Gardens At Camp Hill, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Camp Hill, Pennsylvania.
- Location
- 46 Erford Road, Camp Hill, Pennsylvania 17011
- CMS Provider Number
- 395123
- Inspections on file
- 31
- Latest survey
- July 21, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Gardens At Camp Hill, The during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage and kitchen equipment practices, including unlabeled and undated food and beverages, expired items, improper covering of food, and staff personal items stored in the freezer. There were also significant gaps in required temperature log documentation for kitchen equipment, contrary to facility policy and professional standards.
Staff did not respect a resident's right to privacy when two nurse aides entered her room without knocking or requesting permission while she was engaged in a conversation, contrary to facility policy and expectations set by the DON.
A resident's bathroom was found with black substances on the shower and chair, a stained towel, and vents with visible debris, while the second floor dining room had broken blinds, makeshift air conditioner insulation, and unclean windows. The DON confirmed these areas should be clean and maintained daily, but observations showed ongoing deficiencies.
A resident with a history of CHF and hypertension developed a stage III pressure ulcer and experienced significant weight loss, but the facility did not complete a Significant Change MDS assessment within the required timeframe. The DON confirmed that no such assessment was initiated despite these notable changes in the resident's condition.
Two residents' assessments were found to be inaccurately coded, with one resident's MDS failing to reflect actual falls, pressure ulcers, hospice care, and weight changes, and another resident's discharge MDS incorrectly documenting the discharge location. These errors were confirmed through staff interviews and clinical record reviews.
Surveyors observed that the second floor medication storage room was repeatedly left ajar and accessible without a key, allowing staff and others to enter without proper authorization. The room contained medications, needles, syringes, and treatment supplies. The DON confirmed awareness of the faulty door and acknowledged that no work order had been placed to fix the issue.
Several residents reported that their meals were not served at appropriate temperatures, with hot foods often arriving cold. A test tray confirmed that food and milk were not within required temperature ranges, and the kitchen supervisor identified improper steam table setup as a contributing factor.
A staff member failed to follow safe and sanitary practices during medication administration for two residents by not changing gloves or performing hand hygiene between tasks, handling medications with soiled gloves, and picking up a dropped tablet with contaminated gloves before administering it. The DON confirmed these actions were not in line with proper procedures.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, with observations of rusted and corroded fixtures, soiled and tattered linens, missing tiles, peeling paint, and accumulations of dust and debris in resident areas. A resident voiced concerns about cleanliness, and both the DON and Nursing Home Administrator acknowledged these issues during the inspection.
A resident with Cauda Equina Syndrome and a spinal infection was given medications intended for another individual after a nurse, under orientation by an LPN, failed to follow proper identification protocols. The error involved multiple medications, including an anticoagulant, diuretic, anticonvulsant, and supplements, and was attributed to non-adherence to the facility's medication administration policy.
A resident with schizoaffective disorder and traumatic brain injury was involved in an incident with a staff member, Employee 7, who poured water over the resident during an agitated episode. The resident, who prefers bed baths, was not care planned for such an intervention. The Director of Nursing confirmed the action as abuse, as it was not part of the resident's care plan.
A facility failed to ensure staff had the necessary skills to manage a resident with schizoaffective disorder and a history of traumatic brain injury. During an incident, a nurse poured water on the resident to calm them, despite this not being part of the care plan. Interviews confirmed the resident prefers bed baths, and the Director of Nursing acknowledged the inappropriate intervention.
The facility lacked an effective infection prevention program due to the absence of an Infection Preventionist since April 2024, resulting in no infection tracking. Additionally, a staff member was observed handling medications with bare hands during administration for two residents, contrary to infection control practices. The DON confirmed that staff are expected not to touch medications with bare hands.
A resident with anxiety and major depressive disorders requested a room change due to a disruptive roommate. Despite being at the top of the room change list, the resident was not offered a new room between May and July, even as 10 new male residents were admitted. The DON confirmed the resident should have been offered a room change, highlighting a failure to support resident self-determination.
The facility did not address grievances raised by the Resident Council, as evidenced by the lack of recorded concerns in meeting minutes from April to July 2024. Residents reported issues such as cold food, delayed call bell responses, and rude staff, which were not resolved or reviewed by the administration. The DON acknowledged the need for improved documentation of resident concerns.
The facility failed to provide residents with anonymous access to grievance forms, as forms were not readily available and required asking staff, compromising confidentiality. Additionally, a grievance filed on behalf of a resident with cirrhosis and hypertension was not thoroughly investigated or resolved, lacking documentation of steps taken or findings.
