Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gardens At Orangeville, The during CMS and state inspections, most recent first.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to consistently implement ordered wound care and skin integrity interventions: Two residents did not receive ordered care as documented. One resident with a sacral pressure injury remained on a bedpan for hours overnight, and staff could not show required repositioning or monitoring; the resident also sustained a skin tear when an incorrect dressing was removed. Another resident with impaired mobility did not have the ordered left palm roll in place, and an LPN found the device had been left off after becoming soiled, with nail indentations noted on the palm.
Failure to Consistently Provide Ordered Restorative ROM Services: Staff did not consistently carry out physician-ordered restorative ROM programs for three cognitively intact residents with mobility limitations. One resident with muscular dystrophy, one with diabetes and gait instability, and one with right-sided weakness all had ordered active and/or passive ROM through all joints and planes, but documentation showed multiple missed or unexplained not-applicable entries and variable treatment times. Residents reported the exercises were not being provided as ordered, and an NA stated ROM was sometimes done only incidentally during routine care rather than as the formal restorative program ordered by the physician.
A resident with bipolar disorder, anxiety, and intellectual disability had persistent escalating behaviors including yelling, cursing, throwing objects, physical aggression, self-injury, threats, and sexually inappropriate actions. Despite repeated BH evaluations, 1:1 supervision, and a psychiatric hospitalization, the care plan interventions were not shown to be evaluated or revised in response to the ongoing behaviors, and the NHA could not provide evidence that the interdisciplinary team had reviewed their effectiveness.
A resident with a Foley catheter and a Stage IV sacral pressure ulcer had a physician order for EBP, but no EBP signage or PPE instructions were posted outside the room. Staff also observed the Foley drainage bag lying on the floor, and an RN supervisor and the NHA confirmed the missing signage and improper catheter bag placement.
The facility failed to maintain an effective staff training program based on its facility assessment to ensure LPNs had documented competency for PICC line care and IV medication administration. A resident with osteomyelitis had a PICC line ordered for maintenance and received IV Vancomycin through the line, but employee records contained no competency validation for the LPNs who administered the medication, and the NHA and DON could not provide proof of completed PICC-related competency before care was given.
Failure to promptly notify the physician of a significant change in condition for a resident with acute respiratory failure and HF. The resident refused a newly ordered oral diuretic and continued to have low O2 sats despite an increased O2 order, but the record showed no documented physician notification. The resident was later found unresponsive.
Incomplete investigation of alleged resident property misappropriation: A resident with intact cognition and diagnoses including bipolar disorder, anxiety, and intellectual disability reported that the cord to a personal refrigerator had been cut. Staff notes reflected conflicting statements about who may have damaged it, but the NHA and DON could not explain how it happened or who was responsible until surveyor inquiry. The facility could not produce documentation of a full investigation, including statements from the resident and Maintenance Director, witness interviews, staff assignment review, a written summary, or investigative findings.
Failure to investigate and resolve a grievance about delayed call bell response times. Three cognitively intact residents reported ongoing long waits for assistance, including waits of up to an hour or more, and said they received no follow-up, interviews, or status updates after the complaint was filed. The grievance was closed as resolved without documented evidence of an active investigation or a written decision to the residents.
Failure to maintain a clean and homelike environment: Surveyors observed stained and dirty floors, soiled linens, improperly lined garbage cans, gloves and debris on floors, bathroom items left on the floor, and cluttered resident spaces across East and West units. Additional findings included a dirty dishwashing area in the kitchen and resident care items such as urine graduates and catch basins left on bathroom floors without resident names identified.
Failure to timely notify an interested family member of a resident’s status changes and treatment updates. A cognitively intact resident with spinal stenosis and kidney disease had a new med ordered for elevated blood glucose, an increase in PRN oxycodone for back pain, and a period of no urinary output with ongoing assessment, but the daughter was not shown to have been promptly updated. The family member also was not informed of KUB results until after they were available, and the NHA could not provide evidence of timely notification.
Surveyors found that the facility did not maintain a clean and homelike environment, with soiled equipment, stained walls, foul odors, and unaddressed cleaning needs in resident areas. A resident with chronic kidney disease and paraplegia reported her wheelchair was not properly cleaned after an incident, and observations confirmed the presence of residue and damage to the wheelchair. Additional issues included soiled surfaces, odors, and cobwebs in common areas.
Several residents reported a lack of evening activities, expressing interest in options such as card clubs, arts and crafts, movie nights, and bingo after dinner. The activity calendar confirmed that all scheduled activities ended by mid-afternoon, and both the Activities Director and the Administrator acknowledged that no staff were assigned to facilitate evening programs, resulting in unmet resident needs.
Surveyors identified unsanitary conditions in the food and nutrition services department, including a hole in wall grout and accumulated dirt and debris in the kitchen. In a resident pantry area, several food items such as applesauce, canned pears, and milk were found without required date labeling. The FSD confirmed that food items should be dated to ensure safety, indicating a lapse in proper food storage and handling procedures.
A resident with COPD, who was cognitively intact, had $20.00 deducted monthly from her personal needs allowance (PNA) by the facility to pay off a debt, despite Medicaid covering her care costs. The resident was not informed that she was not required to use her PNA for this purpose, and the deductions continued for nearly two years, violating regulations on resident fund management and rights.
A resident with a history of stroke and moderate cognitive impairment, who had a physician order for a soft palm roll to prevent hand contracture, was frequently observed without the device in place and was non-compliant with its use. Staff confirmed the resident often removed the device, and the care plan did not address the resident's limited range of motion or non-compliance with the therapeutic device. The facility was unable to provide documentation of a care plan to address these needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
A resident with a PEG tube for enteral feeding was found to have an unlabeled and undated enteral syringe in use, with staff confirming the lack of labeling. Facility policy did not address requirements for labeling, dating, or disposal timeframes for enteral syringes, despite staff expectations. This resulted in a deficiency related to the handling and management of enteral feeding equipment.
A resident's nebulizer machine, including tubing and mask, was not maintained or replaced according to facility policy, with equipment remaining in the room months after treatments were discontinued and lacking proper dating. Staff confirmed the equipment had not been changed as required, and there was no current physician's order for its use.
