Fox Subacute At Mechanicsburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Mechanicsburg, Pennsylvania.
- Location
- 120 South Filbert St, Mechanicsburg, Pennsylvania 17055
- CMS Provider Number
- 396122
- Inspections on file
- 21
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Fox Subacute At Mechanicsburg during CMS and state inspections, most recent first.
Surveyors found that the facility did not properly obtain and document informed consent for psychotropic medications for two residents with serious mental health diagnoses. Both residents were receiving antipsychotic and antianxiety, and in one case antidepressant, medications, but their psychotropic consent forms were incomplete, with treatment conditions and/or specific medications left blank. Clinical records lacked documentation that the residents or their representatives were educated on the risks, benefits, side effects, or adverse reactions of these medications. The NHA reported that the facility’s practice was to have a psychotropic consent signed at admission only and not to obtain new consents when medications changed, and no progress notes were found to show that medication changes and related information had been discussed with the representatives.
The facility did not ensure that a physician or prescriber reviewed and responded to consultant pharmacist Medication Regimen Review (MRR) recommendations for three residents with serious conditions including heart failure, respiratory failure, and vertebral fracture. In each case, the pharmacist recommended additional monitoring or clarification of PRN antianxiety or antipsychotic/anticonvulsant orders, and nurses documented actions such as adding monitoring or a 14-day limit. However, there was no physician signature or documentation showing that a prescriber reviewed or addressed these medication irregularities, despite facility policy requiring prescriber involvement.
Surveyors found that care plans were not updated to reflect current interventions for two residents. For a resident with chronic respiratory failure on a ventilator, the care plan continued to list an outdated trach type and size despite a physician order for a different trach. For another resident with chronic respiratory failure and HTN who had a prior unwitnessed fall, the care plan still listed bilateral fall mats as an active intervention with placement every shift, even though the DON reported the mats had been discontinued and staff observations confirmed no mats were present in the room.
A resident with acute and chronic respiratory failure, hypoxia, ventilator dependence, and a gastrostomy tube had medications administered via the G-tube by an RN without prior verification of tube placement, despite facility policy and a physician order requiring confirmation of feeding tube placement before each instillation of tube feeding, medications, or water. The RN reported believing the prior verification policy was no longer in effect, while the DON confirmed that tube placement should have been checked before administering the medications.
A resident with a stage 3 pressure ulcer and other comorbidities did not receive ordered vitamin C 500 mg BID for wound healing after returning from a hospital stay. Although wound care documentation and dietitian notes repeatedly referenced vitamin C as part of the wound treatment plan, the original physician order had been discontinued when the resident was hospitalized and was never re-entered on readmission. The DON confirmed that the order should have been reinstated in accordance with the wound physician’s recommendations and facility policy requiring adherence to specific wound care and medication instructions.
Surveyors found that the facility did not follow its own Pharmacy Services policy requiring all opened multi-dose vials to be dated and discarded per product guidelines. In the first floor medication room, two opened vials of tuberculin skin testing solution were observed: one had no open date, and the other was dated more than 30 days prior, beyond the product’s 30‑day post-puncture expiration period. During interview, the DON and Assistant DON confirmed that multi-dose vials must be dated when opened and acknowledged that the dated tuberculin vial was expired and should have been discarded.
A nurse failed to follow infection control practices while administering medications via a G-tube to a resident. The nurse placed prepared medications on a heating unit, then handled a fall mat from the floor with gloved hands and set the medication cups on the mat. Without changing gloves or performing hand hygiene, the nurse proceeded to administer the medications while holding the end of the tube feeding administration tubing, which connects directly to the G-tube. The NHA and DON later confirmed that proper glove removal and hand hygiene should have occurred before medication administration.
A resident with quadriplegia and hypotension received oxycodone for pain, but staff failed to consistently document administration of the controlled substance on the MAR as required by facility policy. Discrepancies were found between the controlled drug record and the MAR, with several doses not properly signed off or documented at incorrect times. Nursing leadership confirmed the expectation for accurate documentation but could not explain the inconsistencies.
A resident with CHF and hypertension had physician orders for several lab tests, but while the CBC and urinalysis results were documented, the BMP result was missing from the clinical record. An LPN and the provider were aware that the BMP was not viable and decided not to redraw it, but this was not documented as required by facility policy.
The facility failed to perform the mandatory 3-year, 4-hour load bank test on its emergency generator, as required by NFPA standards. This deficiency was confirmed by the Director of Maintenance during an interview, indicating a lapse in the facility's adherence to the maintenance schedule necessary for ensuring reliable emergency power.