The facility failed to update comprehensive care plans for three residents, omitting critical information such as diabetes management, medication use, and the presence of foley catheters. This was confirmed by the DON and other staff members.
The facility failed to conduct and revise care plan meetings for several residents, as required by policy. Residents with various medical conditions, including hypertension, dementia, and COPD, were not invited to participate in care plan meetings following comprehensive assessments. Additionally, care plans lacked necessary updates, such as discharge planning for a resident requesting a transition program. The facility's leadership acknowledged the expectation for care plan meetings to be held after comprehensive assessments.
The facility failed to monitor a resident's pacemaker and ensure an EKG was completed, despite hospital records indicating a pacemaker implant. Additionally, another resident missed a critical oncology appointment due to staff forgetting to schedule transportation, delaying chemotherapy for a brain tumor.
A resident with hypotension, dysphagia, and atrial fibrillation received Midodrine outside prescribed parameters despite a pharmacist's recommendation to adhere to hold parameters. The facility failed to document any response or intervention, leading to repeated medication administration errors.
The facility failed to comply with food safety standards, as observed by undated and improperly stored food items in the kitchen, including personal items in storage areas. Additionally, the facility used incorrect and expired test strips for sanitizing solutions, with no recorded log for sanitizer concentration, indicating non-compliance with professional standards.
The QA Committee at the facility failed to meet attendance requirements, as the NHA and Infection Control Preventionist did not attend meetings in the last quarter of 2023 and the second quarter of 2024. Despite monthly meetings, these key members were absent, violating the quarterly attendance requirement.
The facility failed to maintain an effective antibiotic stewardship program due to the absence of an Infection Preventionist since April 2024. The Director of Nursing was unsure of the last antibiotic tracking, and a review of records showed no tracking for several months, violating the facility's policy and regulations.
The facility did not have an Infection Preventionist (IP) working at least part-time onsite, as required by regulations. The previous IP left in April 2024, and no replacement was designated, which was confirmed by the DON. This non-compliance with the facility's policy and CMS regulations resulted in a deficiency.
The facility failed to provide the required 12 hours of annual in-service training for five nurse aides and did not conduct annual abuse prevention training for one aide. This was confirmed through a review of training records and interviews with the NHA, DON, and Regional Director of Clinical Services, who acknowledged the lack of documentation for the completed training.
The facility failed to involve two residents in the development of their baseline care plans and did not provide them or their representatives with a written summary. Despite facility policies encouraging resident participation, there was no documentation of involvement or receipt of a summary for residents with chronic health conditions. Interviews confirmed the oversight, resulting in a deficiency under relevant state codes.
The facility failed to properly dispose of garbage and maintain sanitary conditions in the garbage storage area. Observations revealed garbage bags on the ground despite an empty dumpster, and the dumpster door was left open. The Dietary Manager indicated the trash was improperly left by housekeeping, and the Nursing Home Administrator expected the area to be clean and the dumpster door closed.
The facility failed to maintain adequate personal grooming for two residents dependent on staff for assistance with ADLs. One resident, with hypertension and COPD, did not receive showers as preferred, while another, with depression and fibromyalgia, was not consistently offered facial hair removal. Both residents' care plans were not followed, impacting their personal hygiene.
A resident with specific dietary needs was not provided beverages in the correct consistency. Despite orders for nectar thick liquids, thin liquids were found at the bedside, and honey thick juice was served during a meal. The DON confirmed these inconsistencies, highlighting a failure to adhere to dietary orders.
A facility failed to provide showering care for a resident with muscle weakness and a malignant neoplasm of the frontal lobe, as documented in their care plan. The resident did not receive any showers over a month-long period, despite being at risk for functional decline in ADLs. The Nursing Home Administrator could not provide documentation of care refusals and speculated that the lack of showers might be related to the resident's pressure injuries and treatments.
A facility failed to serve beverages at palatable temperatures during meal service. A resident reported meals were often cold, and a grievance was filed about delayed and poor-quality food. A test tray showed milk at 55.2 degrees and coffee at 116.2 degrees, both not palatable. The Dietary Manager acknowledged issues with maintaining cold beverage temperatures and planned to use new coffee carafes. The Nursing Home Administrator was informed, but no further information was provided.