Surveyors observed persistent musty urine odors in a resident's bathroom and widespread pest issues, including live and dead ants, spiders, centipedes, and other insects throughout a nursing unit. Multiple residents and a representative reported ongoing problems with odors and pests, and an LPN confirmed recurring ant infestations. The NHA acknowledged the facility's responsibility for ensuring a clean and homelike environment.
The facility failed to meet the required NA to resident ratios across multiple shifts, with staffing levels consistently below the required minimums for day, evening, and night shifts. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in staffing levels.
The facility did not meet the required LPN to resident ratios on four shifts, with insufficient LPN staffing on the day, evening, and night shifts. No additional higher-level staff were available to compensate for these deficiencies, as confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per day, falling short on five out of seven days reviewed. Staffing levels were insufficient, with care hours ranging from 2.74 to 3.09 per resident. The Nursing Home Administrator confirmed the shortfall.
A facility failed to administer Torsemide as ordered for a resident with edema, despite documentation of its presence. Additionally, the resident missed a scheduled Pulmonary Medicine appointment due to the facility's failure to arrange transportation, as confirmed by the administrator.
The facility failed to ensure that the director of food and nutrition services, who was not a qualified dietitian, received frequent consultations from a qualified dietitian. The part-time Consultant RD worked remotely and did not have face-to-face interactions with residents or provide direct nutritional oversight. The nursing home administrator could not provide evidence of scheduled consultations between the director and the Consultant RD.
Residents reported significant delays in receiving assistance after ringing call bells, with wait times often exceeding 45 minutes. One resident, with chronic kidney disease and fibromyalgia, highlighted the issue, noting that staff appeared stressed and unpleasant when responding. A group interview revealed similar concerns, with residents experiencing long waits, particularly during low staffing periods, leading to incidents of soiling themselves. The NHA and DON acknowledged the issue but could not provide an explanation for the delays.
The facility did not maintain a clean and homelike environment in two nursing units. Observations included a bathroom with brown stains, a dusty air conditioning unit, a bed with a stained sheet and debris, and a hallway with stained trim and walls. The NHA confirmed the facility's responsibility for cleanliness.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their clinical records. One resident's assessment inaccurately indicated no anticoagulant medication was received, despite a physician's order for Apixaban. Another resident's discharge status was incorrectly documented as being discharged to a hospital, while the resident was actually discharged home. These inaccuracies were confirmed by facility staff.
A resident with severe cognitive impairment and osteoporosis sustained a laceration during a transfer from bed to wheelchair using a sit-to-stand lift. The injury was discovered after the transfer, and the facility's investigation could not determine the exact cause, though it was suggested the resident's leg might have hit the wheelchair. Both nurse aides involved had satisfactory transfer skills, but the facility failed to implement effective safety measures.
The facility failed to administer IV antibiotics as prescribed for two residents. One resident with chronic osteomyelitis missed multiple doses of Ampicillin and Vancomycin, with no documentation or physician notification. Another resident with a septic knee infection missed a dose of Cefazolin Sodium, also without documentation or notification. The facility's policy requiring eMAR documentation was not followed.
A resident with bipolar disorder and schizoaffective disorder was prescribed Depakote ER 250mg. The consultant pharmacist recommended a gradual dose reduction, but the attending physician did not respond appropriately. Instead, the psychiatric CRNP addressed the recommendation, and the physician cosigned without documenting the rationale for continued use. The DON confirmed the physician's failure to document justification in the clinical record.
A resident with acute respiratory failure and other conditions experienced multiple instances of inadequate nursing care. The resident was found in respiratory distress with low SPO2 levels and was sent to the hospital. Upon readmission, the resident expressed distress and had trouble breathing, but vital signs were not documented. Later, the resident exhibited bradycardia, and increased lung secretions were noted without proper assessment. Eventually, the resident was difficult to arouse with low BP and SPO2, leading to another hospital transfer.
The facility failed to plan menus that accommodate residents' food preferences, leading to dissatisfaction among residents. Despite voicing their preferences during Food Committee meetings, residents felt their input was not considered. A review of the 4-week menu cycle revealed repetitiveness and lack of variety, with beef and poultry served in consecutive meals multiple times. Interviews with the dietary manager and Nursing Home Administrator confirmed these issues.
The facility failed to honor a resident's right to refuse a prescribed therapeutic diet despite the resident being cognitively intact and informed of the risks. The attending physician did not address the resident's wishes for a liberalized diet, and the facility continued to enforce the diet without honoring the resident's decision.
The facility failed to provide adequate housekeeping services, resulting in unsanitary conditions in resident rooms and common areas. Two residents lodged a grievance about the cleanliness of their room, and observations confirmed issues such as a strong smell of urine, soiled rags, sticky floors, and dirty windows. The NHA confirmed that these areas were expected to be clean and sanitary, but the facility did not meet these standards.
The facility failed to ensure that the MDS Assessments accurately reflected a resident's discharge goals. Despite multiple records and staff interviews confirming the resident's wish to return home, the Admission MDS assessment inaccurately indicated that the resident's goal was to remain in the facility.
The facility failed to maintain an environment free of potential accident hazards on the 200-nursing unit. Observations revealed that the hallway from a resident room to 207 was obstructed with mechanical lifts, linen carts, soiled linen and trash hampers, and wheelchairs, blocking access to the corridor handrails intended for resident ambulation or mobility assistance. The Nursing Home Administrator confirmed the obstruction, and the maintenance director measured the distance of the obstructed hallway to be approximately 91 feet.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to consistently implement ordered wound care and skin integrity interventions
Penalty
Summary
The facility failed to consistently implement physician-ordered treatments and care planned interventions to maintain skin integrity for two residents. Facility policy required identification of residents with wounds or pressure injuries, assessment of residents at risk for impaired skin integrity, implementation of preventive and treatment interventions, and ongoing monitoring to promote skin integrity and wound healing. The deficiency involved Resident 15, who was cognitively intact, at risk for impaired skin integrity, had an unhealed unstageable sacral pressure injury, and required staff assistance to turn and reposition in bed because she could not reposition herself independently. Resident 15 reported that staff placed her on a bedpan during the evening and that she fell asleep while on it, remaining on the bedpan until the following morning when she activated the call bell. Nursing documentation and the pressure ulcer investigative report confirmed she was placed on the bedpan at 10:30 PM and remained on it until about 6:30 AM, when staff removed it and found a red outline in the shape of the bedpan on her skin. The Director of Nursing was unable to provide evidence that staff completed the required turning and repositioning every two to three hours or otherwise monitored the resident during that period. The record also showed an order for a calcium alginate dressing for the sacral pressure injury, but staff removed an existing dressing and the resident sustained a skin tear to the left buttock during removal. The facility investigation determined staff had failed to apply the physician-ordered dressing, and the DON stated the incorrect dressing lacked the silicone component intended to allow gentler removal. A similar failure occurred for Resident 27, who had diagnoses including intracerebral hemorrhage and cerebral infarction and a care plan addressing actual and potential skin impairment related to decreased mobility and extensive to total assistance needs. The care plan and physician order required use of a left palm roll as tolerated, with removal each shift for hygiene and range of motion exercises. During observation, the resident was found sitting in a chair with the left hand tightly clenched and the palm roll not in place; an LPN confirmed it was absent and stated it had become soiled during the previous night shift and was not replaced. The LPN manually opened the hand and observed nail indentations on the palm. The clinical record did not document when the palm roll was removed, when it became soiled, or when a clean palm roll was reapplied, and the NHA and DON were unable to provide evidence that the order and care planned intervention were consistently implemented.