The facility failed to maintain common wall doors on the second floor, with gaps exceeding 1/8 inch and lacking positive latching. The doors were only secured by a magnetic release, allowing them to open freely during a fire alarm, as confirmed by the Director of Maintenance.
The facility failed to maintain clear exit access on the second floor, as required by NFPA 101 standards. Observations revealed obstructions in the corridor, including soiled-linen, trash containers, and a clean-linen cart, at various locations. The Director of Maintenance confirmed these obstructions, indicating non-compliance with safety codes.
The facility did not maintain the stairtower doors within the allowed gap margins. An observation revealed that the 2nd floor stairtower door had gaps greater than 1/8 inch, which was confirmed by the Director of Maintenance.
The facility did not conduct or document the required annual 90-minute test of the battery-powered emergency lighting in the Generator Room, as confirmed by the Director of Maintenance.
The facility failed to update and revise care plans for several residents, leading to deficiencies in care. A resident's care plan did not reflect necessary fall interventions, while another's care plan was not updated after medication changes. Additionally, care plans lacked detailed interventions and monitoring guidelines. The DON and staff acknowledged these oversights.
The facility failed to provide care according to professional standards for three residents. A resident with a tracheostomy had no documentation of skin assessments despite an order for antibiotic ointment. Another resident with COPD and hypertension had incomplete documentation of wound care treatments. A third resident with diabetes and renal disease had missing blood sugar checks and incorrect medication administration. The DON confirmed these issues and expected proper documentation and adherence to orders.
A facility failed to provide appropriate catheter care for a resident with an indwelling catheter, leading to multiple undocumented instances of foley output, catheter care, and flush kit changes. This resulted in the resident receiving antibiotic treatment for urinary tract infections twice. The DON confirmed that the facility's process and physician orders were not followed.
A resident with cerebral palsy and a tracheostomy was prescribed triple antibiotic ointment for skin damage at the stoma site without documented evidence of such damage. The facility's consultant pharmacist failed to identify the lack of clinical documentation during multiple reviews. The DON confirmed the oversight, and the resident's physician later discontinued the ointment after finding no skin damage.
A resident with hypertension and bipolar disorder was prescribed clonazepam and lorazepam without documented rationale for their duplicative use. The facility failed to adhere to the prescribed administration schedule and did not document numerous administrations in the MAR. Additionally, lorazepam was administered without an active physician order, indicating a failure to ensure medications were only given with valid orders.
A facility failed to maintain the confidentiality of a resident's medical records, as a paper with the resident's name and clinical findings was visible from the hallway. The paper, which included treatment instructions for the resident's tracheostomy, was improperly placed outside the resident's room instead of being secured.
The facility did not complete the required TB screening for two new employees, as per its infection control plan. Employee 3 had no documentation of a TST or TB blood assay test prior to hire, while Employee 7 had only one TST from a previous employer. The Nursing Home Administrator confirmed the oversight and stated that both employees were removed from the floor and sent for a TB blood assay test.
A facility failed to ensure verbal medication orders were countersigned by the prescribing physician within 48 hours, as required by state regulations. A resident with hypertension and bipolar disorder had verbal orders for lorazepam and clonazepam entered without the necessary physician counter-signature. The facility's policy did not include the requirement for physician signatures on verbal orders, and the Director of Nursing acknowledged the expectation for compliance with state regulations.
A facility failed to notify a resident's representative of a critically low hemoglobin level, as required by their policy. The resident, diagnosed with anemia and atrial fibrillation, had a hemoglobin level of 6.0, significantly below the normal range. The Assistant Director of Nursing confirmed that the representative should have been informed, but no documentation of such notification was found.
A facility failed to follow physician orders for a resident with anemia and Afib, leading to continued administration of Coumadin despite orders to discontinue blood thinners. The facility also lacked documentation of INR results, and the physician assistant was unaware of elevated INR levels.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent for psychotropic medications, as evidenced by record reviews for two residents. One resident had diagnoses including major depressive disorder with psychotic features and generalized anxiety disorder and had physician orders for quetiapine and lorazepam, with a history of being on these types of medications for several months. The resident’s clinical record contained a Psychotropic Medication Treatment Consent form that incorrectly listed the treatment reason as Tracheotomy/Brain Damage, left the medication section blank, and was signed by the resident’s representative. The record did not contain documentation that the resident or representative had been educated on the risks, benefits, side effects, or other adverse reactions associated with the ordered antipsychotic and antianxiety medications. Another resident had diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, and major depressive disorder, and had physician orders for olanzapine, buspirone, and escitalopram. This resident’s Psychotropic Medication Treatment Consent form had both the condition being treated and the medications being used left blank, although it was signed by the resident’s representative. The clinical record similarly lacked documentation that the resident or representative had been informed of the risks and benefits, including side effects and adverse reactions, of the antipsychotic, antianxiety, and antidepressant medications. During an interview, the NHA stated that the facility’s practice was to obtain a psychotropic consent at admission only and not to obtain additional consents, and that staff would review medication changes with representatives and document these discussions in progress notes; however, no such documentation was found for these two residents.