Deficient Food Storage and Temperature Log Practices in Kitchen
Penalty
Summary
The facility failed to store food and beverages and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Observations revealed multiple instances of improper food storage, including a container of bran flake cereal past its use-by date, beverage containers and orange juice in the refrigerator that were not labeled or dated, and a pan of chocolate pudding that was not properly covered and appeared dry. Additional issues included containers of brown beverage and milk powder that were not labeled or dated, a bag of frozen green beans that was not dated and appeared freezer burned, and a container of thickener with a scoop stored inside. There were also staff personal items stored in the walk-in freezer, and an open, improperly sealed container of flour. Review of temperature logs for kitchen equipment showed significant gaps in recordkeeping, with missing logs for the dish machine, pot sink, refrigerators, freezer, and stockroom over several months. Specific dates and meal periods were identified where temperatures were not recorded, indicating a lack of consistent monitoring. The facility's policy required proper labeling, dating, and storage of food items, as well as retention of temperature logs for 12 months, but these standards were not met. The Nursing Home Administrator confirmed that the expectation was for food and beverages to be labeled and dated per policy, and for kitchen equipment to be stored, cleaned, and utilized according to professional standards.
Failure to Ensure Resident Privacy and Confidentiality
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Summary
Staff failed to respect a resident's right to privacy and confidentiality as outlined in facility policy. During an interview in her room, a nurse aide entered without knocking or requesting permission and attempted to make the resident's bed, despite the resident being engaged in conversation. Shortly after, another nurse aide entered the room without knocking or asking permission, left an activity calendar on the bedside table, and exited, prompting the resident to comment on the aide's behavior. The Director of Nursing confirmed that staff are expected to treat all residents with respect, dignity, and privacy.
Failure to Maintain Clean and Homelike Environment on Nursing Unit
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Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on one of its nursing units, specifically the second floor. Observations in a resident's bathroom revealed the presence of a black substance at the base of the shower walls and on the shower chair, a towel with a faded light brown stain hanging on the toilet seat, and a wall vent with dried brown and dark grey fuzzy substances. Additionally, the pipes at the ceiling and the ceiling vent contained a dark grey fuzzy substance. The resident reported that the bathroom should be cleaner, and the DON confirmed that these areas should be clean and that towels should be changed daily. The DON also stated that resident bathrooms are expected to be cleaned daily. Further observations in the second floor dining room showed that two of the six window blinds were broken, and the wall unit air conditioner had makeshift materials, such as half of an orange foam pool noodle and crumpled paper, filling gaps around the unit. The window above the air unit contained multiple cobwebs, dried grass, and bug nests. The DON acknowledged that the blinds should be replaced and the window should be cleaned. These findings indicate that the facility did not uphold the required standards for cleanliness and maintenance in resident areas.
Failure to Complete Significant Change MDS Assessment After Resident Health Decline
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who experienced notable changes in health status. The resident, with a history of congestive heart failure and hypertension, was not coded for significant weight loss or a pressure injury on the most recent Quarterly MDS. However, after this assessment, the resident was diagnosed with a stage III pressure ulcer and later identified as having significant weight loss over a 30-day period while still receiving treatment for the pressure ulcer. Despite these significant changes, the facility did not initiate a Significant Change MDS within 14 days as required. This was confirmed by the Director of Nursing during a staff interview.
Inaccurate Resident Assessments Documented in Clinical Records
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Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for two of twenty records reviewed. For one resident with diagnoses including COPD, hyperlipidemia, and dysphagia, the clinical record showed facility-acquired pressure ulcers, two falls (one with injury), and receipt of hospice services. However, the resident's quarterly MDS assessment was inaccurately coded, indicating a significant weight gain (which was not present), no hospice care, no falls since the previous assessment, and community-acquired rather than facility-acquired pressure ulcers. These inaccuracies were confirmed by the MDS Coordinator during an interview. Another resident with multiple diagnoses, including dehiscence of a surgical wound, COPD, diabetes with polyneuropathy, artificial hip joint, history of falling, chronic kidney disease, and muscle weakness, was documented in the clinical record as having been discharged home to the community. However, the discharge MDS incorrectly coded the discharge as a planned discharge to a short-term general hospital. The DON confirmed during an interview that the discharge MDS was coded incorrectly and should have reflected a discharge to the community.