Failure to Consistently Provide Ordered Restorative ROM Services
Penalty
Summary
The facility failed to consistently implement physician-ordered restorative nursing services for three residents with impaired mobility. The deficiency involved restorative range of motion (ROM) programs that were ordered to help maintain or improve mobility, but were not consistently carried out as directed or documented as completed. The report cites the Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual and facility policy requiring restorative nursing services to be planned, monitored, evaluated, documented, and delivered by trained staff. Resident 85 had muscular dystrophy and was cognitively intact. A physician ordered passive ROM to both lower extremities twice daily, three sets of 10 repetitions through all joints and planes, and physical therapy recommended bilateral lower extremity passive ROM daily in the same format. The resident’s care plan included restorative nursing services with passive ROM to both upper and lower extremities. However, the resident stated staff assisted with dressing, hygiene, and transfers but did not routinely perform the prescribed repetitive passive ROM exercises. July 2026 restorative documentation showed passive ROM services on only some days, and a nurse aide stated she only stretched the resident’s legs twice during personal care and did not perform the ordered program. Resident 15 had diabetes and gait instability and was cognitively intact. Physician orders directed active ROM to both lower extremities every day using two sets of 15 repetitions and active ROM to both upper extremities every day using three sets of 10 repetitions. The resident stated staff were not providing restorative exercises for either upper or lower extremities. The July 2026 restorative documentation included entries marked not applicable on several dates without any explanation, and treatment times varied from five to 15 minutes without documentation explaining the differences. A nurse aide stated ROM was sometimes done during dressing and grooming, but could not explain the ordered program or what exercises through all joints and planes meant. Resident 64 had right-sided weakness and was cognitively intact. Physician orders directed active and passive ROM to the right upper extremity and both lower extremities, three sets of 10 repetitions daily. The resident stated staff were not providing restorative exercises and wanted therapy to become stronger and improve the ability to return home. July 2026 restorative documentation showed multiple dates marked not applicable without explanation, and treatment times varied from five to 15 minutes without documentation explaining the variation. The DON was unable to provide evidence that Residents 15 and 64 consistently received the ordered restorative nursing services or that nursing assistants had been instructed on how to perform the ordered ROM programs in accordance with the physician orders.
Failure to Evaluate and Revise Behavioral Health Interventions
Penalty
Summary
The facility failed to implement, evaluate, and revise behavioral health interventions for a resident with bipolar disorder, anxiety, and intellectual disability who had a persistent and escalating pattern of behavioral symptoms. The resident’s annual MDS dated May 4, 2026, showed he was cognitively intact with a BIMS score of 15. The facility policy required behavioral health services as needed to support residents’ highest practicable physical, mental, and psychosocial well-being, with staff promoting dignity, autonomy, privacy, socialization, and safety. Clinical documentation showed repeated episodes of yelling, screaming, cursing, verbal aggression, physical aggression, throwing objects, destruction of property, threats toward staff, self-injurious behaviors, sexualized behaviors, refusal of care, and behaviors that disrupted other residents. The resident pulled a needle from his arm during a blood draw, spit at and cursed a phlebotomist, threw belongings into the hallway, became combative with care, threatened staff, threw utensils and other items, ripped equipment from the wall, and caused other residents to report fear of him. He also struck another resident in the leg with a highlighter, threatened to kill a nurse, distributed sexually inappropriate notes, threatened to kill staff, and required one-to-one observation and a 302 psychiatric commitment with hospital transfer after escalating aggression and self-harm statements. After returning from the hospital, the resident continued to display frequent and escalating behaviors despite the existing care plan interventions. Documentation showed ongoing yelling, cursing, throwing objects, spitting medications, striking himself, threatening staff, refusing care, and repeated need for behavioral health involvement and one-to-one supervision. The care plan identified risks related to self-harm, physical abuse, inappropriate sexual behavior, and rejection of care, and directed staff to allow self-soothing, monitor triggers, reapproach after agitation, and discourage throwing objects into the hallway. However, the record did not show that the interdisciplinary team evaluated whether those interventions were effective or revised the care plan in response to the resident’s changing behavioral needs. During interview, the NHA was unable to provide evidence that the team had evaluated the interventions or revised the behavioral care plan despite the persistent pattern of escalating behaviors.
Failure to Implement Enhanced Barrier Precautions and Maintain Foley Catheter Infection Control
Penalty
Summary
The facility failed to implement physician-ordered Enhanced Barrier Precautions and failed to maintain appropriate infection prevention and control practices for Resident 109, who had an indwelling Foley catheter and a Stage IV sacral pressure ulcer. The resident was admitted with diagnoses including an unstageable sacral pressure ulcer and osteomyelitis of the sacral and sacrococcygeal region, and nursing documentation noted the Foley catheter and Stage IV sacral wound. A physician order dated July 20, 2026, required Enhanced Barrier Precautions because of the Foley catheter and wounds. Observations on July 28, 2026, and July 29, 2026, showed no Enhanced Barrier Precautions signage posted outside the resident’s room and no instructions identifying the required PPE before entry, contrary to the physician order and facility policy. During those observations, the resident was resting in bed and the Foley catheter drainage bag was lying directly on the floor on its side rather than being maintained off the floor. A nurse aide confirmed the drainage bag was on the floor, a registered nurse supervisor confirmed the resident required Enhanced Barrier Precautions and that the required signage was not posted, and the Nursing Home Administrator acknowledged the missing signage and the drainage bag left on the floor.