Failure to Obtain Physician Response to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were reviewed and acted upon by the attending physician or prescriber, as required by facility policy. The policy titled "Medication Regimen Review (Monthly Report)" stated that recommendations are to be acted upon and documented by facility staff and/or the prescriber. For three residents, documentation showed that nursing staff acknowledged and implemented pharmacist recommendations, but there was no evidence that a physician had reviewed or addressed the identified irregularities. For one resident with heart failure and respiratory failure, the consultant pharmacist recommended on December 10, 2025, that additional monitoring be added for an anticonvulsant medication; a nurse signed the recommendation and documented "added to order," but there was no physician signature or documentation of physician review. For a second resident with heart failure and respiratory failure, the pharmacist recommended on October 17, 2025, that a PRN antianxiety medication either be limited to 14 days or have a documented rationale and duration; a nurse signed and documented "14-day added to order" without any physician signature or evidence of physician review. For a third resident with a fracture of the first thoracic vertebra and respiratory failure, the pharmacist recommended on December 10, 2025, additional monitoring for an antipsychotic medication; a nurse signed and documented "AIMS" without a physician signature or documentation that the physician reviewed or acted on the irregularity. In an interview, the DON stated they would expect the regulation to be followed.
Failure to Update Care Plans to Reflect Current Respiratory and Fall-Prevention Interventions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to reflect residents' current clinical status for two residents. For one resident with chronic respiratory failure and dependence on a respirator, physician orders documented a tracheostomy type and size of #8 Portex starting March 19, 2025. However, the resident’s comprehensive plan of care continued to list a trach type and size of 7 XLT-D cuffed under the care area for ineffective airway clearance related to disease process with vent support as needed and trach. In an interview, the Nursing Home Administrator and DON acknowledged that the resident’s trach size and type had changed and that the care plan was not updated, and the DON stated she would expect care plans to be updated timely. For another resident with chronic respiratory failure and hypertension who had an unwitnessed fall on September 24, 2025, the fall report documented an intervention to place bilateral fall mats on either side of the bed. The comprehensive care plan included a focus area for risk of falls with an intervention for bilateral fall mats and instructions to ensure placement every shift, last revised October 21, 2025. Observations of the resident’s room on two separate days did not reveal bilateral fall mats, and a housekeeper reported not having seen any fall mats in the room. The DON stated in interviews that the fall mats had been reviewed and discontinued around the time of the resident’s most recent hospitalization in November 2025 and that she would expect the care plan to be updated, indicating the care plan was not revised to reflect the discontinuation of the fall mats.
Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications administered via a gastrostomy tube were provided in accordance with professional standards and facility policy. The facility’s Medication Administration policy, last reviewed on December 31, 2025, required that gastrostomy tube placement be confirmed by auscultation with air prior to medication administration. Resident 46’s clinical record showed diagnoses including acute and chronic respiratory failure with hypoxia, ventilator dependence, and the presence of a gastrostomy tube. The physician’s order for this resident directed that feeding tube placement be confirmed prior to every instillation of tube feeding, medications, water, etc., each shift, and that placement be confirmed per policy. During a medication administration observation for Resident 46 on January 22, 2026, at 8:45 AM, a Registered Nurse (Employee 3) administered medications through the resident’s gastrostomy tube without confirming tube placement beforehand. In a subsequent interview, Employee 3 stated that the facility previously had a policy requiring verification of gastrostomy tube placement before medication administration but believed that policy was no longer in effect. In an interview later that morning, the DON confirmed that Employee 3 should have verified the gastrostomy tube placement before administering the medications, indicating that the nurse’s actions did not follow the current policy and physician order.