Medication Storage Room Not Secure Due to Faulty Door
Penalty
Summary
The facility failed to ensure that the second floor medication storage room was secure and that access was limited to authorized personnel via a key. Multiple observations revealed that the door to the medication room was ajar and did not fully close due to catching on the door frame. Staff were seen entering the medication room without the use of a key, and at one point, the surveyor was able to access the room without a key while no staff were present within line of sight. The medication room contained multiple-dose containers of medications, injection supplies such as needles and syringes, and treatment supplies including bandages and scissors. The Director of Nursing (DON) confirmed during observation that the facility was aware of the issue with the door not closing and locking as intended. Additionally, the DON stated in an interview that there was no outstanding work order to address the malfunctioning door. These actions and inactions resulted in the medication storage area not being properly secured as required by regulation.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
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Summary
The facility failed to provide food and beverages at palatable and appealing temperatures during a meal service, as evidenced by both resident interviews and direct observation. Multiple residents reported dissatisfaction with the temperature of their meals, stating that hot food was not served hot and that food was sometimes served cold. One resident also mentioned that the steam table was not always functional, which may have contributed to the issue. A test tray evaluation conducted immediately after meal service revealed that the temperatures of the hot food items (ham, green beans, and mashed sweet potatoes) were below the facility's required standard of 135 degrees Fahrenheit, with recorded temperatures of 107, 109, and 130 degrees Fahrenheit, respectively. Additionally, the milk was served at 50 degrees Fahrenheit, exceeding the maximum allowable temperature of 40 degrees Fahrenheit for cold beverages. The kitchen supervisor attributed the inadequate temperatures to improper arrangement of pans on the steam table, which allowed heat to escape.
Failure to Follow Safe and Sanitary Medication Administration Practices
Penalty
Summary
During medication administration observations, Employee 5 was seen donning gloves and then touching multiple surfaces of the medication cart with gloved hands. Employee 5 retrieved a blood pressure cuff from the cart, entered a resident's room, and performed a blood pressure check, making contact with the resident's skin. Without removing the soiled gloves, Employee 5 proceeded to prepare medications for the same resident, dispensing Vitamin D3 tablets from a multi-dose container and using a gloved finger to prevent a tablet from falling out while pouring it into a medication cup. The medications were then administered to the resident. Following this, Employee 5 used the same gloves to perform a blood pressure check on a second resident and then prepared and crushed medications for that resident. During this process, a tablet fell onto the medication cart, and Employee 5 picked it up with the soiled gloved hand and placed it in the crushing packet before administering the medications. Hand hygiene and glove removal were only performed after these tasks were completed. The Director of Nursing confirmed that Employee 5 should not have handled medications with gloves that had contacted unclean surfaces.
Failure to Maintain Safe, Clean, and Homelike Environment and Linens
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment on both nursing units. Specific findings included rusted and corroded metal fixtures such as towel and safety bars, heater units, and call bell plates in multiple resident bathrooms. There were also instances of soiled, stained, and tattered bath linens in the linen closets, as well as missing tiles, peeling paint, and accumulations of dust and debris in resident bathrooms and common areas. Dried liquid stains and brown spots were noted on walls and floors, and a clear plastic bucket with a dried brown substance was found on a bathroom windowsill. During interviews, a resident expressed concern about the cleanliness of her room and bathroom. The DON and Nursing Home Administrator acknowledged the observed concerns during the facility tour. These findings demonstrate that the facility did not ensure the environment and linens were maintained in a manner that supports resident safety, cleanliness, and comfort, as required by state regulations.
Medication Administration Error Due to Failure in Resident Identification
Penalty
Summary
A deficiency occurred when a registered nurse, who was being oriented by an LPN, prepared and administered medications intended for another resident to a resident diagnosed with Cauda Equina Syndrome and an intervertebral disc infection. The facility's policy required verification of the resident's identity using methods such as checking identification bands, photographs, or confirming with other personnel before administering medications. However, this protocol was not followed, resulting in the resident receiving multiple medications in error, including an anticoagulant, diuretic, anticonvulsant, and several supplements. The incident was documented in the resident's clinical record and confirmed through staff interviews and facility records. The error was identified and reported, and the resident's vital signs and potential side effects were monitored following the event. The report specifically notes that the medication administration error was due to a failure to adhere to established medication administration procedures, as outlined in the facility's policy.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by a staff member, specifically Employee 7, who was involved in an incident with Resident 4. Resident 4, who has a history of schizoaffective disorder and traumatic brain injury, approached the nursing station in an agitated state, demanding to see a doctor. A verbal exchange ensued between Resident 4 and Employee 7, escalating the situation. Resident 4 attempted to push a computer monitor off the nursing station, which Employee 7 prevented from falling. In response, Employee 7 took a water pitcher and poured water over Resident 4, an action witnessed by Employee 4, who intervened and assisted in returning Resident 4 to her room. Interviews with staff, including Employee 4 and Employee 5, confirmed that Resident 4 does not typically take showers and prefers bed baths, contradicting Employee 7's claim that water was used to calm the resident. The facility's policy on preventing resident abuse defines abuse as actions causing physical harm or mental anguish, and the care plan for Resident 4 did not include pouring water as an intervention. The Director of Nursing acknowledged that Resident 4 was not care planned for such an intervention and confirmed that Employee 7 was responsible for the abuse.