Missing competency validation for PICC line care and IV medication administration
Penalty
Summary
The facility failed to develop, implement, and maintain an effective staff training program based on its facility assessment to ensure licensed nursing staff had the knowledge, skills, and documented competencies needed to provide care for a resident with a PICC line. The facility assessment identified that the facility routinely cared for an average of three residents receiving high-risk intravenous or intramuscular medications or infusions and stated that staff would receive education consistent with their assigned responsibilities, with competencies and skill sets identified to meet resident needs. Pennsylvania nursing regulations cited in the report required RNs and LPNs performing intravenous therapy, including central venous catheter care, to complete approved education, supervised clinical instruction, and competency demonstration. Resident 6 was admitted with osteomyelitis and had a physician order to maintain a PICC line and monitor the insertion site each shift for signs of infection or infiltration. A later physician order directed Vancomycin 1,000 mg IV daily for treatment of osteomyelitis. The July 2026 MAR showed an LPN documented administering Vancomycin through the PICC line on multiple occasions. Employee records showed the two LPNs involved were hired in February 2026 and June 2026, but their files contained no documented competency assessment or validation for PICC line management, central venous catheter patency, or administration of medications through a central venous catheter. The competency documentation section also had no completion dates entered for either employee, and during interview the NHA and DON were unable to provide documentation showing either LPN had completed competency validation before providing care to Resident 6.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to promptly notify the attending physician of a significant change in condition for Resident 107. The resident was admitted with diagnoses including acute respiratory failure and heart failure, and a quarterly MDS dated May 26, 2026, showed the resident was cognitively intact with a BIMS score of 15. On June 30, 2026, the resident was seen for weight gain and increasing oxygen requirement. The physician documented that the resident refused an intramuscular diuretic that morning, continued to refuse hospitalization or a change in code status, and had new orders to increase oxygen to 5.0 L/min and later increase oral furosemide to 80 mg twice daily. Later that day, the resident refused the newly ordered oral furosemide 80 mg. The clinical record showed repeated low oxygen saturation readings despite the increased oxygen order, including values of 87% to 89% on June 30 and 88% on July 1 while on nasal cannula oxygen. The record contained no documented evidence that the facility notified the physician of the resident’s refusal of the oral furosemide or of the continued low oxygen saturation after the revised oxygen order was implemented. A progress note on July 1, 2026, at 5:30 AM documented that Resident 107 was found unresponsive. During an interview on July 31, 2026, the Nursing Home Administrator and DON reviewed the findings and confirmed there was no documented evidence that the physician had been notified after the resident refused the newly prescribed oral furosemide or continued to have oxygen saturation levels of 87% to 89%.
Incomplete investigation of alleged resident property misappropriation
Penalty
Summary
The facility failed to conduct a thorough internal investigation after receiving an allegation of possible misappropriation of resident property involving a resident who was cognitively intact with a BIMS score of 15 and had diagnoses including bipolar disorder, anxiety, and intellectual disability. The facility’s Abuse Policy required allegations of abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source to be promptly reported and thoroughly investigated by the administrator and/or designee, with investigations including all reports and allegations of abuse. A nurse’s progress note documented that the resident reported someone had entered the room and cut the electrical cord to the resident’s personal refrigerator, which had been cut in two places. The resident stated someone should be held responsible and said the resident intended to contact law enforcement and a family member. Another note documented the resident later alleged a housekeeper cut the cord, while staff documented housekeeping did not work during the time identified by the resident. During surveyor interview, the resident stated someone had cut the cord but did not know who damaged it or how it occurred, and the refrigerator remained in the room with the cord cut and not operational. The Nursing Home Administrator and DON confirmed they did not know how the cord was cut, who cut it, why it was cut, or where the severed portion was until surveyor inquiry prompted additional discussion. The Maintenance Director stated he had responded to the issue, restored electrical service, spoke with the resident, and later found the severed portion of the cord concealed in the resident’s room. The facility could not provide documentation showing it obtained a statement from the resident or Maintenance Director, identified and interviewed all relevant witnesses, reviewed staff assignments or other investigative information, completed a written investigative summary, or documented investigative findings or a conclusion regarding the allegation.
Failure to Investigate and Resolve Grievance About Delayed Call Bell Response
Penalty
Summary
The facility failed to thoroughly investigate and resolve a grievance regarding delayed call bell response times for three cognitively intact residents with BIMS scores of 13 to 15. Resident Council meeting minutes showed that residents complained that call bells were not being answered in a timely manner, and a grievance was filed on their behalf. The grievance record for the complaint involving the three residents stated that random call bell audits would be completed, the grievance was not confirmed, and the file was closed as resolved on June 1, 2026, but there was no documented evidence that the facility actively investigated the complaint, interviewed the affected residents, or provided a written decision or follow-up conversation before closing the grievance. During interviews, the residents reported that the problem continued after the grievance was filed. One resident stated she still waited up to an hour, especially on later shifts, and had received no contact from staff about the complaint. Another resident reported no follow-up, said she was never interviewed for more details, and described a prolonged wait after ringing the bell. A third resident stated she continued to wait one hour or more for assistance, especially on second shift, and said no one from administration had interviewed her or provided a status update. The NHA was unable to provide evidence of prompt, good faith efforts to investigate or resolve the grievance or to show that the residents were kept informed of the resolution progress.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide services to maintain a clean and homelike environment for residents in two nursing units, East and West. During observations, surveyors found grey circular discolorations, dirt accumulation, and floor stains in front of resident room entrances and bathrooms. In one room, a garbage can had a folded plastic liner sitting on the bottom instead of being properly inserted, and it contained an empty soda bottle, a cup, and several devices used to clean IV sites. The same room also had a bedside chair with an unfolded blanket on the seat, two pillows without pillow covers, a wheelchair with leg rests, a lifting harness, and seating devices placed in front of cabinetry, limiting access. Additional observations showed a urinal on the back of a toilet, a bedpan on the bathroom floor, and debris on the bathroom flooring. In another room, the bedside table had tan liquid stains on the white bed sheets and pillowcase, with a blue disposable glove and pieces of toilet paper under the bed, a clear plastic glove on the floor near the garbage can, and dirt and debris around the can. Surveyors also observed a kitchen tile floor with dirt, debris, and grime under and extending from the dishwashing station, a PVC pipe with sediment and dirt stains, and a plunger stored under a stainless steel table. Other resident rooms had tan, yellow, and gray stains on linens and floors, and urine graduates and catch basins were left on bathroom floors without resident names identified. The findings were reviewed with the NHA during the survey.