Failure to Reinstate Vitamin C Order for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure necessary treatment and services were provided, consistent with professional standards of practice, to promote healing of a pressure ulcer for one resident. Facility policy on Wound Care and Pressure Ulcer Care required staff to check the physician’s order for specific wound care and medication instructions. The resident had diagnoses including a stage 3 pressure ulcer, chronic respiratory failure, and hypertension. Wound Evaluation & Management Summaries over multiple dates documented recommendations from the wound provider for a dietician consult and vitamin C 500 mg BID as part of the wound care plan. Dietitian notes from multiple weekly wound meetings documented that the resident was taking vitamin C as an intervention for wound healing. However, review of the physician’s orders showed that the order for ascorbic acid (vitamin C) 500 mg BID for wounds, which began in mid-September, was discontinued in early October when the resident went to the hospital and was never re-entered upon the resident’s return. During an interview, the DON stated that the vitamin C order was discontinued when the resident was hospitalized and was not reinstated afterward, despite the wound doctor’s continued recommendation, and acknowledged that physician recommendations were expected to be implemented.
Improper Labeling and Failure to Discard Expired Tuberculin Vials in Medication Room
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management practices related to labeling and discarding multi-dose vials. Review of the facility’s Pharmacy Services policy, last reviewed December 31, 2025, showed that all opened multi-dose vials were required to be dated at the time they were opened. Product information for tuberculin skin testing solution indicated that the solution expires 30 days after the initial puncture into the vial. During observation of the first floor medication room with a staff member on January 21, 2026, surveyors found two opened vials of tuberculin skin testing solution, one without any open date and another labeled with an open date of December 4, 2025, which was beyond the 30‑day use period. In an interview, the DON and Assistant DON acknowledged that multi-dose vials should be dated when opened and confirmed that the vial dated December 4, 2025, was expired and should have been discarded. No specific residents or their clinical conditions were mentioned in relation to this deficiency. The findings were limited to the medication storage and labeling practices in one of two medication rooms observed (the first floor medication room), where the presence of an undated vial and an expired vial of tuberculin skin testing solution demonstrated noncompliance with the facility’s own policy and accepted professional standards for medication labeling and expiration dating.
Improper Infection Control During G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow infection prevention and control practices during medication administration for Resident 33, who received medications via a gastrostomy tube. During a medication pass observation, the nurse entered the resident’s room, donned a gown and gloves, and placed the resident’s prepared medication cups on the room’s heating unit. The nurse then used both gloved hands to pick up a fall mat from the floor beside the bed and lean it against the wall, and subsequently placed the cups of prepared medications on top of the upright fall mat. The nurse proceeded to administer the medications through the resident’s gastrostomy tube while also holding the end of the tube feeding administration tubing, which connects directly to the gastrostomy tube, in her left gloved hand. In an immediate interview, the nurse acknowledged that she had touched the fall mat on the floor with her gloved hands and then continued with medication administration without changing gloves or performing hand hygiene. In a later interview, the Nursing Home Administrator and the DON confirmed that the nurse should have removed her gloves, cleansed her hands, and applied clean gloves prior to administering the medications through the gastrostomy tube.
Failure to Document Controlled Substance Administration per Professional Standards
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for one resident. Facility policy required that the Controlled Drug Record be signed by the nurse at the time the drug is given, and that administration be documented on the medication administration record (MAR). For a resident with quadriplegia and hypotension who had physician orders for oxycodone as needed for pain, review of records showed discrepancies between the controlled drug record and the MAR. Specifically, oxycodone was documented as being dispensed 17 times, but only 8 administrations were signed off on the MAR. Additionally, some administrations were recorded on the MAR either before or well after the medication was documented as dispensed, and several dispensed doses were not signed off on the MAR at all. Interviews with the DON, Assistant DON, and Nursing Home Administrator confirmed that staff are expected to document on both the controlled drug record and the MAR when administering controlled substances. However, they were unable to provide an explanation for the discrepancies or missing documentation. This failure to accurately document the administration of controlled substances did not comply with facility policy or professional standards of nursing practice.
Incomplete Documentation of Laboratory Results in Resident Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurately documented in accordance with accepted professional standards. Specifically, for a resident with diagnoses including congestive heart failure and hypertension, there was a physician order for laboratory tests including a CBC, BMP, and urinalysis. While the results for the CBC and urinalysis were documented in the clinical record, there was no documentation of the BMP results. Nursing progress notes indicated that the CBC and urinalysis results were received and reviewed, but did not mention the BMP. Interviews with the LPN and physician revealed that the BMP was not viable due to insufficient blood, and the provider was made aware of this at the time. However, there was no documentation in the resident's clinical record that the provider was notified about the non-viable BMP or that a decision was made not to redraw the test. The Nursing Home Administrator confirmed that such conversations should have been documented in the clinical record, but this was not done.