Inadequate Staff Competency in Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff members possessed the necessary competencies and skills to meet the behavioral health needs of residents, specifically for Resident 4, who has a diagnosis of schizoaffective disorder and a history of traumatic brain injury. The incident involved a Registered Nurse, Employee 7, who engaged in a verbal exchange with Resident 4, leading to the resident becoming more agitated. During the incident, Resident 4 attempted to push a computer monitor off the nursing station, and in response, Employee 7 poured water over the resident in an attempt to calm them down, despite the resident's care plan not including such an intervention. Interviews with staff members, including Employee 4 and Employee 5, confirmed that Resident 4 does not typically take showers and prefers bed baths, contradicting Employee 7's claim that a shower helps calm the resident. The Director of Nursing confirmed that pouring or throwing water on Resident 4 was not part of the care plan for de-escalation. The facility's failure to provide staff with the appropriate competencies and skills to handle residents with mental and psychosocial disorders resulted in an inappropriate response to Resident 4's behavior, compromising the resident's safety and well-being.
Inadequate Infection Control and Medication Handling Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the absence of an Infection Preventionist (IP) since April 2024, which led to a lack of infection tracking and surveillance. The Director of Nursing (DON) confirmed that no infection control surveillance and data analysis had been conducted from April to July 2024. This deficiency was identified through a review of the facility's policy and interviews with staff, revealing a significant gap in the facility's ability to detect, report, and control infections and communicable diseases. Additionally, during medication administration observations, a staff member, identified as Employee 1, was seen handling medications with bare hands, which is against the facility's infection control practices. Specifically, Employee 1 was observed using an ungloved finger to manage excess tablets during medication preparation for two residents, one with end-stage renal disease and dementia, and another with epilepsy and congestive heart failure. The DON acknowledged that the facility's expectation was for staff not to touch medications with their bare hands, indicating a failure to adhere to professional standards of infection control practices.
Failure to Honor Resident's Room Change Request
Penalty
Summary
The facility failed to honor a resident's right to self-determination regarding a room change request. Resident 10, who has diagnoses of anxiety disorder and major depressive disorder, requested a room change due to disturbances caused by their current roommate. The request was initially documented on April 5, 2024, with the resident agreeing to be placed on a waiting list for a male bed. Despite being at the top of this list, the resident was not offered a room change between May 30, 2024, and July 31, 2024, even though the facility admitted 10 new male residents during this period. Interviews with the Nursing Home Administrator and the DON confirmed that Resident 10 remained at the top of the room change list and should have been offered a room change during the specified timeframe. The facility's failure to accommodate the resident's request for a room change, despite the availability of new male admissions, constitutes a deficiency in promoting and facilitating resident self-determination.
Failure to Address Resident Council Grievances
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Summary
The facility failed to provide evidence that grievances raised by the Resident Council were addressed. Despite the facility's policy requiring the Activities/Recreation department to maintain monthly Resident Council minutes and communicate relevant information to staff, the minutes from April to July 2024 showed no concerns were recorded. However, during an interview with a group of five residents, it was revealed that multiple concerns, including cold food, long waits for call bells, and rude staff, were repeatedly brought up in meetings without resolution. The residents expressed frustration that their complaints were not reviewed or addressed by the facility's administration. The Director of Nursing acknowledged that the Activities Director is responsible for documenting these meetings and indicated a need for a better system to document resident concerns.
Failure to Provide Anonymous Grievance Access and Prompt Resolution
Penalty
Summary
The facility failed to provide residents with access to grievance forms in a manner that respects their right to file grievances anonymously. Observations revealed that grievance forms were not readily available to residents or their representatives on the first floor. During a Resident Council group interview, residents reported that grievance forms were located behind the nurses' station, requiring them to ask staff for access, which compromised confidentiality. Additionally, a locked grievance box intended for anonymous submissions was found to be empty of forms. The facility also failed to promptly resolve a grievance filed on behalf of a resident with cirrhosis of the liver and hypertension. The grievance, which included concerns about the resident's care, such as being left unattended and not receiving showers, was not thoroughly investigated. The grievance form lacked documentation of steps taken to address the issues or a summary of findings, and it did not address all the concerns raised. The Nursing Home Administrator acknowledged the expectation for grievances to be available for anonymous filing and for appropriate resolution.