Failure to Timely Notify Family Member of Resident Status Changes and Treatment Updates
Penalty
Summary
The facility failed to timely inform and update an interested family member about a cognitively intact resident’s changes in condition, ongoing assessments, diagnostic results, and medication changes. The resident was admitted with spinal stenosis and kidney disease, and the admission MDS dated March 20, 2026, showed a BIMS score of 13. The resident’s daughter was identified in the clinical record as the interested family member involved in the resident’s care and well-being. The record showed a new medication was ordered for elevated blood glucose levels on March 23, 2026, and an increase in Oxycodone from 2.5 mg to 5 mg as needed for back pain on March 24, 2026, but there was no evidence the daughter was timely notified of either change. On March 31, 2026, the resident had not voided during the day and evening shifts, and although the daughter was notified at 9:38 PM, subsequent notes at 2:30 AM and 6:06 AM on April 1, 2026, did not show that she was updated about the continued lack of urinary output and ongoing assessment. A KUB result became available on April 21, 2026, at 2:50 PM, but the daughter was not informed until April 22, 2026, at 8:09 AM. The Nursing Home Administrator was unable to provide evidence that the family member was timely informed or updated regarding these status changes, assessments, diagnostic results, or medication adjustments.
Failure to Maintain Clean and Homelike Environment Across Nursing Units
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment on both the West and East Nursing Units, as evidenced by multiple observations and resident reports. Specifically, the outer surface and surrounding floor of the ice machine in the East Nursing Unit were visibly soiled, and the wall fabric opposite the ice machine was stained and discolored. The vinyl baseboard molding in the area was also in need of repair. A strong urine-like odor was detected in the Short Hall of the East Nursing Unit, and the floors in a resident room were sticky and tacky, with a foul odor present in both the room and the adjacent hallway. Additionally, a large soiled brief was found in the bathroom sink between two resident rooms. In the dining/activity area of another unit, a buildup of cobwebs was observed behind the counter next to the refrigerator. A resident with chronic kidney disease and paraplegia, who was cognitively intact, reported that after a bowel movement in her wheelchair, staff cleaned her but missed areas of the wheelchair, which remained unclean. Upon inspection, the wheelchair's back support was found to have a rip in the fabric, forming a pocket that contained a thick brown and black residue. The Nursing Home Administrator confirmed that it is the facility's responsibility to provide services to maintain a clean and homelike environment for all residents.
Failure to Provide Evening Activities to Meet Resident Needs
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of residents, specifically by not offering evening activities. During a resident group interview, four out of five residents expressed concerns about the lack of evening activities, with specific requests for the return of a recreation card club, arts and crafts, movie nights, and bingo after dinner. The residents indicated that there was little to do in the evenings and desired more structured activities during that time. A review of the Resident Activity Calendar for the month showed that the latest scheduled activity each day was at 2:00 PM, with no activities planned for the evening. The Director of Activities confirmed that there were no staff scheduled to facilitate evening programs and acknowledged that residents had requested such activities. The Nursing Home Administrator also confirmed the absence of structured evening activities, attributing it to staffing limitations. This lack of evening programming resulted in the facility not meeting the activity needs and interests of its residents.
Unsanitary Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the food and nutrition services department and a resident pantry area, which could lead to food contamination and microbial growth. Specifically, there was a three-quarter inch hole in the wall grout near the handwashing sink, and a build-up of dirt and debris was found along the perimeter of the kitchen and under the tray line counter area. These unsanitary conditions were directly observed during the initial tour with the foodservice director. Additionally, in the resident pantry area on the West Nursing Unit, two four-ounce containers of applesauce, two four-ounce containers of canned pears, and two covered eight-ounce glasses of milk were found without dates indicating when they were available for use. The food service director confirmed that food items were required to be dated to ensure quality and food safety. These findings demonstrate a failure to follow safe food storage and handling practices as required by professional standards and facility policy.
Improper Deduction of Medicaid Resident's Personal Needs Allowance for Facility Debt
Penalty
Summary
The facility failed to protect a resident's personal funds by charging her personal needs allowance (PNA) for services that are covered under Medicaid. The resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease (COPD), was admitted with a monthly income from which the PNA was deducted, as required by Medicaid regulations. Despite this, the facility deducted an additional $20.00 each month from the resident's PNA to pay off a debt owed to the facility, as agreed upon in a payment agreement signed by the resident. The deductions were made over a period of nearly two years, totaling $460.00, with additional unclear debits also noted in the resident's account. Interviews with the resident and facility staff confirmed that the resident was not informed that she was not obligated to pay her outstanding balance from her PNA funds. The business office manager acknowledged the arrangement and the facility's role as the resident's representative payee, while the nursing home administrator confirmed the ongoing deductions and the lack of documentation showing the resident was properly informed of her rights regarding the use of her PNA. The facility's actions were found to be in violation of state regulations regarding the management of resident funds and resident rights.
