Gardens At West Shore, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Camp Hill, Pennsylvania.
- Location
- 770 Poplar Church Road, Camp Hill, Pennsylvania 17011
- CMS Provider Number
- 395223
- Inspections on file
- 47
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Gardens At West Shore, The during CMS and state inspections, most recent first.
A resident with alcoholic cirrhosis, hepatic encephalopathy, and GERD, care planned as a moderate elopement risk with a wander guard and need for direct supervision outdoors, exited through the main entrance undetected. Facility policy required monitoring of elopement-risk residents and functional wander guard devices, but camera footage showed the resident leaving the lobby while the receptionist did not notice anyone exiting. The resident’s absence was not recognized for several hours, and staff only initiated a search after noting the resident had been gone a long time. The NHA later reported that the door’s wander guard system was only intermittently alarming and had a closing delay that could allow exit without an alarm. The resident was found in the street some distance from the facility, and this failure to supervise also placed multiple other elopement-risk residents with wander guards on unlocked units in Immediate Jeopardy.
A resident with depression, CHF, HTN, and a care plan identifying risk for skin breakdown due to incontinence and mobility deficits was not provided needed incontinence care by the assigned CNA, despite having requested help after a bowel movement. Later in the day, another CNA found the resident soaked in urine and feces, with diarrhea caked from groin to thighs and bright red buttocks, and the resident reported not being changed since morning and fearing retaliation. Review of assignment sheets and documentation showed the resident was on the CNA’s assignment, but no incontinence care was documented for that shift, and subsequent RN assessments documented reddened, non-blanchable and then blanching redness and moisture in the peri area consistent with superficial incontinence-associated dermatitis.
A resident with alcoholic cirrhosis, hepatic encephalopathy, and GERD eloped from the facility and was later found off premises. Although an incident report with a detailed description of the elopement was completed and marked as privileged and not part of the medical record, no corresponding progress note or documentation of the event appeared in the resident’s clinical record. The RDCS indicated that a system step may not have been completed to transfer the risk management note into the clinical record, resulting in noncompliance with facility policy and state medical record requirements.
Surveyors observed one shower room with visible black, pink, and brown substances on the ceiling, walls, and floor, as well as a strong mildew odor and scattered items on the floor. Two residents expressed concerns about the room being dirty and containing mold. The facility's policy requires a clean and safe environment, which was not upheld in this case.
Three residents' assessments were found to be inaccurate: a resident's use of a removable soft helmet was incorrectly coded as a restraint, another resident's use of a hypnotic medication was omitted from MDS documentation, and a third resident's receipt of antipsychotic medication was not reflected in the MDS, despite administration records and staff confirmation.
A resident's care plan was not updated to reflect a change in code status, the development of a new pressure ulcer, or the discontinuation of a PICC line. The care plan continued to list outdated information and omitted new physician orders, despite facility policy requiring ongoing assessment and revision of care plans as resident conditions change.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet required care standards.
The facility did not ensure that pharmacy recommendations for two residents were properly addressed and documented. For one resident, there was no evidence of a physician response to a pharmacy suggestion for gradual dose reduction of multiple medications. For another, repeated pharmacy recommendations to reduce a psychotropic medication were declined by the physician, citing psychiatric follow-up that was not supported by recent documentation. Staff confirmed the lack of appropriate clinical rationale and documentation for these actions.
The facility did not ensure that kitchen equipment, including the dish machine, was operated and monitored according to professional standards. Dish machine rinse temperatures were repeatedly below required levels, and temperature logs for both the dish machine and refrigerators were incomplete or missing for extended periods. Staff were uncertain about proper procedures, and no corrective actions were documented.
A resident with diabetes and hypertension was repeatedly observed lying in bed with their call bell on the floor and out of reach, despite being able to use it and facility policy requiring accessibility. The DON confirmed the expectation that the call bell should have been within reach.
A resident with PTSD and anxiety disorder had a PRN order for Klonopin to treat anxiety that did not include the required 14-day stop date or documented rationale for extension, as mandated by facility policy. The facility's electronic health record system classified the medication as an anticonvulsant, which prevented the order from being flagged for review, resulting in noncompliance with psychotropic medication protocols.
