Gardens At Millville, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Millville, Pennsylvania.
- Location
- 48 Haven Lane, Millville, Pennsylvania 17846
- CMS Provider Number
- 395872
- Inspections on file
- 30
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Gardens At Millville, The during CMS and state inspections, most recent first.
A resident with dementia, muscle weakness, and a history of falls required staff assistance and a roller walker for ambulation. The resident was found on the floor after attempting to walk without the walker, and later suffered a major head injury when a nurse aide assisted her without the required device or adequate help. The resident sustained a subdural hematoma and other injuries, leading to hospitalization and eventual death. The facility failed to provide necessary assistance and supervision to prevent these accidents.
The facility did not ensure that controlled drug administration was properly documented for two residents with severe cognitive impairment and anxiety. Doses of Ativan were signed out on controlled substance records as removed for administration, but these doses were not recorded on the MAR as administered, resulting in inconsistencies confirmed by the DON.
The facility was cited for multiple food safety and sanitation deficiencies, including improper waste management, inadequate cleaning, and improper food storage. Observations revealed overfilled garbage cans, dirt and debris accumulation, and improper labeling of thawed nutritional items. Staff were also noted handling food without proper beard covers, and clean mugs were found with coffee stains, indicating poor sanitation practices.
A resident with severe cognitive impairment experienced multiple choking incidents due to the facility's failure to provide necessary meal tray setup assistance. Despite requiring supervision and assistance with feeding, the resident's food was not cut into bite-sized pieces, leading to the use of a LifeVac device to dislodge large pieces of food. Interviews confirmed the lack of adherence to meal assistance protocols.
The facility failed to provide individualized activities for residents with dementia and sensory deficits. Observations showed residents unengaged in a day room, despite scheduled activities. Clinical records indicated specific preferences, but activity logs revealed minimal engagement. The Activities Director cited staffing shortages as a barrier to providing personalized activities.
The facility failed to serve meals at safe and appetizing temperatures, affecting seven residents. Residents reported that hot food was often cold, and a test tray evaluation confirmed that meals were served below the required temperature. The foodservice director acknowledged the deficiency.
The facility failed to conduct a comprehensive assessment to identify resources necessary for resident care, particularly for those with Alzheimer's, dementia, and behavioral health needs. The assessment did not reflect the current population's needs, including staff competencies and equipment requirements. The Nursing Home Administrator acknowledged the assessment's deficiencies.
A facility failed to maintain a comprehensive infection prevention and control program. An RN was observed administering medications to three residents without proper hand hygiene or glove use. Additionally, infection control logs for two months were incomplete due to a gap in staffing for the Infection Preventionist role.
A resident with severe cognitive impairment and a history of aggressive behavior physically abused another resident. The facility's care plan failed to identify specific behaviors or implement person-centered interventions, leading to an incident where the aggressive resident struck another resident in the chest.
A facility failed to follow a physician-ordered 1000 ml fluid restriction for a resident with end-stage kidney disease on dialysis. The electronic system was incorrectly set to a 1500 ml restriction, leading to multiple instances of excessive fluid intake. The Director of Nursing confirmed the oversight, which was inconsistent with the facility's policy on fluid management.
A resident with Alzheimer's and dysphagia was not provided with the prescribed maroon pediatric spoon for safe swallowing, as observed during meal times. Staff used a white plastic spoon instead, and interviews confirmed the absence of the correct utensil. The Director of Rehab acknowledged the facility's failure to provide the necessary adaptive equipment, increasing the risk of choking.
The facility did not meet the required nurse aide to resident ratios on 35 out of 63 shifts, as per Pennsylvania regulations effective July 2024. Staffing records showed discrepancies in the number of nurse aides across various shifts, with no additional higher-level staff to compensate. The Nursing Home Administrator confirmed the shortfall during an interview.
The facility did not consistently provide the required 3.2 hours of direct resident care per resident in a 24-hour period, as mandated by regulations. This deficiency was confirmed through a review of staffing levels and an interview with the Nursing Home Administrator, with several instances of non-compliance noted.
The facility failed to maintain a clean and safe environment in two units, A and C, as observed on a survey. In the A unit, rooms had issues such as dried brown spots on bins, soiled urinals, and foley catheter bags tied to grab bars, and a strong urine smell. In the C unit, a room had feces-like substances on the toilet and a soiled bedpan tied to the grab bar. The Nursing Home Administrator confirmed these deficiencies, violating residents' rights to a safe and clean environment.
The facility failed to maintain a clean environment and comfortable water temperatures for residents. Observations revealed dirt, debris, and a sticky substance in resident rooms, and inadequate hot water temperatures in shower rooms. The Administrator confirmed the need for cleanliness and comfortable water temperatures.
A resident with a history of inappropriate sexual behavior was not effectively monitored, leading to incidents of sexual verbal abuse towards another resident. Despite known aggressive behaviors, interventions like 1:1 supervision and motion sensors were ineffective, resulting in repeated incidents of exposure and inappropriate contact.
The facility failed to maintain a safe environment by allowing obstructions in a resident hallway, including wheelchairs, carts, and a trash bin, which blocked access to handrails. Residents were observed navigating the area with wheelchairs and walkers, and the Nursing Home Administrator acknowledged that handrails should remain unobstructed.
A resident with COPD and pulmonary hypertension was found with a Combivent Respimat inhaler without a current physician order or assessment for self-administration. The resident, assessed as cognitively intact, stated that nursing had given him the inhaler, but the facility's records lacked necessary documentation and care planning for self-administration, violating facility policies and state regulations.
The facility failed to maintain infection control practices, as observed with a resident's urinary Foley catheter collection bag placed on the floor without a privacy bag. Uncovered and open medical supplies were found on the resident's bedside table, and a wash basin contained used hand towels and other items. An uncapped container of distilled water was also found in another resident's room. The DON confirmed these items should be kept sanitary.
A facility failed to maintain safe hot water temperatures, placing 27 out of 97 residents at risk of serious burns. Observations showed hot water temperatures exceeding safe levels in resident rooms and common bathing areas. Staff interviews revealed inadequate training on checking and recording water temperatures, with some employees inaccurately documenting or reporting false readings. Residents reported discomfort and temperature fluctuations during showers. The Nursing Home Administrator confirmed the unsafe conditions, including the lack of running cold water in one resident's room. The deficiency was attributed to inadequate monitoring and documentation practices by staff.
The facility failed to maintain acceptable practices for food storage and service, leading to potential contamination and microbial growth. Issues included undated thawed shakes, food stored directly on the floor, uncovered utensils, and unsanitary conditions in the dementia care unit's kitchenette and medication rooms. The CDM and NHA confirmed these deficiencies.