Failure to Develop Person-Centered Care Plan for Limited Range of Motion and Device Non-Compliance
Penalty
Summary
The facility failed to develop a person-centered care plan to address a resident's limited range of motion in the left upper extremity and non-compliance with a physician-ordered therapeutic device. The resident, who had a history of cerebrovascular accident (stroke) and depression, was documented to have moderate cognitive impairment and impairment of the left upper extremity. Physician orders and occupational therapy recommendations specified the use of a soft palm roll to the left hand at all times, except during range of motion, hygiene, and skin checks, to maintain skin integrity and prevent further contracture. Despite these orders, observations revealed the resident was frequently found without the soft palm roll in place, and staff confirmed the resident often removed the device using her right hand. Review of the resident's care plan showed it did not address the limited range of motion or the resident's non-compliance with the prescribed soft palm roll. Interviews with staff, including an LPN and the DON, confirmed the resident's non-compliance and the absence of a care plan to address these issues. The Nursing Home Administrator was unable to provide documentation of a care plan that included interventions for the resident's limited range of motion or strategies to address non-compliance with the therapeutic device, resulting in a deficiency under nursing services regulations.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Label and Date Enteral Feeding Syringes
Penalty
Summary
The facility failed to ensure that enteral feeding syringes in use were labeled and dated, and did not provide direction on the maximum time such syringes may remain in service. Observation revealed a 60 mL enteral syringe used for a resident's PEG tube was found on the room windowsill with a clear plastic bag beneath it containing tan residue; neither the syringe nor the bag was labeled or dated. Staff confirmed the syringe was opened but not labeled or dated. Review of the facility's policy showed it did not address labeling, dating, rinsing, or disposal timeframes for enteral syringes, despite staff and administration stating that syringes should be labeled and dated. The resident involved had diagnoses including dysphagia and non-traumatic intracerebral hemorrhage, and required a PEG tube for continuous enteral feeding. Physician orders directed staff to check PEG placement prior to each use and to administer water before and after medications. The lack of labeling and dating of the enteral syringe, as well as the absence of clear policy guidance on the handling and disposal of these syringes, constituted the deficiency identified during the survey.
Failure to Maintain and Remove Respiratory Equipment per Policy
Penalty
Summary
The facility failed to maintain respiratory equipment in accordance with its own Equipment Management Policy for one resident. The policy required that nebulizer machine tubing and masks be changed weekly and as needed to ensure sanitary conditions and safe function. Observation revealed that a nebulizer machine in a resident's room contained tubing and a mask that were not dated to indicate when they were last changed. The nebulizer bowl and tubing were marked with a date from three months prior, and staff confirmed that these items had not been replaced since that time, contrary to facility policy. Further review of the resident's clinical record showed that there was no current physician's order for nebulizer treatments, and the DON confirmed that the resident had previously received treatments earlier in the year, but the equipment was not removed from the room after treatments were discontinued. The respiratory equipment remained in the resident's room and was not maintained as required by policy, as confirmed by staff interviews and record review.
Failure to Maintain Clean and Homelike Environment Due to Persistent Odors and Pest Infestation
Penalty
Summary
The facility failed to maintain a clean and homelike environment on one of its nursing units, as evidenced by multiple observations and resident and staff interviews. In one resident's bathroom, a persistent, strong musty urine odor was noted, with the resident's representative confirming that the smell returns shortly after cleaning and negatively impacts the resident's living experience. Follow-up observation confirmed the odor remained present. Additionally, live and dead insects, including large black ants, spiders, flying insects, centipedes, and worms, were observed throughout the unit's common areas, hallways, and resident rooms. In one resident's room, several large black ants were seen crawling on the bedside table and personal items, and the resident reported that the ants had been present for several weeks, causing frustration and distress. An LPN confirmed the ongoing ant issue and removed contaminated items from the resident's bedside table. Further observations revealed several large spiders with extensive webs, dead ants, a flying insect, and a dead worm near the west exit area. Another resident reported frequently seeing and killing ants in her room, describing them as large black ants. A dead centipede was also found in the unit dining room. The Nursing Home Administrator confirmed the presence of live and dead pests during a subsequent tour and acknowledged the facility's responsibility to maintain a clean and homelike environment for residents.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum required number of NAs on the day, evening, and night shifts for 18 out of 21 shifts reviewed. On the day shift, the facility consistently fell short of the required 1:10 NA to resident ratio, with staffing levels ranging from 5.66 to 7.72 NAs for resident censuses between 80 and 83. Similarly, the evening shift did not meet the 1:11 ratio, with staffing levels between 6.06 and 7.16 NAs for the same resident censuses. The night shift also failed to meet the 1:15 ratio, with staffing levels between 3.56 and 4.69 NAs. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged the facility's failure to meet the required staffing levels. The report does not mention any additional higher-level staff being available to compensate for the staffing shortfall. This consistent understaffing across multiple shifts indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. The new scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on four shifts out of 21 reviewed. Specifically, on March 27 and March 29, 2025, the day shift staffing was below the required 1 LPN per 25 residents, with 3.22 and 3.06 LPNs respectively, instead of the required 3.28 for a census of 82. On March 28, 2025, the evening shift had 2.69 LPNs instead of the required 2.73 for a 1:30 ratio, and the night shift had 1.88 LPNs instead of the required 2.05 for a 1:40 ratio. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates during an interview on April 1, 2025.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. New scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. LPN call outs are the issue with fulfilling this need consistently, so all efforts are made to replace this hole when it occurs. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day. This deficiency was identified through a review of the facility's staffing levels and confirmed by staff interviews. Specifically, on five out of the seven days reviewed, the facility's nursing care hours fell below the required minimum. On March 27, 2025, the facility provided 3.09 hours, on March 28, 2025, 2.74 hours, on March 29, 2025, 2.80 hours, on March 30, 2025, 2.85 hours, and on March 31, 2025, 3.05 hours of direct care per resident. An interview with the Nursing Home Administrator confirmed the facility's failure to consistently meet the required nursing care hours.
Plan Of Correction
Facility cannot retroactively correct this deficiency. New scheduling system in place to assist with replacing call offs and filling open shifts via automatic blasts to staff. New scheduling system also has the ability to post open shifts to all staff including agency. Agency call offs are attempted to be replaced by the agency with additional bonus as needed. Recruitment of nursing staff will continue via facility website, Indeed, recruiting group, social media websites, local newspaper, job fairs, open house and off site recruiters. Agency utilized for open shifts. Retention efforts made with any resignation. Agency rates are reviewed weekly to ensure marketable and adjustments made as necessary. Text Blast for all open shifts. Facility recruiters have purchased list of nursing and aide staff to reach out to for recruitment. New onsite HR Director hired with extensive retention and recruitment experience. Calculation of daily PPD and shift ratios will be completed and reviewed daily for accuracy by the scheduler/back up scheduler, DON/ADON and NHA. All efforts will be made to meet PPD and staffing ratios. If call offs occur, all efforts will be made to attempt to fill that position. Daily PPD and ratios will be audited weekly x4, then monthly x2. Results to QA for review and recommendations.
