Nursing Home Administrator. The administrator acknowledged the failure to meet the minimum RN staffing ratios on the specified days and shifts. This lack of adequate RN staffing could potentially impact the quality of care provided to the residents, although the report does not detail any specific adverse outcomes resulting from this deficiency.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. The Director of Nursing or designee will monitor to ensure future ratios do not fall below 1 RN per 250 residents on all shifts. The DON or designee will proactively preview daily ratios to ensure adequate staff coverage. The scheduler or designee will review projected staffing levels with the Director of Nursing or designee, 3 times a week for 2 weeks, two times a week for 2 weeks, and then monthly for 2 months to ensure that any foreseeable issues with regard to adequate ratios to ensure regulation is met. The scheduler or designee will review the working schedules with the Director of Nursing or designee, 3 times a week for 2 weeks, two times a week for 2 weeks, and then monthly for 2 months to determine what changes need to be made to ensure staffing levels are met. Fairview Manor recruiter will continue to aggressively advertise externally for recruitment of RNs to enhance current staffing levels. Fairview Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized as needed to motivate employees to pick up unscheduled shifts. Agency RN usage will be utilized as needed. Scheduler and nursing supervisors have been educated on required staffing ratios. Results of audits will be reviewed at the Quality Assurance committee. 03/05/2025 Date of compliance.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to comply with the regulatory requirement of having a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified through a review of nursing time schedules and staff interviews, which revealed that for a period of 21 days, from December 7, 2024, to December 27, 2024, the facility did not have an RN on duty for the required hours. Specific shifts on multiple days were noted where no RN hours were worked, despite the requirement for 8 hours of RN coverage per shift. The deficiency was confirmed during an interview with the Nursing Home administrator on January 2, 2025, who acknowledged the absence of an RN for the required shifts on the specified dates. This lack of RN coverage is a violation of the federal regulation §483.35(b) and the state codes 28 Pa. Code 201.18(e)(1) and 28 Pa. Code 211.12(c), which mandate adequate nursing services and management in long-term care facilities.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. The Director of Nursing or designee will monitor to ensure the facility provides the services of a Registered Nurse (RN) for 8 consecutive hour nursing shifts daily. The scheduler or designee will review projected staffing levels via the daily log to ensure that any foreseeable issues with regard to adequate RN coverage is met. Fairview Manor recruiter will continue to aggressively advertise externally for recruitment of RNs to enhance current staffing levels. Fairview Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized as needed to motivate employees to pick up unscheduled shifts. 1 Full Time day shift Registered Nurse, 1 Full Time night shift Registered Nurse and Director Of Nursing began in General Orientation 1/16/25. Scheduler and nursing supervisors have been educated on required RN/DON staffing requirements. Results of audits will be reviewed at Quality Assurance committee 2/28/25 Date of compliance.
Inaccurate Documentation of Enteral Feeding and Water Flushes
Penalty
Summary
The facility failed to maintain complete and accurate documentation for a resident identified as R11, who was receiving enteral feeding and water flushes via a gastric tube. The resident's clinical record showed discrepancies in the documentation of the prescribed enteral feeding and water flushes over several months. The physician's orders specified the amounts and frequency of the enteral feeding and water flushes, but the Medication Administration Records (MAR) for January through May 2024 revealed numerous instances of incomplete, inaccurate, or missing documentation. For the enteral feeding, the MARs indicated that the documented intake was often below the ordered amount, with some entries left blank or marked as 'NA' (not applicable). In some cases, the intake was recorded as being above the ordered amount. Similarly, the documentation for the water flushes showed inconsistencies, with entries indicating amounts both above and below the prescribed levels, as well as some entries being left blank or marked incorrectly. During an interview, the Director of Nursing confirmed the presence of incomplete and inaccurate documentation in Resident R11's clinical record concerning the tube feeding formula and water flushes. This deficiency was identified as a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as required by the relevant state codes.
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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