The facility failed to maintain a comprehensive infection prevention and control program. Multiple resident infections were identified monthly from August 2023 through March 2024, but there was no documented evidence of evaluation, tracking, or interventions. The infection tracking logs lacked essential information, and the limited data was not evaluated for preventive measures. An interview with the Infection Control Nurse confirmed the program did not meet regulatory requirements.
The facility failed to maintain a clean and orderly environment across all four nursing units. Observations revealed broken or missing window blinds, dust and debris accumulation, dirty and sticky floors, and unclean bathroom fixtures. The Nursing Home Administrator confirmed the expectation for cleanliness, but the facility did not meet these standards.
A facility failed to provide a planned restorative nursing program for a resident with end-stage renal disease, despite recommendations and the resident's willingness to participate. The resident reported not being offered the program consistently, and the Nursing Home Administrator confirmed the failure to provide and document the services accurately.
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and records for a resident. The administration of Oxycodone 10 mg was not recorded on the MAR on multiple occasions, and narcotic sign-out records were missing for several months. The DON confirmed the inconsistencies and the absence of records to verify administration.
The facility failed to serve menus that accommodated resident food preferences, leading to dissatisfaction with meals. Residents reported repetitive menu options and meals that did not align with their preferences or the available kitchen equipment. The CDM confirmed budget constraints and lack of involvement in menu development, resulting in substitutions and repetitive meals. The NHA acknowledged the deficiency in dietary services and resident rights.
The facility failed to maintain safe hot water temperatures, placing residents at risk for serious burns. Observations revealed temperatures as high as 134.6 degrees Fahrenheit. Staff interviews indicated a lack of proper training and inconsistent methods for checking and recording water temperatures. Immediate Jeopardy was called due to the facility's failure to maintain a safe environment.
The facility failed to conduct a comprehensive facility-wide assessment that accurately reflected the personnel and specific resources available and necessary to care for its current resident population, particularly those in the Dementia/Memory care unit. The assessment lacked updated data and did not address the needs of residents with Dementia/Alzheimer's disease.
The facility failed to investigate injuries of unknown origin for a resident with multiple bruises, despite policies requiring timely and thorough investigations. The DON was unaware of the injuries, and no follow-up investigation was documented.
The facility failed to include minimum standards of care in the baseline plan for a resident with significant cardiac conditions, including an AICD. The facility did not timely identify and address the resident's care needs, provide AICD checks, or monitor for complications. Emergency care procedures for the AICD were also not addressed.
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the resident's safety and well-being. Despite ongoing aggressive behaviors, the resident's care plan had not been revised, and interventions were often ineffective.
A resident with dementia and chronic kidney disease was prescribed Augmentin for a suspected UTI without clinical signs of infection and before receiving urinalysis and culture results. The antibiotic was later switched to Ceftin based on a follow-up assessment and the resident's mother's suspicion of a UTI. The Director of Nursing confirmed that the administration of Augmentin was not clinically justified.
The facility failed to ensure proper storage and use by dates for multi-dose medications in Med Room West. An inspection revealed a multi-dose bottle of Aplisol and a vial of Spikevax (COVID-19 vaccine) that were beyond their discard dates. The RN Supervisor confirmed the findings, and the Nursing Home Administrator and DON acknowledged that medication expiration dates should be checked and expired medications removed.
The facility failed to maintain a safe, clean, comfortable, and homelike environment across four nursing units. Despite a corrective plan, a revisit survey revealed ongoing deficiencies in housekeeping and maintenance.
A resident with dementia and chronic kidney disease was prescribed antibiotics without proper documentation or rationale, leading to unnecessary doses. The facility lacked a functioning antibiotic stewardship program to monitor and prevent unnecessary antibiotic use, as confirmed by the Director of Nursing.
Failure to Provide Adequate Supervision and Assistance Resulting in Major Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary assistance with activities of daily living and adequate supervision to prevent an accident for a resident with dementia, muscle weakness, hypertension, and a history of falls. The resident was assessed as moderately cognitively intact and required staff assistance for ADLs, including ambulation with a roller walker. Despite this, the resident was found on the floor of a locked dementia dining/activity room without her roller walker present, having attempted to ambulate by pushing a wheelchair while wearing slipper socks. Staff did not witness the fall, and the resident reported her legs became tangled as she tried to walk without the proper assistive device. Following this incident, the resident's care plan and physician orders were updated to require assistance of two staff with a roller walker for all transfers and ambulation. However, a subsequent event occurred when a nurse aide assisted the resident from bed to a standing position without the roller walker present. The aide stood the resident up alone, and the resident leaned forward, fell into the wall, and sustained a major head injury. The aide admitted she was aware the resident used a roller walker for transfers and ambulation but did not have the device in the room at the time and could not recall if she had reviewed the electronic Kardex for current care needs prior to providing care. As a result of the fall, the resident suffered a 7 cm scalp laceration, an acute right-sided subdural hematoma with mass effect and midline shift, and additional injuries, requiring hospitalization and intensive care. The resident's condition continued to decline, leading to hospice care and eventual death. The deficiency was identified through review of clinical records, facility policy, investigative documentation, and staff and resident interviews, confirming that the facility did not ensure necessary assistance and supervision to prevent accidents as required.
Failure to Reconcile Controlled Drug Administration Records
Penalty
Summary
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and maintaining accurate records of their administration for two residents. According to the facility's Medication Administration policy, medications are to be prepared and administered only by authorized personnel, with each administration documented immediately on the medication administration record (MAR). However, a review of controlled substance records and MARs for two residents revealed discrepancies: doses of Ativan, a controlled antianxiety medication, were signed out on the controlled substance records as removed for administration, but these doses were not documented as administered on the corresponding MARs. One resident, with diagnoses including dementia, anxiety, and mood disorder, had multiple doses of Ativan signed out on the controlled substance record over several dates, but these administrations were not reflected on the MAR. The resident was noted to be severely cognitively impaired and required assistance with activities of daily living. Similarly, another resident with dementia and anxiety had numerous doses of Ativan signed out on the controlled substance record across several months, but these were also not documented on the MAR as administered. During an interview, the Director of Nursing confirmed the inconsistencies between the controlled drug records and the MARs, acknowledging that doses were documented as given on the narcotic reconciliation record but not signed out as administered on the MAR. These findings indicate a failure to follow established pharmacy and medication administration procedures as required by facility policy and state regulations.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility was found to have several deficiencies related to food safety and sanitation practices. During an inspection of the food and nutrition services department, it was observed that a lidded garbage can next to the handwashing sink was overfilled, preventing it from closing and posing a contamination risk. Additionally, there was a visible build-up of dirt and debris beneath the tray line and steam table, and the kitchen floor perimeter showed signs of heavy soiling. The backsplash on the stove had accumulated grease and food stains, which could lead to cross-contamination. In the walk-in cooler, cases of cottage cheese were stored too close to the ceiling, compromising temperature regulation, and several thawed nutritional drinks and desserts lacked appropriate thaw and discard dates. Furthermore, bags of frozen mixed vegetables were undated, and food items were improperly stored directly on the floor in the dry storage room. During meal service, it was noted that both a cook and the food service director were handling food without wearing proper beard covers, which is against hygiene standards. In the dish room area, thermal beverage mugs labeled as clean had visible coffee stains, indicating inadequate cleaning practices. The food service director confirmed that all food and beverages must be stored and thawed according to manufacturer guidelines and facility protocols to prevent contamination, and that the dietary department must be maintained in a sanitary condition to comply with federal food safety regulations.