A resident with left-sided weakness following a stroke did not receive timely evaluation or provision of a lower extremity brace, despite repeated provider requests for a PT consult. The necessary therapy request was not submitted, and there was a lack of communication between the CRNP and nursing staff, resulting in the resident not receiving appropriate services or equipment to maintain or improve mobility.
The facility did not ensure that nurse aides completed the required 12 hours of annual in-service training, including dementia management and abuse prevention. Three nurse aides, hired in 2001, 2005, and 2010, lacked documentation of completing these training requirements in the past year. The Nursing Home Administrator acknowledged the deficiency and mentioned a future training event to address the issue.
The facility failed to ensure accurate MDS coding for several residents, leading to discrepancies in documented diagnoses and treatments. Errors included unreported hospice services, incorrect fall reports, and omitted diagnoses such as PTSD and bipolar disorder. These inaccuracies reflect systemic issues in the facility's assessment practices.
The facility failed to update care plans for several residents, including those with new medical conditions or changes in treatment, such as fungal infections, UTIs, and advanced directives. Additionally, a resident was not invited to participate in care plan meetings, violating their right to be involved in their care planning process.
A facility failed to provide dialysis care consistent with professional standards for a resident with ESRD. The facility did not maintain complete records of dialysis communication, with missing sheets and undocumented weights. Additionally, blood pressure was incorrectly documented in the resident's arm with the dialysis access, contrary to the care plan. Interviews confirmed the inability to locate missing documentation and acknowledged inaccuracies.
The facility did not complete annual performance evaluations for four nurse aides, as required. The personnel files for these employees lacked documentation of evaluations, despite their long-standing employment. The Nursing Home Administrator confirmed the absence of these evaluations during an interview.
The facility failed to maintain professional standards for food service safety, with expired test strips used for sanitizer testing, unlabeled and undated food storage bins, and incomplete temperature logs in multiple pantry areas. Spills and unclean conditions were also observed, indicating non-compliance with facility policies.
The facility failed to implement proper infection control measures for three residents. A resident with ESBL colonization lacked EBP signage, and another with a suprapubic catheter was not placed on EBP until the survey. Additionally, staff did not wear gowns during wound care for a resident on EBP, indicating a lapse in adherence to infection control protocols.
A facility failed to follow physician orders for a resident with bipolar disorder and diabetes mellitus. The resident's blood sugar levels exceeded 400 on multiple occasions, but there was no documentation that the physician was notified as required. The Regional Director of Clinical Services confirmed the lack of documentation and the expectation to follow physician orders.
A resident at risk for pressure ulcers was observed multiple times without the prescribed heel lift suspension boots, which were intended to reduce pressure and promote healing. Despite the clinical record indicating daily use, the boots were found in the corner of the room. The Nursing Home Administrator acknowledged the issue, revealing a lapse in implementing the resident's care plan.
A resident with schizoaffective disorder and muscle weakness was found on the floor after being left unattended in a wheelchair without access to a call bell. The care plan, which required the call light to be within reach, was not followed, leading to the incident. The facility failed to provide adequate supervision and assistance, as required by Pennsylvania Code regulations.
A resident with PTSD and major depressive disorder did not receive trauma-informed care due to the absence of a comprehensive care plan addressing her condition and triggers. Facility staff, including an LPN and the Regional Director of Clinical Services, were unaware of the resident's trauma history and triggers, as the necessary care plan was not developed. The Social Worker admitted the admission assessment was likely missed, leading to this oversight.
A facility failed to maintain accurate records for controlled drugs, as evidenced by an unsigned medication disposition form for a resident who had Alzheimer's and hypertension. The form, which should have included signatures for medications like Trazadone and Risperidone, was incomplete, indicating a lapse in the facility's pharmaceutical services.