Deficiency in Comprehensive Care Plan Updates
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Summary
The facility failed to ensure that the comprehensive care plans for three residents accurately reflected their needs. Resident 20, who had diagnoses including type two diabetes mellitus, generalized anxiety disorder, and paroxysmal atrial fibrillation, did not have focus areas or interventions in their care plan addressing diabetes management, insulin use, anticoagulant medication, and psychotropic medication. This omission was confirmed during an interview with the Nursing Home Administrator, Director of Nursing, and other staff members. Similarly, Resident 60, diagnosed with stage three chronic kidney disease and type two diabetes mellitus, had a foley catheter placed, but this was not updated in their care plan. Resident 72, with hypertension and stage three chronic kidney disease, also had a foley catheter placed, yet their care plan did not reflect this change. The Director of Nursing confirmed that it was the facility's expectation for care plans to be updated to include such significant changes in the residents' conditions.
Failure to Conduct and Revise Care Plan Meetings
Penalty
Summary
The facility failed to review and revise the care plans of seven residents, as required by their policy and regulatory standards. The policy mandates that residents, their families, or legal representatives be encouraged to participate in care plan development and revisions. However, interviews with several residents revealed that they were not invited to participate in their care plan meetings. For instance, Resident 3, who has hypertension and dementia, was not invited to a care plan meeting following their comprehensive assessment in May 2024. Similarly, Resident 56, with hyperlipidemia, diabetes, and major depressive disorder, reported not being invited to quarterly care plan meetings, and there was no evidence of such meetings being held. The facility's records showed a lack of evidence that care plan meetings were conducted in response to comprehensive assessments for several residents. Resident 34, with end-stage renal disease and dementia, had no care plan meeting after a significant change MDS assessment in November 2023. Resident 58, diagnosed with epilepsy and hypertension, also lacked evidence of a care plan meeting following an annual MDS assessment in September 2024. Additionally, Resident 71, with COPD and chronic respiratory failure, was not invited to a care plan meeting after a quarterly MDS assessment in May 2024. Furthermore, Resident 73, who has congestive heart failure and hypertension, had a care plan that did not include discharge planning, despite requesting a Nursing Home Transition Program. The Director of Nursing confirmed that the facility expected care plans to include discharge plans. Resident 81, with major depressive disorder and hyperlipidemia, had never had a care plan meeting since admission in January 2024. The Nursing Home Administrator and Director of Nursing both acknowledged the expectation for care plan meetings to be held at least after comprehensive assessments.
Failure to Monitor Pacemaker and Schedule Critical Appointment
Penalty
Summary
The facility failed to ensure that two residents received treatment in accordance with professional standards of practice. For Resident 25, who has a history of schizophrenia and a right bundle branch block, the facility did not have orders for monitoring the resident's pacemaker, despite hospital records indicating a leadless pacemaker implant in March 2024. The clinical record also lacked evidence of an EKG being completed, which was part of the care plan for monitoring potential complications related to the pacemaker. Interviews with staff revealed confusion about whether Resident 25 had a pacemaker, and the Director of Nursing (DON) confirmed that no EKG had been done, expecting the hospital to provide pacemaker care orders upon discharge. For Resident 85, who has cirrhosis of the liver and hypertension, the facility failed to schedule transportation for an oncology appointment, resulting in a missed chemotherapy session for a brain tumor. The appointment was documented in the Medication Administration Record (MAR) but was marked with a code indicating a hold. A nursing progress note confirmed the appointment was rescheduled, and the DON acknowledged the oversight in scheduling transportation. This delay in treatment was due to staff forgetting to arrange the necessary transportation.
Failure to Act on Pharmacist's Medication Irregularity Report
Penalty
Summary
The facility failed to act upon a licensed pharmacist's report of a medication irregularity for a resident reviewed for unnecessary medications. The facility's policy requires that recommendations from the consultant pharmacist's monthly medication regimen review (MRR) be acted upon and documented by facility staff or the prescriber. However, for a resident with diagnoses including hypotension, dysphagia, and atrial fibrillation, the pharmacist's recommendation to adhere to hold parameters for Midodrine administration was not followed. The medication was administered outside the specified parameters on multiple occasions in December 2023, January 2024, and February 2024. The Director of Nursing was unable to provide documentation indicating that the facility responded to the pharmacist's recommendation or that any interventions or staff education were implemented. This lack of action and documentation led to the continued administration of Midodrine outside the prescribed parameters, violating the facility's policy and state regulations regarding pharmacy and nursing services.