Plan Of Correction
The facility cannot retroactively correct the deficiency noted by the surveyor. The lidded garbage can next to the handwashing sink was emptied to assure proper closure. The build-up of dirt and debris beneath the tray line and steam table was cleaned. The kitchen floor was stripped and re-waxed. The backsplash of the stove was clean of grease and food stains. The cases of cottage cheese in the walk-in cooler were moved to a more suitable location. Four thawed eight-ounce nutritional juice drinks and three thawed four-ounce nutritional shakes lacking thaw and discard dates were disposed of. Three thawed four-ounce nutritional desserts not labeled with discard dates were disposed of. Four bags of frozen mixed vegetables in the walk-in freezer that were undated were disposed of. Three cases of assorted food items stored directly on the floor in the dry storage room were uncased and properly stored. The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring. The Registered Dietitian (RD) will re-educate the Dietary Manager and dietary staff on acceptable practices for storage and service of food to prevent the potential for contamination and the wearing of proper beard covers. The RD or designee will conduct weekly audits of food storage and beard covers for four weeks and then monthly for two months to verify compliance. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for three months.
Failure to Provide Meal Assistance Leads to Choking Incidents
Penalty
Summary
The facility failed to provide necessary meal tray setup assistance for a resident, identified as Resident 76, who was unable to independently manage their meals due to severe cognitive impairment. The resident, diagnosed with dementia and anxiety, was admitted with a regular diet order and required supervision or touching assistance for feeding. Despite this, the resident's care plan did not adequately address the extent of meal assistance required, specifically the need for food to be cut into bite-sized pieces to ensure safe swallowing. On two separate occasions, the resident experienced choking incidents while consuming meals, necessitating the use of a LifeVac device to dislodge large pieces of food. The first incident involved a piece of chicken the size of a fifty-cent coin, and the second involved a large piece of meat. These incidents occurred because the resident was not provided with the necessary setup assistance to ensure their food was appropriately prepared for safe consumption. The facility's failure to cut the resident's food into manageable pieces directly contributed to these choking events. Interviews with facility staff, including the Director of Nursing and the foodservice director, confirmed that the resident required tray setup assistance, which was not provided. The facility's policies on meal assistance and the use of the LifeVac device were reviewed, highlighting the lack of adherence to established protocols. The deficiency was further evidenced by the absence of documented tray setup assistance and the serving of whole chicken breasts to the resident, contrary to their needs.
Plan Of Correction
Resident 76's care plan has been reviewed and updated to reflect the extent of meal assistance the resident requires for meals. Residents with documented need for meal tray set-up assistance will have care plans reviewed by The Clinical Care Coordinators and updated to ensure the appropriate level of assistance has been developed, documented, and implemented to meet the individual needs of the residents. The Clinical RAI Specialist will provide re-education to the Licensed nursing staff on how to develop and implement a care plan that addresses the extent of meal assistance the resident requires. The Director of Nursing or designee will re-educate the nursing staff on meal tray set-up assistance to ensure each resident's individual level of assistance is met. Clinical Care Coordinator or designee will perform random audits weekly for 4 weeks and then monthly for 2 months to verify resident with need for meal tray set-up has a care plan reflecting the extent of meal assistance needed. The Director of Nursing or designee will perform random audits weekly for 4 weeks and then monthly for 2 months to verify meal tray set-up is being completed as required for the individual residents. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.
Failure to Provide Individualized Activities for Residents with Dementia
Penalty
Summary
The facility failed to provide an individualized activities program for residents with dementia and/or sensory deficits, as evidenced by observations, clinical records, and interviews. Five residents were observed in a day room with a television on, but none were engaged with the program or participating in meaningful activities. The facility's activity calendar indicated a scheduled 'Ladies Group' activity, but the female residents in the day room were not participating. Clinical records revealed that these residents had specific activity preferences and cognitive impairments. For example, one resident with bilateral sensorineural hearing loss and cataracts had preferences for music, animals, and religious services, but her activity log showed only one recorded activity in 75 days. Another resident with Alzheimer's disease and cerebrovascular disease had preferences for reading and music, yet his log showed only four activities in the same period. Similar patterns of insufficient engagement were noted for the other residents, indicating a lack of consistent and individualized activities. The Activities Director acknowledged that the department was short-staffed, which hindered their ability to provide one-on-one visits and engagement for residents with dementia and sensory deficits. This staffing issue contributed to the failure to deliver adequate and personalized activities programming, as required by the residents' needs, abilities, and preferences.
Plan Of Correction
0679 An individualized activities program has been developed to meet the specific functional needs, abilities, and preferences for residents 15, 46, 96, 65, and 51 who have dementia and/or sensory deficits. The facility recognizes that other residents with dementia and/or sensory deficits could be affected and will be audited by the Nursing Home Administrator or designee to verify an activities program has been developed to meet their specific needs. The Nursing Home Administrator or designee will re-educate the Activities Director on the need to have an individualized activities program developed to meet the needs of residents who have dementia and/or sensory deficits. The Nursing Home Administrator or designee will randomly audit the activity programs for residents with dementia and/or sensory deficits weekly for 4 weeks and then monthly for 2 months to verify their specific needs are being met. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable and at a safe and appetizing temperature for seven out of twenty-three residents sampled. Observations and interviews revealed that residents frequently received meals that were not hot enough, with several residents expressing dissatisfaction with the temperature of their food. A group interview with six alert and oriented residents confirmed that hot food temperatures were often cold, with one resident stating that the food was cold every day at all meals, and another describing the food as lukewarm at best. A test tray evaluation conducted on the East D Wing Nursing Unit further confirmed the deficiency. The meal, which included chicken with gravy and a waffle, was served at a temperature of 102.5°F, below the required minimum of 135°F. The food was described as cold and not palatable, with the waffle being soggy and not toasted. The foodservice director acknowledged that the test tray results did not meet the facility's policy or regulatory requirements, confirming the deficiency in maintaining appropriate food temperatures.