A facility failed to monitor a resident for side effects of an antipsychotic medication, risperidone, as required by their policy. The resident, diagnosed with dementia and psychosis, had no documentation of side effect monitoring in their clinical record, and their care plan did not reflect the medication use. The Nursing Home Administrator confirmed that monitoring should have been implemented.
A resident with psychosis and dementia experienced a significant weight loss of 34 pounds over one month, which was not adequately monitored or documented by the facility. The facility's policy required regular weight checks, but weights were not recorded in June or September. Staff indicated the resident often refused weights, but this was not documented or care planned. A pending order for weekly weights was noted but not yet implemented.
The facility failed to maintain a comfortable environment on the 1300 unit due to air conditioning issues. Residents reported discomfort from the heat, with room temperatures reaching up to 86°F. The facility's policy requires regular monitoring and maintenance of air conditioning systems, but these measures were not effectively implemented.
A resident with Alzheimer's and a history of stroke fell and required a CT scan, which was delayed due to scheduling issues and lack of communication. The scan was ordered after the fall, but not scheduled until over a month later, without informing the physician.
A resident with an unstageable pressure ulcer did not receive timely treatment due to the facility's failure to obtain necessary wound vac supplies. Despite recommendations from a wound clinic, the wound vac was not applied until several days later, as the facility struggled to source the supplies from central supply and pharmacy. Alternative treatments were ordered, but the facility could not provide evidence of attempts to acquire the supplies.
The facility failed to provide appropriate suprapubic catheter care and monitoring for a resident, resulting in an active infection requiring antibiotic treatment. The resident did not receive the prescribed catheter care due to an error in transcribing the physician's orders, and the facility did not implement urology specialist recommendations, leading to a significant lapse in care.
A resident with hypertension and anxiety was left in wet briefs for hours despite requesting to be changed. The facility had sufficient staff, but the care was delayed, and proper documentation was not maintained.
Elopement of At-Risk Resident Due to Door Alarm Failure and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent the elopement of a resident identified as being at risk for elopement. Facility policy on elopement, revised June 2023, states that residents at risk for elopement will be appropriately monitored to reduce potential injury and defines elopement as a resident leaving the premises without staff knowledge and supervision. Resident 3 had an elopement care plan in place since November 2025, identifying a potential for elopement and associated injury related to exit-seeking behavior and a desire to go home. Interventions included reorientation, encouragement of group activities, provision of diversional activities when exit seeking, redirection from exits, and use of a wander guard device with checks for placement and function each shift. Resident 3’s clinical record showed diagnoses including alcoholic cirrhosis of the liver, hepatic encephalopathy, and GERD. The resident had physician orders for a wander guard device, initially to the right ankle and later changed to the left ankle, with instructions to check placement every shift and function every night shift. An elopement/wander risk evaluation dated November 1, 2025, scored the resident as a moderate elopement risk. The care plan also documented that the resident required direct supervision while outdoors and needed one-person assistance with a walker for ambulation. Despite these identified risks and interventions, camera footage confirmed that Resident 3 exited the main entrance at 5:33 PM on February 4, 2026, without staff awareness. The resident’s absence was not discovered until approximately 8:45 PM, when staff realized the resident could not be located on the unit and within the facility, and the resident had not signed out. Staff interviews and witness statements indicated that the resident was last seen around dinner time and that staff only began searching after a nurse aide noted the resident had been gone for a long time. The receptionist reported not noticing anyone by the door and not seeing the resident exit. The Nursing Home Administrator later stated that the facility determined there was an issue with the wander guard system at the main entrance door, which was alarming only intermittently and had a closing delay that could allow someone to exit without triggering an alarm. Resident 3 was ultimately found by a staff RN in the street approximately 0.3 miles from the facility, after having crossed a heavily trafficked roadway in cold, dark conditions. This failure to provide adequate supervision and maintain effective elopement prevention measures also placed eight additional residents with elopement risk and wander guard orders on unlocked units in an Immediate Jeopardy situation.
Removal Plan
- Resident 3 was returned to the facility with no adverse outcome, a new wander guard was placed on the resident, and an updated elopement evaluation was completed.