Failure to Administer Medication and Arrange Transportation
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for a resident who was admitted with multiple diagnoses, including respiratory failure with hypoxia, COPD, congestive heart failure, and diabetes. A physician order dated December 17, 2024, required the administration of Torsemide, a diuretic, every 24 hours as needed for edema for three days. Despite documentation indicating the presence of edema on multiple shifts between December 17 and December 20, 2024, the medication was never administered. There was no nursing assessment describing the extent or location of the edema, nor was there any evidence that the physician was notified to clarify whether the medication should have been given. Additionally, the resident had a scheduled Pulmonary Medicine appointment on December 23, 2024, which was missed due to the facility's failure to arrange necessary transportation. An interview with the administrator confirmed these deficiencies, indicating that the facility did not ensure the resident received treatment and care in accordance with professional standards of practice and physician orders, potentially impacting the resident's health and well-being.
Deficiency in Nutritional Oversight and Consultation
Penalty
Summary
The facility failed to ensure that the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. The director of food and nutrition services had been employed for four years and had recently completed a course to become a certified dietary manager but had not yet passed the exam. Although the facility employed a part-time Consultant Registered Dietitian (RD) who worked remotely approximately 20 hours per week, there were no frequently scheduled consultations between the director and the Consultant RD. The Consultant RD confirmed that she completed all job tasks, including nutritional assessments, remotely with input from the interdisciplinary team, including nursing and the director of food and nutrition services. However, the Consultant RD did not have face-to-face interactions with residents, did not contact residents by phone before completing nutritional assessments, and had not been in the facility to observe residents' ability to eat or provide nutritional consultation. The nursing home administrator failed to provide documented evidence that the services of the Consultant RD included face-to-face interactions with residents to ensure appropriate nutritional oversight, nor that the director received frequently scheduled consultations from the Consultant RD.
Delayed Response to Resident Call Bells Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely assistance to residents, compromising their quality of life and dignity. Resident 42, who is cognitively intact and suffers from chronic kidney disease and fibromyalgia, reported waiting 45 minutes to an hour for assistance after ringing the call bell, particularly during the second shift. The resident expressed frustration over the long wait times and noted that staff often appeared stressed and unpleasant when they finally responded. This issue was attributed to low nurse staffing, which occurred several times a week. During a group interview, four out of five residents expressed similar concerns about prolonged wait times for assistance. One resident reported waiting over 20 minutes when staffing was low, while another mentioned waiting over an hour, resulting in soiling themselves due to the delay. These residents indicated that the longest wait times occurred in the mornings and afternoons, and they felt the facility was understaffed multiple times a week. The Nursing Home Administrator and Director of Nursing acknowledged that residents should be treated with dignity and respect but could not explain the untimely responses to residents' requests for assistance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two out of three nursing units, specifically the 100 and 200 Halls. Observations revealed several deficiencies: a bathroom with brown stains on the floor and doorframe, a window air conditioning unit with a large build-up of dust and black substances, a bed with a stained sheet and debris on the floor, and a hallway with stained and discolored floor trim and wall fabric. These observations were confirmed by the Nursing Home Administrator, who acknowledged the facility's responsibility to provide a clean environment for residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their clinical records. Resident 53, who was admitted with a diagnosis of Alzheimer's disease, had a physician's order for Apixaban, an anticoagulant medication, to be administered twice daily. Despite this, the resident's quarterly MDS assessment inaccurately indicated that no anticoagulant medication was received during the 7-day look-back period. This inaccuracy was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview. Similarly, Resident 70's discharge MDS assessment inaccurately documented the discharge status. The assessment stated that the resident was discharged to a short-term general hospital, whereas a discharge note revealed that the resident was actually discharged home, accompanied by her spouse. This discrepancy was confirmed by the Nursing Home Administrator. These inaccuracies in the MDS assessments reflect a failure in the facility's management and nursing services as per the cited Pennsylvania Code regulations.
Failure to Prevent Injury During Resident Transfer
Penalty
Summary
The facility failed to implement effective safety measures to prevent an injury during a transfer for a resident with severe cognitive impairment and osteoporosis. The resident required extensive-to-total assistance with mobility and transfers, as indicated in their care plan. On the day of the incident, the resident sustained a laceration on the right shin during a transfer from bed to wheelchair using a sit-to-stand lift. The injury was discovered after the transfer when blood was noticed on the resident's pants. The facility's investigation could not determine the exact cause of the injury, but it was suggested that the resident's leg might have hit the wheelchair during the initial transfer attempt. The resident was admitted to the emergency department for further evaluation, where the laceration was treated with sutures. Both nurse aides involved in the transfer had satisfactory competency evaluations for transfer skills and knowledge. Despite this, the Nursing Home Administrator confirmed that the facility is responsible for ensuring effective safety measures to prevent such accidents and injuries. The deficiency was identified under the Pennsylvania Code for nursing services and management.
Failure to Administer IV Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure the proper administration of physician-ordered intravenous antibiotics for two residents. Resident CR1, who was admitted with chronic osteomyelitis of the left ankle and foot, had orders for Ampicillin and Vancomycin to be administered at specific times. However, on multiple occasions, doses of these antibiotics were not administered as scheduled, and there was no documentation of the reasons for the missed doses or notification to the physician. Specifically, on November 10, 2024, two doses of Ampicillin were missed, and on November 13, 2024, a dose of both Ampicillin and Vancomycin was missed. The facility's policy requires documentation in the eMAR system after each medication administration, which was not adhered to in these instances. Similarly, Resident 122, admitted with a septic left knee prosthetic joint infection, had a physician order for Cefazolin Sodium to be administered every eight hours. On November 30, 2024, the 10:00 PM dose was not administered, and there was no documented evidence that the physician was notified of this missed dose. The Nursing Home Administrator confirmed the lack of documentation and adherence to the facility's policy, which mandates that medication administration be documented in the eMAR system to confirm compliance with physician orders.
Failure to Act on Pharmacist's Medication Review
Penalty
Summary
The attending physician failed to act upon pharmacist-identified irregularities in the medication regimen of a resident diagnosed with bipolar disorder and schizoaffective disorder. The resident was prescribed Depakote ER 250mg, a medication used to stabilize mood, and the consultant pharmacist recommended a review for a gradual dose reduction. However, the attending physician did not provide an appropriate response to this recommendation. Instead, the facility's consultant psychiatric CRNP responded to the pharmacy recommendation and signed off on it, while the attending physician merely cosigned without documenting the rationale and justification for the continued use of Depakote. An interview with the Director of Nursing confirmed that the CRNP was handling the pharmacy recommendations and that the attending physician failed to document the justification for the continued use of the medication in the resident's clinical record.