Failure to Perform Required Generator Load Bank Test
Penalty
Summary
The facility failed to maintain its emergency generator system as required by NFPA standards. Specifically, the facility did not perform the mandatory 3-year, 4-hour load bank test on the generator, which is crucial for ensuring the generator's capability to supply emergency power within the required 10 seconds. This deficiency was identified during a document review and interview conducted on January 23, 2025, between 9:15 AM and 10:30 AM. The Director of Maintenance confirmed during an interview that the load bank test had not been performed. This oversight indicates a lapse in the facility's adherence to the maintenance and testing schedule outlined in NFPA 110, which mandates regular inspections and testing to ensure the reliability of emergency power systems. The failure to conduct this test could potentially compromise the facility's ability to provide essential power during emergencies.
Plan Of Correction
1. Facility has contracted with an outside vendor to complete the 4 hour load bank test, to be completed by Compliance date. 2. Maintenance Director or Designee will ensure the generator load bank scheduling will be reviewed yearly for documentation of the 3 year, 4-hour load bank test on the generator was performed as required. 3. Maintenance Director will report findings to the QAPI committee.
Deficiency in Common Wall Door Maintenance
Penalty
Summary
The facility failed to maintain the integrity of common wall doors on the second floor, as observed during a survey on January 23, 2025. Specifically, the common wall door at the bridge to the elevator had gaps greater than 1/8 inch, which exceeds the allowed gap margins. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the door did not meet the required standards. Additionally, another observation on the same day revealed that common wall doors on the second floor by the East Lounge also had gaps greater than 1/8 inch and lacked manual positive latching. These doors were only held closed by a coded magnetic release, which allowed them to open freely when the fire alarm was activated. The Director of Maintenance confirmed these findings, indicating that the doors did not comply with the necessary safety requirements.
Plan Of Correction
1. The distance between the common wall doors by the East lounge have been adjusted and corrected to meet one-eighth-inch requirement. 2. Door was adjusted to ensure manual positive latching. 3. Facility Maintenance Director or his designee will audit random doors for gaps for the next 3 months and then quarterly. 4. Maintenance Director will report findings to the QAPI committee.
Obstructed Exit Access on Second Floor
Penalty
Summary
The facility failed to maintain clear and unobstructed exit access on one of its two floors, as required by NFPA 101 Means of Egress standards. During an observation conducted on January 23, 2025, between 12:15 PM and 12:45 PM, it was noted that the corridor on the second floor was obstructed at several locations. Specifically, between Resident Rooms 201 and 202, a soiled-linen and a trash container were blocking the corridor. Outside Resident Room 202, a clean-linen cart was found obstructing the passageway. Additionally, outside Resident Room 208, a clean-linen, a soiled-linen, and a trash container were also obstructing the corridor. An interview with the Director of Maintenance confirmed these obstructions, indicating a failure to keep the means of egress free from impediments as required by the relevant safety codes.
Plan Of Correction
1. Hallways on 2nd floor have been cleared of identified obstructions. 2. All other floors have been cleared of possible obstructions. 3. Facility Maintenance Director or his designee will perform random audits weekly for the next 3 months and then quarterly. The audits will be conducted not less than monthly, at random times and dates.
Stairtower Door Gap Exceeds Allowable Limit
Penalty
Summary
The facility failed to maintain the stairtower doors within the allowed gap margins on one of two floors. During an observation on January 23, 2025, at 12:10 PM, it was noted that the 2nd floor stairtower door, located by the elevator, had gaps greater than 1/8 inch. This observation was confirmed through an interview with the Director of Maintenance at the same time.
Plan Of Correction
1. The distance between the stair tower doors have been adjusted and corrected to meet one-eighth-inch requirement. 2. Facility Maintenance Director or his designee will audit random doors for gaps for the next 3 months and then quarterly. 3. Maintenance Director will report findings to the QAPI committee.
Failure to Test Emergency Lighting
Penalty
Summary
The facility failed to meet the requirement for emergency lighting as outlined in NFPA 101. Specifically, the facility did not perform functional tests of the battery-powered emergency lighting source located in the Generator Room, which serves the entire component. During a document review conducted on January 23, 2025, it was revealed that there was no documentation verifying that the Generator Room's battery back-up emergency lighting was tested for 90 minutes annually. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged the lack of recorded annual testing.