- All facility residents with active orders for wander guards had devices checked for function.
- House-wide resident elopement scores were reviewed for accuracy and to ensure care plans were in place as indicated.
- Elopement binders were reviewed and updated to include residents with wander guards.
- The door system was evaluated for function.
- The over-ride button at the receptionist desk was disengaged and disabled until the door and wander guard system is repaired and function validated.
- A service call was placed to the door company and repairs were scheduled.
- A surveillance camera was installed in the lobby to continuously monitor the lobby area.
- Signage was installed on lobby exiting doors to remind visitors and staff to check surroundings when exiting the facility.
- The building entrance door was monitored continuously by the receptionist or designee until repairs were completed and the door and system were fully operational.
- Facility staff were re-educated on the facility elopement policy.
- Reception staff were educated that the over-ride button was disabled and that manual code entry must be used to unlock the door.
- Facility staff were educated to be mindful of who is behind them when exiting and to monitor for residents attempting to exit before the door fully closes.
- The DON or designee will conduct observational audits of door code entry to ensure the door is monitored until fully closed and report results to QAPI.
- The Maintenance Director or designee will conduct door and wander guard function audits once the door is repaired and report results to QAPI.
- Wander guard function audits will be checked daily on the shift and report results to QAPI.
Neglect of Incontinence Care Resulting in Incontinence-Associated Dermatitis
Penalty
Summary
The facility failed to ensure a resident’s right to be free from neglect when an assigned nurse aide did not provide necessary incontinence care, resulting in superficial incontinence-associated dermatitis. Facility policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The resident had diagnoses including major depressive disorder, congestive heart failure, and hypertension, and a comprehensive care plan identifying risk for skin breakdown and pressure injury related to incontinence and mobility deficits, with an intervention for assistance with AM/PM care and reporting abnormal skin observations. On the day of the incident, the resident reported to an aide at some point before noon that she had experienced a bowel movement and needed to be changed. The aide reportedly told the resident she would inform the assigned aide, and then left the room after the resident turned off the call light. Later, at the start of the evening shift, another nurse aide responded to the resident’s call bell and found the resident incontinent of urine and feces. The resident stated she had not been changed since the morning. An RN assessment at that time noted the bed was soaked from side to side, the brief was saturated and dripping, diarrhea was caked from the upper groin to both thighs, and the bilateral buttocks were bright red. The resident also stated she was fearful of retaliation from the aide she believed would think she had reported her. Review of the nurse aide assignment sheet showed that the resident was assigned to a specific nurse aide on day shift, although that aide later stated she did not provide any care to the resident because she believed the resident was not on her assignment. The NHA indicated that nurse aide assignments are created by licensed nursing staff and that aides are responsible for reviewing and understanding their assignments prior to the start of their shift. Review of nurse aide task documentation for that day showed no recorded incontinence care for the resident on day shift. Subsequent nursing documentation described reddened, non-blanchable skin to the buttocks and gluteal fold, with the resident reporting mild pain, and later notes described intact skin with blanching redness and moisture trapped in the peri area with redness, consistent with superficial incontinence-associated dermatitis.