Plan Of Correction
The facility cannot retroactively correct the deficiency noted by the surveyor for residents 44, 201, 38, 16, 88, 54, and 34. The facility recognizes that all residents have the potential to be affected. See section 3 and 4 for system changes and monitoring. The Dietary Manager will re-educate dietary staff on serving palatable meals at a safe and appetizing temperature. The Dietary Manager or designee will do test trays weekly for 4 weeks and then monthly for 2 months to verify meals are palatable and served at a safe and appetizing temperature which meets the regulatory requirements. Test tray results will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.
Inadequate Facility Assessment for Resident Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment using evidence-based methods to identify the specific resources necessary to care for its resident population. The assessment did not accurately reflect the needs and services required by the various subsets and characteristics of the resident population, including those with Alzheimer's, dementia, and behavioral health needs. The facility's assessment was not updated to include critical factors such as specific staff competencies, equipment needs, and services required to meet the individual and collective needs of the residents. The review of the facility's Resident Matrix revealed a total census of 98 residents, with 46 residents diagnosed with Alzheimer's or dementia and 26 residents receiving psychiatric and/or psychological services. Despite these characteristics, the facility assessment presented to the survey team indicated there were no residents with behavioral health needs requiring special treatments and conditions. This oversight failed to ensure resident safety and did not accurately reflect the current population's needs. Additionally, the facility assessment did not include the necessary resources, such as the overall number of facility staff, including dietary and activity staff, and contracted staff like agency nursing staff. It also failed to evaluate the physical resources needed, including resident care equipment, medical supplies, and non-medical supplies, to provide the required care and services. During an interview, the Nursing Home Administrator acknowledged that the Facility Assessment did not contain all the required information needed to meet regulatory requirements and address the specific needs of the resident population.
Plan Of Correction
The facility cannot retroactively correct the deficiency cited by the surveyors. The facility assessment will be updated to contain all the required information needed to meet regulatory requirements and address the specific needs of the resident population. The facility recognizes that all residents have the potential to be affected by the noted practice. See section 3 and 4 for system changes and monitoring. The Nursing Home Administrator will continue to review and update the facility assessment quarterly as required and make changes as needed. The assessment will be reviewed at the quarterly Quality Assurance with the Interdisciplinary team for any recommendations.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, as evidenced by multiple observations and interviews. Employee 3, a registered nurse, was observed administering medications to three residents on the A Hall nursing unit without following proper infection control techniques. The nurse used her bare hands to remove medications from the medication card and placed them in the residents' medication cups without performing hand hygiene or donning gloves. This occurred with the administration of Folic Acid to Resident 6, Tamsulosin to Resident 22, and Buspirone to Resident 32. The nurse also failed to wash her hands after administering the medications. The facility's infection control logs for August and September 2024 were incomplete, as confirmed by the Infection Preventionist (IP) and the Nursing Home Administrator (NHA). The IP, who started on September 23, 2024, verified that there was no current IP working in the facility prior to her hire, and the infection control tracking logs were not completed for those months. The NHA confirmed that the previous IP stopped working on August 30, 2024, and the new IP did not start until September 23, 2024, leading to a gap in infection control tracking. The facility's failure to demonstrate a comprehensive infection control program included a lack of a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors. This deficiency was confirmed through interviews with the Director of Nursing and the Infection Preventionist, highlighting the facility's inability to maintain a comprehensive program to monitor and prevent infections.
Plan Of Correction
The facility cannot retroactively correct the deficiency noted by the surveyor for residents 6, 22, and 32 on C-Hall. The facility understands that all residents have the potential to be affected by the deficiency as noted by the surveyor. Please see sections 3 for system changes. The Director of Nursing (DON) or designee will re-educate the Licensed Nursing Staff on medication administration and hand hygiene. The facility now has an Infection Preventionist (IP) as well as a backup who will be reviewing any new infections at the daily morning meeting and verify it is documented on the tracking log. The DON or designee will randomly audit medication pass, verify hand hygiene, and the tracking of infections weekly for 4 weeks and then monthly for 2 months to verify compliance. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that Resident 40 was free from physical abuse by another resident, Resident 81. Resident 40, who was moderately impaired cognitively with a BIMS score of 9, was admitted with diagnoses including unspecified dementia and generalized anxiety disorder. Resident 81, who was severely impaired cognitively with a BIMS score of 4, had a history of aggressive behaviors, including agitation, verbal and physical abuse towards staff and other residents, and refusal of medications. Despite these behaviors, the facility's care plan for Resident 81 did not identify specific behaviors or implement person-centered interventions to manage the resident's aggression. On January 23, 2025, Resident 81 was involved in an altercation with Resident 40, during which Resident 81 struck Resident 40 in the chest while she was sitting in her wheelchair. A facility investigation confirmed the incident, and a staff member witnessed Resident 81 hitting Resident 40 and grabbing her by the shirt. The facility's failure to develop and implement appropriate interventions for Resident 81's known aggressive behaviors resulted in the physical abuse of Resident 40.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance as of March 25, 2025. 0600 Resident 81's care plan has been reviewed and updated to reflect approaches to managing her socially inappropriate behavior. Residents with documented behaviors will have care plans reviewed and updated by The Clinical Care Coordinator to ensure appropriate approaches/interventions have been developed, documented, and implemented to attempt to manage the behavior noted and to protect others. The Regional Social Service Director will provide re-education to the Clinical Care Coordinator, Social Service Director, and Licensed nursing staff on how to develop and implement a socially inappropriate behavior care plan to ensure the safety of residents. Behaviors will be reviewed at daily morning IDT meetings and care plans reviewed to verify they address appropriate interventions. The Clinical Care Coordinator or designee will perform random audits weekly for 4 weeks and then monthly for 2 months identifying resident behavior and ensuring the developed care plan is in place. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.
Failure to Adhere to Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a resident receiving dialysis, identified as Resident 13. The resident, who was admitted with diagnoses including diabetes and end-stage kidney disease, was ordered to maintain a 1000 ml fluid restriction. However, the facility's electronic system was incorrectly set to a 1500 ml fluid restriction, leading to multiple instances where the resident's fluid intake exceeded the prescribed limit. This discrepancy was confirmed through a review of the resident's clinical records and fluid intake reports, which documented several days where the fluid intake surpassed the 1000 ml restriction. The deficiency was further corroborated by an interview with the Director of Nursing, who acknowledged the failure to comply with the physician's order. The facility's policy on fluid management, which requires verification of physician orders and adherence to specified fluid amounts, was not followed, resulting in the resident receiving more fluids than medically prescribed. This oversight highlights a significant lapse in ensuring the resident's care plan was executed as intended, potentially impacting the resident's health due to the excess fluid intake.