Non-compliance with Food Safety Standards in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen, as evidenced by multiple observations of improperly stored and labeled food items. During a review of the facility's policy, it was noted that packaged food should be labeled according to law and protected from contamination. However, observations revealed several instances of non-compliance, including undated bags of vegetables, cakes, and beverages in the walk-in freezer, as well as undated and improperly stored items in various refrigerators. Additionally, personal items belonging to staff were found in facility food storage areas, which is against the facility's policy. Further deficiencies were noted in the handling and testing of sanitizing solutions. The surveyor observed that the test strips used to measure the concentration of sanitizing solutions were not stored in their original container, making it impossible to verify their expiration date. Moreover, the test strips were incorrect for the sanitizer being used and had expired. Employee 5, the Dietary Manager, admitted to not having a recorded log for the sanitizer concentration at the three-compartment sink, which is used for both food preparation and sanitizing kitchen equipment. These findings indicate a lack of adherence to professional standards and facility policies regarding food safety and sanitation.
QA Committee Attendance Deficiency
Penalty
Summary
The facility's Quality Assurance (QA) Committee failed to meet the required attendance standards for its members, specifically the Nursing Home Administrator (NHA) and the Infection Control Preventionist. Documentation review revealed that these members did not attend any QA meetings during the last quarter of 2023 and the second quarter of 2024. Despite the NHA's assertion that the QA committee meets monthly, he confirmed the absence of these key members during the specified periods. This lack of attendance was identified through the review of sign-in sheets and staff interviews, indicating a failure to comply with the requirement for all necessary members to attend at least one meeting quarterly.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program as required by their infection prevention and control policy. The policy, last reviewed in July 2024, outlines the need for a comprehensive process to monitor antibiotic use, including a formal review procedure for the appropriateness of antibiotics prescribed and regular tracking of antibiotic prescribing and resistance patterns. However, during an interview with the Director of Nursing (DON), it was revealed that the facility has been without an Infection Preventionist since April 2024, and the DON was unsure when antibiotic tracking was last completed. A review of the facility's Infection Prevention binder showed no antibiotic tracking had been conducted for the months of April, May, June, and July 2024, indicating a lapse in compliance with the facility's policy and state and federal regulations.
Failure to Designate Onsite Infection Preventionist
Penalty
Summary
The facility failed to comply with the Centers for Medicare and Medicaid Services regulation S483.80(b)(3), which mandates that a nursing home must designate one or more individuals as Infection Preventionists (IPs) responsible for the facility's Infection Prevention and Control Program (IPCP). The regulation requires that the IP must work at least part-time and be physically present onsite at the facility. However, the facility did not have an IP working at least part-time, as the previous IP left the role in April 2024, and no replacement had been designated. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of an IP. The facility's policy, last reviewed in July 2024, also stipulates the requirement for an IP to work at least part-time, yet this was not adhered to, leading to the deficiency.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that nurse aides received the required in-service training of no less than 12 hours per year, as evidenced by the review of personnel training records and staff interviews. This deficiency was identified for five nurse aide employees, specifically Employees 6, 7, 8, 9, and 10, whose records did not show completion of the mandatory annual training hours within the past 12 months. Additionally, the facility did not provide annual training on resident abuse prevention for Employee 6, further highlighting a lapse in compliance with training requirements. During interviews with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Director of Clinical Services (Employee 4), it was confirmed that there was no documentation available to verify that the required training had been completed by the nurse aides. The NHA and DON acknowledged the expectation for nurse aides to receive the necessary 12 hours of education annually, and the DON confirmed the absence of documentation for abuse prevention training for Employee 6. This lack of compliance with training requirements is a violation of the specified Pennsylvania Code regulations regarding staff development and personnel policies.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to include two residents in the development of their baseline care plans and did not provide them or their representatives with a written summary of these plans. This deficiency was identified through a review of facility policies, clinical records, and staff interviews. The facility's policy on baseline care plans, last revised in December 2016, mandates that residents and their representatives receive a written summary of the baseline care plan by the completion of the comprehensive care plan. Additionally, the policy on interdisciplinary care planning encourages the participation of residents and their families in care plan development. However, for both residents reviewed, there was no documentation indicating their involvement or receipt of a written summary. Resident 6, admitted with chronic diastolic congestive heart failure and hypertension, had a baseline care plan completed and signed by six facility staff members, but lacked signatures from the resident or family. Similarly, Resident 30, admitted with COPD and PTSD, also had a baseline care plan completed without resident or family signatures. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that both residents should have been involved in the care plan development and provided with a summary. The facility's failure to adhere to its policies resulted in a deficiency under 28 Pa. Code 201.29(a) and 28 Pa. Code 211.12(d)(2).