Plan Of Correction
1. The Generator Room battery back-up emergency lighting was tested 90 minutes to ensure lighting during power outage. 2. Back up lighting unit will be added to the facility Preventative Maintenance log to ensure the working condition and will be audited monthly. 3. Maintenance Director will report findings to the QAPI committee.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the care plans for four residents, leading to deficiencies in their care. Resident 2, who was dependent on a ventilator and had a history of falls, had an outdated care plan that did not reflect the intervention for bilateral fall mats after an unwitnessed fall. The RNAC acknowledged that the physician's order was not updated, which prevented the care plan from being revised accordingly. The DON confirmed that the care plan should have been updated with the fall intervention. Resident 26's care plan was not updated to reflect the discontinuation of Amphetamine-Dextroamphetamine, and the care plan for anti-anxiety medications lacked detailed interventions and monitoring guidelines. The care plan for anti-psychotic medication was also not individualized. The DON and Nursing Home Administrator both recognized that the care plan should have been revised during the care plan meeting. Resident 29's care plan did not initially include the use of bilateral thick fall mats, despite having an order for them and their presence since admission. The care plan was only updated after the surveyor's observation. Resident 37's care plan still included a resolved blister wound, which had not been revised since March 2024. The DON acknowledged that the care plan should have been updated to reflect the resolution of the wound.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R2, R26, R29, R37. 2) The Facility updated R2, R26, R29, R37 care plans to reflect current resident orders and plan of care. 3) All resident care plans were reviewed to ensure that care plans to reflect current resident orders and plan of care. Two: system changes and measures that will be taken: 1) All Licensed and IDC staff will be in-serviced on initiating, updating and resolving care plan items. 2) Care plans will be monitored at Daily Clinical meetings and updated as necessary. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 (5) random residents 3x week for 4 weeks for compliance with careplans, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Document and Administer Care as Ordered
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for three residents. Resident 9, who had a tracheostomy and was dependent on a ventilator, had an order for triple antibiotic ointment to be applied to moisture-associated skin damage at the tracheostomy site every shift. However, there was no clinical documentation of any skin damage or assessments from September 24, 2024, to January 8, 2025. The Director of Nursing (DON) confirmed the absence of documentation and noted that the physician assessed the site on January 8, 2025, finding no skin damage and discontinued the ointment. Resident 14, diagnosed with COPD and hypertension, had multiple treatment orders for pressure areas and wounds on the left buttock and thigh. The treatment administration records (TAR) for October, November, and December 2024 showed several instances where treatments were not documented as completed. The DON believed the treatments were completed but acknowledged the lack of documentation, which should have been recorded on the TAR. Resident 17, with Type 2 Diabetes Mellitus and end-stage renal disease, had orders for blood sugar checks and medication administration. The medication administration records for October, November, and December 2024, and January 2025, revealed multiple instances where blood sugar checks were not documented, and a high blood sugar reading was not followed up with physician notification. Additionally, Midodrine was administered despite a blood pressure reading that should have prompted holding the medication. The DON confirmed these discrepancies and expected staff to document medication administration and follow-up communication with the physician as ordered.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R9, R14, R17. 2) The Facility reviewed R9, and had a new skin assessment completed, site has been healed and treatment d/cd. R14 was assessed and is still receiving treatment to her open areas. R17 chart was reviewed for missing documentation and medication administration. 3) All current residents were reviewed for vital signs, incomplete documentation and correct skin assessments and orders relating to those skin assessments. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accuracy, including vital signs, notifying physician on follow up and on lab values and abnormal lab values, accurate skin assessments and treatment orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on five (5) random residents 3x a week for 4 weeks for compliance with documentation accuracy, including vital signs, notifying physician on follow up and on lab values and abnormal lab values, accurate skin assessments and treatment orders, and careplans, then five (5) random residents 1 x a week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling catheter. The resident, who had diagnoses including obstructive uropathy, congestive heart failure, and muscle weakness, had specific physician orders for catheter care. These orders included documenting foley output every shift, performing catheter care every shift, and changing the foley flush kit every night shift. However, the facility did not consistently document the completion of these orders. From April 2024 through December 2024, there were multiple instances where foley output was not documented, catheter care was not completed, and the foley flush kit was not changed as ordered. As a result of these lapses in care, the resident received antibiotic treatment for urinary tract infections on two occasions, from July 15-22, 2024, and November 3-15, 2024. The Director of Nursing confirmed that the facility's process and physician orders were not followed as expected. This deficiency was identified during a review of the facility's policy, the resident's clinical record, and through staff interviews, highlighting a failure to adhere to the care plan designed to prevent infections related to the indwelling catheter.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R37. 2) The Facility reviewed R37, for missing documentation. 3) All current residents with Catheters were reviewed for incomplete documentation, Foley care, output, and Foley Flush Kit changes. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accuracy, Foley care, documentation of output and Foley Flush Kit changes. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with Foley care, documentation, output and direct observation of residents that have orders for Foley Flush Kits were done, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Discontinue Unnecessary Antibiotic Ointment