Plan Of Correction
The facility cannot retroactively correct the deficiency noted by the surveyor for resident 13. Resident 13's order has been verified to be summarized in the resident's tasks. The facility recognizes that other residents with orders for fluid restrictions have the potential to be affected, and the Director of Nursing (DON) or designee will audit residents with orders for fluid restrictions to verify the orders are being maintained. The DON or designee will re-educate the dietary and nursing staff on following fluid restrictions as ordered. The DON or designee will randomly audit residents with orders for fluid restrictions weekly for 4 weeks and then monthly for 2 months to verify compliance. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide the necessary adaptive dining equipment for a resident, identified as Resident 46, who required specific utensils due to medical conditions. Resident 46 was admitted with early onset Alzheimer's disease and cerebrovascular disease, and had a care plan indicating a need for a maroon pediatric spoon to aid in safe swallowing due to dysphagia. Despite the physician's orders, the resident was observed being fed with a white plastic spoon instead of the prescribed maroon spoon on multiple occasions. Observations on two separate days revealed that the staff did not use the required maroon spoon during meal times, and interviews with staff confirmed the absence of the correct utensil. The Director of Rehab acknowledged the facility's failure to provide the adaptive equipment as ordered, which increased the risk of choking and compromised the resident's safety.
Plan Of Correction
The facility cannot retroactively correct the deficiency noted by the surveyor for resident 23. The facility recognizes that all residents with orders for adaptive equipment have the potential to be affected. The Registered Dietitian or designee will audit residents with orders for adaptive equipment to verify the equipment is being utilized as ordered. The Registered Dietitian (RD) or designee will re-educate the dietary and nursing staff on utilizing adaptive equipment as ordered for meals. The RD or designee will conduct weekly audits for 4 weeks and then monthly for 2 months to verify adaptive equipment is being utilized as ordered for meals. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months. F 0810
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2024. The regulation specifies a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. A review of the facility's staffing records revealed that on 35 out of 63 shifts reviewed, the facility did not provide the minimum required number of nurse aides. Specific dates were identified where the number of nurse aides fell short of the required ratios, with discrepancies noted across day, evening, and night shifts. The facility's census on the dates in question ranged from 94 to 99 residents, and the shortfall in staffing was not compensated by additional higher-level staff. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the staffing requirements on the specified dates. This deficiency was identified through a review of staffing records and staff interviews, highlighting a significant lapse in compliance with the staffing regulations set forth for long-term care facilities.
Plan Of Correction
The facility cannot retroactively correct the deficiency cited by the surveyor related to maintaining the required staffing ratio for nurse aides on dates and shifts identified. The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring. The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required nurse staffing ratio for nurse aides. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs, and off-site recruiters. Agency will be utilized for open shifts as needed and available. Calculation of daily shift ratios will be completed and reviewed for accuracy by the scheduler, DON, or NHA. All efforts will be made to meet the staffing ratio. If call-offs occur, all efforts will be made to attempt to fill that position. Daily ratios will be audited weekly for 4 weeks and then monthly for 2 months. Results will be forwarded to the QA committee monthly for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. This deficiency was identified through a review of the facility's staffing levels and confirmed by the Nursing Home Administrator. Specific dates were noted where the facility's nursing care hours fell below the mandated threshold, with the lowest recorded at 2.86 hours per resident. The deficiency was documented in accordance with the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, which stipulates the minimum nursing care hours effective July 1, 2024. The facility's failure to consistently provide the required nursing care hours was confirmed during an interview with the Nursing Home Administrator, highlighting a pattern of non-compliance with the staffing requirements.
Plan Of Correction
The facility cannot retroactively correct the deficiency cited by the surveyor related to not maintaining the required PPD on dates identified. The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring. The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required minimum daily PPD. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs, and off-site recruiters. Agency will be utilized for open shifts as needed and available. Calculation of daily PPD will be completed and reviewed for accuracy by the scheduler, DON, or NHA. All efforts will be made to meet the PPD daily. If call-offs occur, all efforts will be made to attempt to fill that position. Daily PPD will be audited weekly for 4 weeks and then monthly for 2 months. Results will be forwarded to the QA committee monthly for review and recommendations.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to ensure a clean and safe environment for residents in two of the four units observed, specifically the A and C units. During an observation on August 27, 2024, several deficiencies were noted in the A hall nursing unit. In one room, a plastic three-drawer bin was covered with dried brown spots, and the bathroom contained a plastic garbage bag tied to the grab bar with a soiled urinal and a foley catheter bag with a brown substance. Additionally, a toilet brush encrusted with a yellow substance was found in a plastic container on the bathroom floor. Another room had a plastic garbage bag tied to the grab bar containing a urine-covered graduated cylinder, and another cylinder stained with a yellow substance was found on top of the toilet, accompanied by a strong smell of urine. A third room also had a plastic garbage bag tied to the grab bar with a graduated cylinder containing urine. In the C hall nursing unit, an observation revealed a dark feces-like substance present in the toilet and covering the toilet seat in one room. A plastic garbage bag tied to the grab bar contained a soiled bedpan with urine at the bottom. An interview with the Nursing Home Administrator confirmed the facility's failure to maintain a clean and sanitary environment for the residents, violating the residents' right to a safe, clean, comfortable, and homelike environment as per 28 Pa. Code 201.18 (e)(2.1) Management.
Deficiencies in Housekeeping and Water Temperature Maintenance
Penalty
Summary
The facility failed to provide necessary housekeeping and maintenance services to ensure a clean and comfortable environment for residents. During an environmental tour, it was observed that the floor surrounding and beneath the bed in a resident's room was littered with dirt, paper debris, and a brown sticky substance. Another resident's room was similarly affected, with dirt, paper debris, and a brown sticky substance found on the floor, under the bed, and around the bedside table. Additionally, the facility did not maintain hot water temperatures at a level comfortable for residents during bathing or showering. The hot water temperature in the 200 hallway resident shower room was recorded at 100 degrees Fahrenheit, while the locked dementia care unit shower room had a temperature of only 98 degrees Fahrenheit. In the 100 hallway shower rooms, temperatures ranged from 90 to 98 degrees Fahrenheit. An interview with the Administrator confirmed that the resident environment should be clean and that comfortable hot water temperatures should be maintained.