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to ensure proper disposal of garbage and maintain sanitary conditions in the garbage storage area. During an observation of the receiving area dumpster, it was noted that there were two bags of garbage on the ground in front of the dumpster, with one bag open and garbage spilled onto the ground. Additionally, five bags of garbage were piled up on the ground to the left of the dumpster, despite the dumpster itself being empty. An interview with the Dietary Manager revealed that the trash was left by housekeeping staff and should not have been on the ground. Further observations revealed that the sliding door to the dumpster was left open while not in use. The Nursing Home Administrator stated that it is expected that the dumpster sliding door should be kept closed and the area around the dumpster should be clean and free of waste. This deficiency was cited under 28 Pa. Code: 201.18 (b)(3) Management.
Failure to Maintain Personal Grooming for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain adequate personal grooming for residents dependent on staff for assistance with activities of daily living. Resident 36, diagnosed with hypertension and chronic obstructive pulmonary disease, expressed that she had not received a shower in a long time and preferred showers over bed baths. Despite her care plan indicating a preference for showers, her clinical record showed she only received bed baths on specific dates and no showers in the past 30 days. The Director of Nursing acknowledged that Resident 36 should not be receiving bed baths regularly. Resident 53, diagnosed with major depressive disorder and fibromyalgia, was observed with facial hair on her chin and upper lip. She expressed a preference for having her facial hair shaved, but staff did not offer this service consistently. Her care plan included ensuring she was well-groomed and required staff assistance with personal hygiene. Despite this, observations on multiple days showed she remained with facial hair, and the Director of Nursing stated that she had been offered facial hair removal. These findings indicate a failure to adhere to the residents' care plans and preferences, impacting their personal grooming and hygiene.
Failure to Provide Beverages in Correct Consistency
Penalty
Summary
The facility failed to provide beverages in the appropriate consistency for a resident with specific dietary needs. The resident, who has diagnoses including hypertension and chronic obstructive pulmonary disease (COPD), had a physician's order for a regular diet with mechanical soft texture and nectar consistency liquids. Despite this, a grievance was filed when thin liquids were found at the resident's bedside, contrary to the nectar thick requirement. An observation confirmed the presence of thin cranberry juice in the resident's room, which was acknowledged by the Director of Nursing (DON) as inappropriate. Further observation in the dining room revealed that the resident was given honey thick apple juice instead of the prescribed nectar thick consistency. The DON was informed of this discrepancy and reiterated the expectation that the resident's ordered diet and liquid consistency should be adhered to. These findings indicate a failure to consistently provide beverages in the form required to meet the resident's individual dietary needs.
Failure to Provide Showering Care for a Resident
Penalty
Summary
The facility failed to provide adequate care and services regarding showering for a resident who was unable to perform activities of daily living independently. The facility's policy on supporting activities of daily living states that appropriate care and services should be provided for residents who cannot carry out these activities independently. However, a review of the clinical record for a resident with diagnoses of muscle weakness and a malignant neoplasm of the frontal lobe revealed no documentation of showers from April 13, 2024, to May 12, 2024. The resident's care plan, which identified a risk for functional decline in activities of daily living, was initiated on March 13, 2024. During an interview, the Nursing Home Administrator could not provide further documentation of any refusals of care and speculated that the lack of showers might be related to the resident's pressure injuries and the treatments applied.
Failure to Provide Palatable Beverage Temperatures
Penalty
Summary
The facility failed to provide beverages at palatable temperatures during meal service, as evidenced by a test tray conducted on April 1, 2024. A resident reported dissatisfaction with meals, noting they were often served cold. A grievance was filed on March 26, 2024, regarding delayed meal service and poor food quality. During an observation of the second-floor meal service, it was noted that all residents had been served, and a test tray revealed that the milk was at 55.2 degrees and the coffee at 116.2 degrees, both of which were not palatable. The Dietary Manager admitted that cold beverages were not kept submerged in ice, leading to temperature increases, and mentioned plans to use new coffee carafes to maintain hot beverage temperatures. The Nursing Home Administrator was informed of these concerns, but no further information was provided.
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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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