Failure to Document Resident Elopement in Clinical Record
Penalty
Summary
The facility failed to maintain a complete clinical record for one resident following an elopement event. Facility policy on elopement, revised June 2023, required that after an elopement and upon the resident’s return, the DON or charge nurse complete and file an incident report and document the event in the resident’s medical record. The resident involved had diagnoses including alcoholic cirrhosis of the liver, hepatic encephalopathy, and GERD. On the evening of February 4, 2026, facility staff were unable to locate this resident at approximately 8:45 PM, and the resident was later found on the street about 0.3 miles from the facility at approximately 9:10 PM. An incident report dated February 4, 2026, contained a detailed description of the resident’s elopement, but the form was labeled at the bottom as “Privileged and Confidential–Not part of the Medical Record.” Review of the resident’s clinical record on February 9, 2026, showed no progress notes or any other documentation of the elopement event. During interviews, the Regional Director of Clinical Services stated that the nurse’s risk management note on the incident report should have populated into the clinical record progress notes, but a required button may not have been clicked, preventing the note from appearing in the clinical record. As a result, the resident’s medical record did not contain documentation of the elopement as required by facility policy and 28 Pa Code 211.5(f)(ii)(iii) regarding medical records.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in one of three shower rooms observed. During an observation of the 800/900 Hall shower room, surveyors noted a spotty black substance on one side and in one corner of the ceiling above the shower, a pink substance along the wall, and black and brown substances on the shower floor. The pink and black/brown substances on the floor were able to be wiped away with a paper towel. The shower room also exhibited a strong foul odor consistent with mildew. Additional observations revealed five shampoo bottles toppled over and scattered across the shower floor, as well as several white wipe materials on the floor. Interviews with two residents confirmed concerns about the shower room being dirty and containing mold. The Nursing Home Administrator acknowledged the condition of the shower room and stated that he would expect it to be kept clean and to provide a safe, clean, comfortable, and homelike environment for residents. The facility's policy requires the environment to be maintained in a clean, safe, and orderly manner, with precautions to prevent infection and cross-contamination, which was not followed in this instance.
Inaccurate Resident Assessments and MDS Coding Errors
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of three residents. For one resident with anxiety disorder and dementia, a soft padded helmet was ordered for injury prevention at the family's and hospice's request. Although the helmet could be removed by the resident at will and did not meet the definition of a restraint, it was incorrectly coded as a restraint on multiple Minimum Data Set (MDS) assessments. Staff interviews and documentation confirmed that the helmet was not restrictive, and the coding was acknowledged as erroneous by facility leadership. Another resident with depressive disorder and hypertension had an active order for zolpidem, a hypnotic medication, but this was not coded in the medication section of both the annual and quarterly MDS assessments. Additionally, a third resident with dementia and schizoaffective disorder was receiving haloperidol, an antipsychotic medication, as documented in the Medication Administration Record, but the corresponding MDS assessment incorrectly indicated that no antipsychotic medications had been administered. These inaccuracies were confirmed by the Director of Nursing and the Nursing Home Administrator.
Failure to Timely Update Resident Care Plan After Changes in Condition and Orders
Penalty
Summary
The facility failed to review and revise the care plan for a resident following significant changes in the resident's condition and physician orders. Specifically, the resident had a change in code status from full code to do not resuscitate, but the care plan continued to reflect the previous status and was not updated at the time of the change. Additionally, the resident developed a pressure ulcer on the left lateral malleolus, which was not included in the care plan, despite physician orders for wound care. The care plan also continued to reference a PICC line after it had been discontinued, indicating that resolved conditions were not promptly removed from the care plan. These deficiencies were identified through facility policy review, clinical record review, and staff interviews. The Director of Nursing confirmed that the care plan was not updated when the resident's code status changed and that the pressure ulcer and PICC line status were not accurately reflected in the care plan until after the issues were identified. The Nursing Home Administrator also confirmed that the care plan should have been revised to reflect all changes in the resident's condition and treatment.
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 established directives or the expressed wishes and objectives of the resident, resulting in a deviation from the required standard of care.
Failure to Act on Pharmacy Recommendations and Inadequate Documentation of Clinical Rationale
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were appropriately acted upon and documented for two residents. For one resident with diagnoses including major depressive disorder, anxiety, and bipolar disorder, the December 2024 pharmacy review recommended a gradual dose reduction (GDR) for Zolpidem, Hydroxyzine, and Haloperidol. However, there was no evidence in the clinical record that the physician responded to this pharmacy recommendation, and facility staff were unable to locate documentation of a physician response. For another resident with depressive disorder and hypertension, the pharmacy made three separate recommendations over several months to attempt a GDR of Zolpidem 5 mg. Each time, the physician declined the recommendation, citing that the resident was being followed by psychiatric services. However, review of the clinical record revealed that the last psychiatric consultation occurred in August 2024, and there was no evidence of ongoing psychiatric follow-up during the periods when the GDR recommendations were made. Staff confirmed the absence of recent psychiatric consultation reports and acknowledged that declined pharmacy recommendations should have an appropriate clinical rationale.