Failure to Protect Resident from Sexual Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident A3, from sexual verbal abuse by another resident, identified as Resident A2. Resident A2, who was admitted with diagnoses including dementia and alcohol abuse, exhibited a history of inappropriate sexual behaviors. Despite being moderately cognitively impaired, Resident A2 was known for verbal aggression and inappropriate sexual conduct, including exposing himself and making inappropriate comments. The facility's interventions, such as 1:1 supervision and motion sensor alarms, were ineffective in preventing these behaviors. On two separate occasions, Resident A2 was found in compromising situations with Resident A3, who was also moderately cognitively impaired and required assistance with daily activities. In one incident, Resident A3 was found touching Resident A2's genitals, and in another, Resident A2 was observed with his pants down, exposing himself to Resident A3. The facility's interventions, including motion sensors and alarms, failed to prevent these incidents, as Resident A2 was able to disable or circumvent them. The Director of Nursing (DON) confirmed that the facility was aware of Resident A2's aggressive and sexual behaviors but failed to ensure Resident A3's safety from abuse. The facility's inability to implement effective measures to prevent Resident A2's inappropriate conduct resulted in a deficiency in protecting residents from abuse, as required by regulations.
Obstructed Hallway Handrails in Resident Area
Penalty
Summary
The facility failed to maintain an environment free from accident hazards in one of two resident hallways. Observations on the east hallway at various times revealed obstructions on the left side of the corridor, including wheelchairs, a straight back chair, a large linen cart, dirty linen carts, a trash bin, and a wheelchair charger plugged into a hallway outlet. These items obstructed access to the handrails on the wall, which are essential for resident safety. Residents were observed moving around the unit, either self-propelling in wheelchairs or ambulating with walkers, during these times. The Nursing Home Administrator confirmed in an interview that the hallway handrails should not be obstructed and that residents should have unimpeded access to them. This deficiency was noted under 28 Pa. Code 201.18 (e)(2.1) Management, indicating a failure to ensure a safe environment for residents.
Failure to Assess Resident's Capability for Self-Administration of Medication
Penalty
Summary
The facility failed to determine a resident's capability to self-administer medication, specifically for one resident diagnosed with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension. The resident, who was assessed as cognitively intact with a BIMS score of 13, was found to be in possession of a Combivent Respimat inhaler, which he used one or two times a day. The resident stated that nursing had given him the inhaler some time ago, but there was no current physician order for its use, nor was there an assessment of the resident's ability to self-administer the medication. During an interview with an LPN, it was confirmed that the resident's clinical record lacked a current physician order for the inhaler, a self-administration assessment, and a care plan indicating self-administration. The physician's order for the inhaler had been discontinued several months prior, yet the inhaler remained in the resident's possession. This oversight was in violation of the facility's policies regarding medication administration and self-administration, as well as state regulations concerning pharmacy services and resident care policies.
Infection Control Deficiency
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed in the case of one resident. During multiple observations, the resident's urinary Foley catheter collection bag was found directly on the floor without a privacy bag. Additionally, the resident's bedside table contained multiple uncovered and open medical supplies, including clean dressings, tubes of Hydrocortisone and Triamcinolone creams, and a bottle of sodium chloride solution without an open date. An uncovered clean incontinence brief was also found among these supplies. Furthermore, a wash basin on the resident's dresser contained used hand towels, both sealed and unsealed dressings, gloves, and dressing tape. In another resident's room, an uncapped open plastic gallon container of distilled water was found on the dresser. The Director of Nursing confirmed that these items should be maintained in a sanitary manner.
Hot Water Temperature Monitoring Deficiency Puts Residents at Risk
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards related to hot water temperatures, placing 27 out of 97 residents in immediate jeopardy of serious burns. Observations revealed hot water temperatures exceeding safe levels in resident rooms and common bathing areas. Staff interviews indicated a lack of proper training on checking and recording water temperatures, with some employees inaccurately documenting temperatures or instructed to report false readings. Residents reported discomfort and fluctuations in water temperatures during showers, highlighting the risk posed by the elevated hot water temperatures in the facility. Employee interviews revealed varying levels of awareness and adherence to proper procedures for monitoring water temperatures, with some staff members relying on inaccurate documentation practices. The Nursing Home Administrator confirmed the unsafe hot water temperatures and acknowledged Resident 12's risk of burns due to the lack of running cold water in the resident's room. The facility was placed under Immediate Jeopardy status due to the failure to ensure a safe environment for residents in the affected units, with the deficiency stemming from inadequate monitoring and documentation of hot water temperatures by staff members.
Failure to Maintain Food Storage and Service Standards
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, leading to potential contamination and microbial growth. During an initial tour of the kitchen, 19 cases of food were observed stored directly on the floor, and four cases of thawed high-calorie shake supplements were not dated with a thaw date or discard date. Additionally, bulk flour and sugar in the dry storage area were not dated, and there were brown stains on two ceiling tiles near an air conditioning unit. Serving and food preparation utensils were found uncovered and hanging next to utility pipes and under water-stained ceiling tiles. In the dementia care unit's kitchenette, a gallon of vanilla ice cream dated December 2023 was melted and refrozen, and six frozen cheese pizzas were not dated. The kitchenette also had a sticky brown substance splattered on the cabinets, wall, and ceiling, and an accumulation of dirt and debris on the floor. A dirty broom and dustpan were left next to the wall ovens. In the East Wing medication room, a 32-ounce fortified nutritional shake was opened and not dated, and in the [NAME] Wing medication room, a high-calorie shake was beyond the manufacturer's recommended discard date, and another shake lacked a thaw date or discard date. The facility's Certified Dietary Manager (CDM) confirmed the issues with the undated shakes and was unsure when they were thawed for use. The Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that the dietary department and resident pantry/kitchenette food storage were maintained in a sanitary manner and failed to ensure proper labeling. These deficiencies were observed during a tour of the kitchen, dementia care unit's kitchenette, and medication rooms, highlighting the facility's failure to adhere to food safety and inspection standards for safe food handling, cooking, and storage.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program. A review of the facility's infection control policy revealed that the program's purpose is to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections. However, the facility did not adhere to this policy. From August 2023 through March 2024, multiple resident infections were identified each month, but there was no documented evidence that the infection preventionist or designee evaluated potential causative factors, tracked the infections for patterns or trends, or implemented applicable interventions to prevent similar infections. The monthly infection tracking logs lacked descriptive information on the infections, including symptoms, culture or testing results, organisms identified, completed treatment information, or resolution dates. The facility's limited infection data was not evaluated to determine preventive measures for the spread or recurrence of infections. The facility failed to demonstrate that its infection control program included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors, following accepted standards and guidelines. An interview with the facility Infection Control Nurse confirmed that the current infection control program did not meet the requirements contained in the long-term care regulations.