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of an antibiotic ointment. The facility's policy requires a thorough evaluation of each resident's drug regimen to promote positive outcomes and minimize risks. However, for one resident with cerebral palsy, chronic respiratory failure, a tracheostomy, and ventilator dependence, there was an ongoing order for triple antibiotic ointment to be applied to the tracheostomy stoma site. This order was in place from September 24, 2024, without any documented clinical assessment or evidence of skin damage that would necessitate its use. The facility's consultant pharmacist reviewed the resident's medication regimen multiple times between October and December 2024 but did not identify the lack of clinical documentation supporting the use of the antibiotic ointment. During an interview, the Director of Nursing confirmed the absence of documentation for skin damage and acknowledged that the ongoing use of the ointment should have been identified and addressed earlier. The resident's physician eventually assessed the tracheostomy site and discontinued the ointment after finding no skin damage.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R9. 2) The Facility reviewed R9, and had a new skin assessment completed, site has been healed and treatment d/cd. 3) All current residents were reviewed for correct skin assessments and orders relating to those skin assessments. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accurate skin assessments and treatment orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. 3) Education will be provided to consultant pharmacist re: reviewing all medications to include ointments and treatment medications and Pharmacy Recommendations will be reviewed to ensure that ointments and treatment medications are reviewed by the Pharmacist. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with treatments for skin assessments then five (5) random residents 1x week for 2 months. 2) The Director of Nursing or her designee will conduct random audits for ointments and treatment medications to compare Physician orders against Pharmacy Reviews and will review 5 random residents pharmacy recommendations monthly for compliance with treatments for skin assessments and pharmacy recommendations, then five (5) random residents for 2 months. Pharmacy recommendations are received monthly. 3) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Manage Psychotropic Medications and Documentation
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The clinical record review revealed that a resident with diagnoses of hypertension and bipolar disorder was prescribed clonazepam and lorazepam, both benzodiazepines, for anxiety and restlessness. These medications were continuously reordered without documented clinical rationale for their duplicative use, despite a pharmacy recommendation to consolidate the medications. The provider disagreed with the recommendation, citing perceived benefits over risks, but no documented review of the risks and benefits was found. Additionally, the facility did not adhere to the prescribed administration schedule for lorazepam. The Controlled Drug Record showed instances where lorazepam was administered less than six hours apart, contrary to the physician's orders. Furthermore, there were discrepancies between the Controlled Drug Record and the electronic Medication Administration Record (MAR), with numerous administrations not recorded in the MAR. The facility also administered lorazepam to the resident during a period when there was no active physician order for the medication. This occurred on multiple occasions, indicating a failure to ensure that medications were only administered with a valid physician order. The Director of Nursing confirmed that it was the facility's expectation for staff to follow prescribed time frames and document all medication administrations accurately.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R26. 2) The Facility reviewed R26, but resident has since discharged and no longer resides at the facility. 3) All current residents were reviewed for duplicate therapy and Physician documentation for Risk/Benefit and orders and signed Physician orders. 4) All current residents were reviewed for Medication Administration and Controlled drug record for correct administration times frames as prescribed and for missing documentation. Two: system changes and measures that will be taken: 1) All Licensed staff and Medical Director and Medical Providers will be in-serviced on documentation Psychotropic drug use, Duplicate Therapy, correct administration times frames as prescribed and for missing documentation. 2) Documentation will be monitored at Daily Clinical meetings for accuracy. 3) Pharmacy Consultant to review for accuracy and discrepancies. 4) Medical Director and his staff will be in-serviced on documentation for Risk/Benefits of use. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with Psychotropic drug use, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Confidentiality Breach of Resident's Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal and medical records, specifically for one resident diagnosed with quadriplegia and tracheostomy status. During an observation, it was noted that a paper containing the resident's first name and clinical assessment findings was taped to the wall outside the resident's room, visible from the hallway. This paper included information pertinent to the resident's treatment, such as suctioning instructions for the tracheostomy, and was dated January 4, 2025. During a staff interview, the Nursing Home Administrator acknowledged that the paper should have been placed on the back of the resident's door to prevent it from being in plain sight from the hallway.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R18. 2) The Facility immediately removed the written paper on January 7, 2025. 3) All resident rooms were inspected for any personal identifying information outside of their rooms. Two: system changes and measures that will be taken: 1) All staff will be educated on the privacy of our residents. 2) Any privacy concerns will be addressed by Nursing Administration. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with privacy outside of their rooms, then five (5) random residents 1x a week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Complete TB Screening for New Employees