Failure to Timely Assess and Provide Care for Resident
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for a resident who was admitted with acute respiratory failure, atrial fibrillation, bradycardia, and adult failure to thrive. On one occasion, the resident was found in respiratory distress with a blood oxygen level of 60%, and despite being administered oxygen, the level only increased to 78%. The resident was sent to the hospital for acute respiratory distress and pneumonia. Upon readmission, the resident expressed feeling like he was dying and had trouble breathing, but there were no documented vital signs at that time. Later, the resident exhibited bradycardia, and a stat EKG was ordered. Further documentation revealed that the resident had increased lung secretions, but no vital signs or physical assessment were documented at that time. Eventually, the resident was found difficult to arouse, with low blood pressure and low SPO2 levels, leading to another hospital transfer for acute respiratory failure with hypoxia. The Nursing Home Administrator and Director of Nursing confirmed that the facility staff failed to timely assess and provide care after a change in the resident's condition was noted.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to plan menus that accommodate residents' food preferences, leading to dissatisfaction among residents. This deficiency was identified through a review of the facility's grievance log, interviews with residents and staff, and an examination of the facility's planned menus. Residents B2, B3, B4, and B5 expressed concerns about the lack of variety and repetitiveness in the meals served. Despite voicing their preferences and suggestions during Food Committee meetings, residents felt their input was not considered in the menu planning process. Specific grievances included Resident B2's concern about the lack of variety and Resident B5's complaint about the overuse of eggs at breakfast. Interviews with the dietary manager and the Nursing Home Administrator confirmed these issues, revealing that the facility's cycle menus were developed by the corporate dietitian without adequately considering the residents' preferences. A detailed review of the facility's 4-week Spring/Summer menu cycle further highlighted the repetitiveness and lack of variety in meal planning. For instance, beef and poultry were served in consecutive meals multiple times, and similar meal patterns were observed across different weeks. The dietary manager acknowledged that residents' preferences were not always considered in menu development, and the Nursing Home Administrator confirmed the lack of variety and repetitiveness in the meals. This failure to accommodate residents' food preferences and provide appealing meal options led to dissatisfaction among the residents, as documented in the grievance log and resident interviews.
Failure to Honor Resident's Right to Refuse Treatment
Penalty
Summary
The facility failed to honor a resident's right to participate in their treatment and health care decision-making, including the right to refuse specific treatment. Resident B1, who was cognitively intact with a BIMS score of 15, expressed a desire to refuse the prescribed therapeutic diet despite being informed of the risks by the facility's Registered Dietitian (RD) and Assistant Director of Nursing (ADON). The resident, diagnosed with type two diabetes, cirrhosis of the liver, and major depressive disorder, stated a preference to eat whatever they wanted, acknowledging the risks involved. Despite this, the attending physician did not address the resident's wishes for a liberalized diet, and the facility continued to enforce the therapeutic diet without honoring the resident's decision to refuse it. During an interview with the Nursing Home Administrator (NHA), it was confirmed that the resident was capable of making their own decisions and that the facility failed to honor the resident's right to make informed decisions about their dietary treatment plan. The NHA acknowledged that the attending physician would not agree to liberalizing the diet, despite the resident's continued non-compliance and expressed wishes. This failure to respect the resident's autonomy and right to refuse treatment constitutes a deficiency in the facility's compliance with long-term care regulatory requirements.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide adequate housekeeping services to maintain a clean and orderly environment for residents, specifically Residents B2 and B3. A grievance lodged by these residents on March 26, 2024, highlighted concerns about the cleanliness of their room, particularly on weekends. During an interview on April 16, 2024, both residents confirmed that their bathroom was not always cleaned, and the windows and window treatments in their room were very dirty. Observations on the same day revealed a strong smell of urine, a soiled rag on the bathroom floor, sticky floors, and yellow urine-like stains on the base of the toilet. Additionally, several soiled briefs were found in the bathroom garbage receptacle. The windows were heavily coated with a white film, and the window treatments were dusty. Similar cleanliness issues were observed in the west recreation lounge and another resident bathroom, where a pink substance was found in the sink and on the floor, and the base of the toilet had yellow stains. The windows and blinds in this room were also dirty and dusty. An interview with the Nursing Home Administrator (NHA) confirmed that resident rooms, bathrooms, and common areas were expected to be maintained in a clean and sanitary manner. However, the observations and grievances indicate that the facility failed to meet these standards, resulting in an unsanitary living environment for the residents. The findings were in violation of 28 Pa. Code 201.18 (e)(2.1) Management.
Inaccurate MDS Assessment for Resident Discharge Goals
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, Resident 62's Admission MDS assessment inaccurately indicated that her overall goal for discharge was to remain in the facility, despite multiple records and staff interviews confirming her goal was to return home after her therapeutic stay. The resident's clinical record, plan of care, and progress notes all indicated her wish to be rehabilitated and return to her daughter's home. This discrepancy was confirmed through interviews with the Social Services employee and the Nursing Home Administrator.
Obstructed Hallway Creates Accident Hazard
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards and obstacles to safe mobility on the 200-nursing unit. Observations on April 16, 2024, at approximately 10:35 AM and 10:50 AM revealed that the hallway from resident room [ROOM NUMBER] to 207 was obstructed with mechanical lifts, linen carts, soiled linen and trash hampers, and wheelchairs. These items blocked access to the corridor handrails, which are intended for resident ambulation or mobility assistance. The Nursing Home Administrator confirmed the obstruction at approximately 10:55 AM, and the maintenance director measured the distance of the obstructed hallway to be approximately 91 feet at 11:30 AM.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Orangeville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Ridge Rehabilitation And Nursing Center | 2.8 mi | ★★★★★ | 13 | 0 |
| Gardens At Millville, The | 6.5 mi | ★★★★★ | 13 | 0 |
| Glen Brook Rehabilitation And Healthcare Center | 9.3 mi | ★★★★★ | 14 | 0 |
| Bonham Nursing And Rehabilitation Center | 11.4 mi | — | 1 | 0 |
| Grandview Nursing And Rehabilitation | 11.7 mi | — | 20 | 0 |
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