Failure to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to provide housekeeping services to maintain a clean and orderly environment across all four nursing units. Observations revealed multiple deficiencies, including broken or missing window blinds, dust and debris accumulation on window sills and radiator covers, and dirty and sticky floors in various rooms. Specific instances included a green chair with white stains in a resident dayroom, a window with a detached hinge in a resident room, and a shower chair with a brown fecal-like substance in a resident shower room. Additionally, a plastic ceiling light fixture in a shower room contained dead insects, and the corners of the shower room floor had a buildup of dirt, dust, and a sticky film. Bathrooms in resident rooms were found to have dirt, debris, and sticky substances, including a thick yellow urine-like substance and a sticky brown film around the base of toilets and sinks. During an interview, the Nursing Home Administrator confirmed that the facility is expected to be maintained in a clean and sanitary manner. However, the observations made by the surveyors clearly indicated that the facility failed to meet these standards, resulting in an environment that was neither clean nor orderly. The deficiencies were noted under the Pennsylvania Code 201.18 (e)(1)(2.1) Management and 201.29 (a) Resident Rights.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services as planned for a resident (Resident 16) to maintain mobility and functional abilities. Resident 16, who is cognitively intact with a BIMS score of 15, was admitted with end-stage renal disease and had a care plan initiated to prevent a decline in ambulatory function. The care plan included a restorative ambulation program where the resident was to walk 50 feet daily with a two-wheeled walker and the assistance of one staff member. Despite a Physical Therapy Discharge Summary recommending this program, facility tracking revealed inconsistent implementation, with the resident refusing assistance 16 times, participating five times, and the task being marked as not applicable once. Resident 16 reported that staff did not offer or provide the restorative walking assistance as planned and expressed a desire to walk more often to get stronger. The Nursing Home Administrator confirmed the resident's alertness and orientation and acknowledged the failure to consistently provide the planned services and accurately document refusals. Further review of the facility's tracking showed discrepancies in the documentation of the resident's participation in the restorative program. On specific dates, the resident was noted to have declined or been unavailable for the program, but the resident stated that she was not offered the program on those dates. The Nursing Home Administrator was unable to explain why staff were not consistently providing the program and documenting refusals accurately. This failure to provide the planned restorative nursing services and accurately document the resident's participation or refusals constitutes a deficiency in the facility's care provision.
Failure to Reconcile Controlled Drug Records
Penalty
Summary
The facility failed to implement proper pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one resident. Specifically, Resident 36 had a physician order for Oxycodone 10 mg to be administered as needed for severe pain. However, the administration of this controlled drug was not recorded on the resident's Medication Administration Record (MAR) on multiple occasions in April 2024. Additionally, there were no controlled drug narcotic sign-out records available for the months of December 2023, January 2024, February 2024, and March 2024 to reconcile the accounting of the resident's supply of the controlled drug. This discrepancy was confirmed by the Director of Nursing during an interview on April 11, 2024. A review of Resident 36's MAR revealed that nursing staff signed out a significant number of doses of Oxycodone 10 mg over several months, but the corresponding narcotic sign-out records were missing. The Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medications and acknowledged that the narcotic drug records were not available to verify the administration to the resident on the specified dates and times. This failure to maintain accurate records and reconcile controlled substances led to the identified deficiency.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to serve menus that accommodated the food preferences of the resident population, leading to dissatisfaction with meals among residents. Resident 69 reported that the food served lacked flavor and variety, and despite voicing concerns at food committee meetings, the issues persisted due to budgetary restraints and the corporate dietitian's lack of consideration for local and cultural preferences. The facility's CDM and RD were not involved in menu development, which was done by the corporate dietitian for multiple facilities without considering the specific needs of each location. This resulted in repetitive menu options and meals that did not align with the residents' preferences or the available kitchen equipment. During a group meeting, residents expressed frustration over the repetitive menu and the facility's disregard for their suggestions. Specific examples included the inability to properly prepare grilled cheese sandwiches due to the lack of a grill and frequent repetition of beef and chicken meals. The CDM confirmed that substitutions were made due to budget constraints, such as replacing watermelon with mixed fruit cocktail. The NHA acknowledged the failure to develop menus that reflect variety and accommodate resident preferences, confirming the deficiency in dietary services and resident rights as per 28 Pa. Code 211.6 (a) and 28 Pa. Code 201.18 (a).
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain safe hot water temperatures, placing residents at risk for serious burns. Observations revealed that water temperatures in various locations, including resident rooms and common shower areas, were significantly above the safe range. For instance, temperatures as high as 134.6 degrees Fahrenheit were recorded, which could cause third-degree burns with prolonged exposure. Staff interviews indicated a lack of proper training and inconsistent methods for checking and recording water temperatures. Some staff members were instructed to document incorrect temperatures, further compromising resident safety. Resident interviews corroborated these findings, with one resident reporting fluctuating water temperatures during showers, requiring them to wait for the water to cool down. Another resident was observed attempting to use a sink with only hot water available, as the cold water was turned off without proper notification to maintenance. This situation was confirmed by the Nursing Home Administrator, who acknowledged the elevated temperatures and the risk they posed to residents. The deficiency was cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.12(a)(1), indicating that the Nursing Home Administrator and Director of Nursing failed to ensure the safety of the residents and adherence to regulatory guidelines. Immediate Jeopardy was called due to the facility's failure to maintain a safe environment, specifically regarding the elevated hot water temperatures in the A and B units, including the locked dementia unit.