Penalty
Summary
The facility failed to adhere to its tuberculosis (TB) infection control plan by not completing the required TB screening for two employees, identified as Employees 3 and 7. According to the facility's policy, new employees must have either two negative tuberculin skin tests (TSTs) administered not more than three weeks apart or a negative TB blood assay test not more than one year old, along with a completed Baseline TB Individual Risk Assessment and Symptoms Questionnaire. However, the personnel file for Employee 3, who was hired on November 6, 2024, did not contain any documentation of a TST or TB blood assay test prior to hire. Similarly, Employee 7, hired on December 17, 2024, had only one TST documented from a previous employer, dated April 3, 2024, which was negative. There was no additional documentation of a second TST or a TB blood assay test prior to their employment at the facility. During an interview, the Nursing Home Administrator confirmed the lack of documentation and stated that both employees had been removed from the floor and sent for a TB blood assay test, pending negative results before returning to work. The administrator acknowledged the expectation that all new hires should be appropriately screened for TB according to the facility's policy.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for Employee 3 and 7. 2) The Facility removed both employees from the schedule until their TB screening was completed and reviewed. 3) All current employees were reviewed for accurate TB screening requirements. Two: system changes and measures that will be taken: 1) HRA, DON, ADON, Department Heads and Infection Preventionist will be in-serviced on Facility TB policy. 2) Infection Preventionist will review all new employees for correct and accurate TB screening before new employees are allowed to start. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits weekly audits of all new hires for 4 weeks and then monthly for 2 months for accuracy. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Countersign Verbal Medication Orders
Penalty
Summary
The facility failed to ensure that verbal orders for medications were countersigned by the prescribing physician within the required 48-hour timeframe, as mandated by state regulations. This deficiency was identified during a review of clinical records, facility policy, and staff interviews. Specifically, the facility's policy titled "Verbal Orders, Physician Orders and Diagnostic/Lab Results," last reviewed in December 2024, did not include language requiring the physician to sign verbal orders. This oversight was evident in the case of one resident, who had verbal orders for lorazepam and clonazepam entered into their clinical record without the necessary counter-signature from the prescribing physician. The resident in question, identified as Resident 26, had a medical history that included hypertension and bipolar disorder. On December 30, 2024, verbal orders were entered for lorazepam and clonazepam, both of which are schedule IV controlled medications. However, these orders lacked the required counter-signature by the prescribing physician. During a staff interview, the Director of Nursing confirmed that it was the facility's expectation for verbal orders to be signed by the physician as required by state regulation, highlighting a lapse in adherence to this policy.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R26. 2) The Facility reviewed R26, but resident has since discharged and no longer resides at the facility. 3) All current residents were reviewed to ensure that all verbal orders are being countersigned by the physician. Two: system changes and measures that will be taken: 1) All Licensed staff and Physician and Medical Providers will be in-serviced on Physician verbal orders and Physician countersigning orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x week for 4 weeks for compliance with verbal orders then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Failure to Notify Resident's Representative of Critical Lab Value
Penalty
Summary
The facility failed to notify the emergency contact person of a critical lab value for a resident, which was a deficiency identified during a review of facility policy, clinical records, and staff interviews. The facility's policy, titled Notification of Change in Status, requires that patients and/or family members be informed of any changes in treatments or status, including non-life-threatening situations such as changes in treatment or medication and test results. However, the review of Resident 1's clinical record revealed that the resident's representative was not notified of a critically low hemoglobin level of 6.0, which was significantly below the reference range of 12.8-16.6. Resident 1 had diagnoses of anemia and atrial fibrillation, conditions that could be significantly impacted by such a low hemoglobin level. Despite the critical nature of this lab result, there was no documentation in the clinical record indicating that the resident's representative was informed. During an interview, the Assistant Director of Nursing acknowledged that the representative should have been notified. A follow-up interview with the Nursing Home Administrator and the ADON did not provide any additional information regarding the notification failure.
Failure to Follow Physician Orders for Blood Thinner Management
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with anemia and atrial fibrillation. The physician had ordered the discontinuation of blood thinners and specific lab tests following an episode of hematuria. However, the clinical record showed that the resident continued to receive Coumadin, a blood thinner, despite the physician's order to discontinue all blood thinners. There was no evidence that the order was clarified with the physician to determine which specific medications should be discontinued, and no order was found to hold aspirin, which was documented as being held. Additionally, the facility did not have the INR lab results from the scheduled blood draw on record, and the physician assistant was unaware of the elevated INR result of 4.2. The facility was unable to provide evidence that the INR result was communicated to them by the lab. This lack of communication and failure to follow physician orders contributed to the deficiency in meeting the resident's care needs.
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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