Failure to Maintain Proper Dish Machine and Kitchen Equipment Temperatures
Penalty
Summary
The facility failed to utilize kitchen equipment in accordance with professional standards for food service safety. Observations revealed that the dish machine in the main kitchen was operating at rinse temperatures significantly below the required minimum for both high-temperature and low-temperature sanitizing cycles. Specifically, the dish machine was observed with rinse temperatures of 93 and 96 degrees Fahrenheit, well below the minimum safe rinse temperature of 180 degrees Fahrenheit for high-temperature machines and below the 120-140 degrees Fahrenheit range required for low-temperature sanitizer use. Staff interviews confirmed uncertainty regarding the low temperatures and indicated that maintenance had not yet addressed the issue. Review of safety data sheets and temperature logs further revealed that the dish machine had consistently recorded rinse temperatures below 120 degrees Fahrenheit over several days, with no corrective actions documented. Additionally, there were significant gaps in the recording of wash and rinse temperatures for the dish machine across multiple months, as well as missing temperature logs for various refrigerators and the dish machine for an entire month. The Nursing Home Administrator acknowledged the expectation that kitchen equipment should be used according to professional standards, but the facility was unable to provide complete temperature logs for several pieces of kitchen equipment. These findings indicate a pattern of noncompliance with required food safety and equipment monitoring protocols.
Call Bell Not Accessible to Resident in Bed
Penalty
Summary
The facility failed to ensure that the environment met the individual needs of a resident by not keeping the call system within the resident's reach. Multiple observations on the same day showed the resident lying in bed with the call bell on the floor, placed on a fall mat to the left side of the bed, and out of the resident's reach. This occurred despite the facility's policy, which requires that the call light be accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor. The resident involved had diagnoses including type 2 diabetes mellitus and hypertension. According to the Minimum Data Set, the resident was able to make themselves understood and understand others. Interviews with the DON confirmed that the resident was capable of using the call bell and that it was expected to be within reach, yet it was repeatedly observed out of reach during the survey.
Failure to Include Required 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications, as required by facility policy and regulations. Specifically, a resident with diagnoses of post-traumatic stress disorder (PTSD) and anxiety disorder had a physician order for PRN (as needed) Klonopin (clonazepam) to treat anxiety. The order, dated June 30, 2025, did not include a required 14-day stop date or documented rationale for extending the PRN use beyond 14 days, as stipulated in the facility's policy for psychotropic medications. Review of the resident's medication administration records for three months showed that no doses of Klonopin were administered. During staff interviews, it was revealed that the facility's electronic health record system classified clonazepam as an anticonvulsant rather than a benzodiazepine, which resulted in the system not flagging the order for the required 14-day stop date. Staff acknowledged that the 14-day stop date should have been included since the medication was being used to treat anxiety.