Failure to Conduct Comprehensive Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment that accurately reflected the personnel and specific resources available and necessary to care for its current resident population. During the survey ending April 12, 2024, it was found that the facility's assessment, last reviewed on June 3, 2023, did not address the needs of the locked B unit, which is the Dementia/Memory care unit. Specifically, the assessment did not include any focus on the care and needs of the 48 residents with documented diagnoses of Dementia/Alzheimer's disease, including the 27 residents residing on the locked dementia unit. The facility assessment presented to the survey team lacked updated comprehensive data regarding the current resident population and the necessary resources to competently and safely care for the residents. This omission meant that the facility did not identify the available resources for making staffing and operating budget decisions while managing the resident census to ensure that the facility had the necessary staff resources to care for its resident population in a manner that met minimum licensure and certification standards.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for one resident, identified as Resident 90. The resident was admitted with diagnoses including dysphagia, a history of falls, and generalized muscle weakness. On January 22, 2024, an LPN discovered multiple bruises on Resident 90's body, including the left hip, left inner thigh, and left wrist. Despite the facility's policy requiring timely and thorough investigations of such injuries, there was no documented evidence that the facility investigated the potential origin of these bruises to rule out abuse, neglect, or mistreatment. The Director of Nursing (DON) was unaware of the bruises and confirmed that the facility did not implement its abuse prevention policy in this case. The facility's policies on abuse and incident reporting, last reviewed on June 21, 2023, mandate immediate reporting and thorough investigation of all allegations of abuse, neglect, and injuries of unknown origin. However, the facility did not follow these policies in the case of Resident 90. The progress notes indicated that the resident had no recollection of how the bruises formed, and while alarms were placed on the resident's bed, there was no follow-up investigation documented. This failure to investigate and document the origin of the bruises constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Address Immediate Care Needs for Resident with AICD
Penalty
Summary
The facility failed to include minimum standards of care in the baseline plan of care for a resident admitted with significant cardiac conditions, including ischemic cardiomyopathy, paroxysmal atrial fibrillation, and an automatic implantable cardiac defibrillator (AICD). Upon review of the clinical record and staff interviews, it was found that the facility did not timely identify and address the resident's care needs related to the AICD device. Specifically, there was no documented evidence that the facility provided AICD checks as ordered or monitored for signs and symptoms of AICD complications. Additionally, the facility did not address emergency care procedures for the AICD device, such as consulting the physician, obtaining vital signs, and ensuring the safety of the resident and staff in case the AICD was activated. An interview with the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to sufficiently address the care and management of the resident's AICD in the baseline plan of care. This deficiency was identified during a survey ending on April 12, 2024, and it was determined that the facility did not meet the required standards of care for the resident's immediate needs upon admission.
Failure to Manage Dementia-Related Behavioral Symptoms
Penalty
Summary
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the resident's safety and well-being. Resident 14, diagnosed with Alzheimer's disease and unspecified psychosis, exhibited moderate cognitive impairment and displayed aggressive behaviors such as yelling, kicking, and hitting staff. Despite these ongoing behaviors, the resident's care plan had not been revised since June 5, 2023, and there was no evidence of a review of the existing interventions to manage these behaviors effectively. Progress notes from November 2023 to April 2024 documented multiple incidents of aggression, including physical attacks on staff and other residents. However, the interventions attempted were often ineffective, and there was a lack of documentation describing the resident's behavior or the interventions used. An interview with the Nursing Home Administrator on April 11, 2024, confirmed that the facility did not evaluate the planned interventions through an interdisciplinary team approach to ensure their appropriateness and effectiveness in managing the resident's dementia-related behavioral symptoms.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that Resident 15's drug regimen was free from unnecessary antibiotic drugs. Resident 15, who was admitted with diagnoses including dementia and chronic kidney disease stage 3, was prescribed Augmentin for a suspected urinary tract infection (UTI) despite no clinical signs of infection and stable vital signs. The RN Practitioner ordered a urinalysis and culture and sensitivity (C&S) to rule out a UTI, but the initial antibiotic prescription was made before receiving the C&S results. Nursing documentation from March 1 to March 15, 2024, did not indicate any signs or symptoms of a UTI in Resident 15. On March 19, 2024, the RN Practitioner discontinued Augmentin and started Ceftin based on a follow-up assessment and the resident's mother's suspicion of a UTI. The culture and sensitivity results received on March 21, 2024, revealed the presence of Klebsiella pneumoniae bacteria, but the initial antibiotic, Augmentin, was not included in the sensitivity report. There was no documentation to justify the initial prescription of Augmentin or the subsequent switch to Ceftin before receiving the C&S results. The Director of Nursing confirmed that the administration of Augmentin was not clinically justified for treating Resident 15's UTI.
Failure to Ensure Proper Storage and Use by Dates for Multi-Dose Medications
Penalty
Summary
The facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications in one of the medication storage rooms (Med Room West). During an observation of the medication room on the [NAME] Wing, a multi-dose bottle of Aplisol, which had been opened and dated November 19, 2023, was found in the medication refrigerator. According to the manufacturer's recommendations, vials in use for more than 30 days should be discarded, but this vial was 5 months beyond the recommended discard date. Additionally, a multi-dose vial of Spikevax (COVID-19 vaccine) was found with a discard date of March 20, 2024, which was 21 days beyond the discard date. The observations were confirmed by the RN Supervisor present during the inspection. An interview with the Nursing Home Administrator and Director of Nursing further confirmed that medication expiration/use by dates were to be checked prior to administration and removed from the medication refrigerator upon expiration. The facility's policy on Vials and Ampules of Injectable Medications, last reviewed on June 21, 2023, indicates that medications should be used in accordance with the manufacturer's recommendations or the provider pharmacy directions for storage, use, and disposal, and that the beyond use date and initials of the first person to use the vial should be recorded on the multidose vials.
Failure to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as required. During an abbreviated complaint survey, it was found that the facility did not provide adequate housekeeping services to maintain a clean and orderly environment across four nursing units (Nursing Hall A, B, C, and D). Specific areas noted for deficiencies included resident TV rooms, hallways, rooms, shower rooms, walls, floor molding, exit doors, chair seat cushions, and laundry cart covers. These areas were found to be unclean, in disrepair, or inadequately maintained. Despite the facility's plan of correction, which included re-education of staff and regular rounds by the Environmental Services Director, Maintenance Director, and Nursing Home Administrator, a revisit survey revealed that the facility continued to fail in maintaining a clean and orderly environment. The quality assurance monitoring plan did not effectively identify or address the ongoing deficiencies in housekeeping and maintenance, leading to continued non-compliance with the requirement for a safe, clean, comfortable, and homelike environment.
Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the case of Resident 15. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, was prescribed antibiotics without proper documentation or rationale. On March 15, 2024, an RN Practitioner ordered a urinalysis and culture and sensitivity test to rule out a urinary tract infection (UTI) and prescribed Augmentin. However, there were no clinical signs of infection documented, and the resident received multiple doses of Augmentin before it was discontinued and replaced with Ceftin on March 19, 2024, prior to receiving the culture and sensitivity results. The results, dated March 21, 2024, revealed the presence of Klebsiella pneumoniae, but did not include Augmentin as a suitable antibiotic, raising questions about the initial prescription's appropriateness. The Director of Nursing confirmed that the resident received unnecessary doses of antibiotics, which was inconsistent with the facility's antibiotic stewardship program. The facility's policy for Antibiotic Stewardship, reviewed on June 21, 2023, aimed to comply with state and federal regulations and improve antibiotic use. However, the lack of a functioning antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use was evident. The survey revealed that there was no evidence of a system to prevent unnecessary antibiotic use, as demonstrated by the case of Resident 15. The Director of Nursing acknowledged the deficiency, confirming that the resident received unnecessary antibiotics, which was not aligned with the facility's infection control and antibiotic stewardship goals.
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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