Failure to Provide Timely Mobility Services and Equipment
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis following a stroke, resulting in left-sided weakness, did not receive timely and appropriate services, equipment, or assistance to maintain or improve range of motion and mobility. The resident reported that she was supposed to receive a brace for her left leg, but it was significantly delayed. Clinical record review showed repeated documentation by a Certified Registered Nurse Practitioner (CRNP) and a physician requesting a physical therapy (PT) consult to evaluate the need for a lower left extremity (LLE) brace, but there was no evidence of current PT treatment orders or follow-through on these consult requests. The resident's care plan included interventions for limited physical mobility and referrals to PT and occupational therapy (OT) as needed, but these interventions were not implemented as required. Staff interviews revealed that the CRNP did not submit the necessary therapy request for a screen, which is the process used by therapy to identify outstanding evaluations. There was a lack of communication between the nurse practitioner and nursing staff regarding the ongoing provider request, resulting in the resident not receiving the needed evaluation and equipment in a timely manner.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that each nurse aide received the required in-service training of no less than 12 hours per year, which should include dementia management and resident abuse prevention training. This deficiency was identified through a review of personnel training records and staff interviews, revealing that three out of five nurse aide employee records reviewed did not meet these training requirements. Specifically, Employees 11, 12, and 13, hired in 2001, 2005, and 2010 respectively, had not completed the necessary annual training hours or the specified training topics in the past 12 months. During an interview, the Nursing Home Administrator confirmed the lack of documentation for the required training and mentioned that the facility planned to address annual training topics and hours through an upcoming two-day education and skills fair. However, this plan was not yet implemented at the time of the survey.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate resident assessments, as evidenced by multiple coding errors in the Minimum Data Set (MDS) for several residents. Resident 6's MDS was not updated to reflect hospice services and a recent urinary tract infection, despite physician orders and hospital discharge paperwork indicating these conditions. Similarly, Resident 7's MDS inaccurately reported a fall that did not occur, and Resident 17's MDS incorrectly indicated the use of physical restraints, which were not observed during the survey. Further discrepancies were noted in the MDS assessments of other residents. Resident 43's MDS failed to acknowledge an active diagnosis of PTSD, while Resident 67's MDS did not reflect tobacco use, despite a smoking evaluation confirming this behavior. Resident 74's MDS inaccurately reported the absence of pressure-reducing devices, which were documented as in use in the resident's care plan. Additionally, Resident 80's MDS contained conflicting information regarding range of motion impairments, inconsistent with therapy evaluations. Other errors included Resident 83's MDS not reflecting a therapeutic diet that was ordered and provided, and Resident 85's MDS inaccurately documenting the date of a clinically contraindicated gradual dose reduction for antipsychotic medication. Resident 109's MDS omitted hospice services and the use of a restraint, contrary to physician orders. Lastly, Resident 142's MDS failed to document a diagnosis of bipolar disorder, despite medication being prescribed for bipolar depression. These inaccuracies highlight a systemic issue with the facility's MDS coding practices.
Care Plan Deficiencies and Lack of Resident Involvement
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for seven residents, and did not provide one resident the opportunity to participate in their care plan development. Resident 7, diagnosed with dementia, Type 2 Diabetes Mellitus, and hypertension, had a fungal infection that was not included in their care plan. Similarly, Resident 80, who had dementia and hemiplegia, was diagnosed with a urinary tract infection, which was not reflected in their care plan. Resident 85's care plan was outdated, showing a Full Code status despite a Do Not Resuscitate order being in place. Resident 96, with dementia and delusional disorder, had a wound and was on antipsychotic medication, neither of which were updated in their care plan. Resident 124 experienced significant weight loss, but their nutritional care plan had not been updated since the previous year. Resident 142, with a cardiac pacemaker, did not have this noted in their care plan. Resident 171, who had a suprapubic catheter, had a care plan that generically mentioned a catheter without specifying the type. Additionally, Resident 61, diagnosed with muscle weakness and major depressive disorder, was not invited to participate in care plan meetings, which is a right according to the facility's policy. These deficiencies indicate a lack of timely updates and resident involvement in care planning, as required by the facility's policies and regulations.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards for a resident with end-stage renal disease (ESRD). The facility's policy required that residents with ESRD be cared for according to recognized standards, including proper communication between the facility and the contracted dialysis center. However, the facility did not maintain complete and accurate records of dialysis communication for Resident 158, who had diagnoses of ESRD, hypertension, and diabetes mellitus. The resident's care plan included interventions for dialysis and specified no venipuncture or blood pressure measurements in the extremity with the dialysis shunt. Despite this, there were missing dialysis communication sheets on multiple dates, and several instances where pre- or post-dialysis weights were not documented. Additionally, the facility documented blood pressure measurements in the resident's left arm, where the dialysis access was located, 73 times since the resident's admission. This was contrary to the care plan's directive to avoid such measurements in the arm with the shunt. Interviews with the Regional Director of Clinical Services and the Nursing Home Administrator confirmed the inability to locate the missing documentation and acknowledged the inaccuracies in the blood pressure records. The facility's failure to maintain accurate medical records and adhere to the care plan's directives contributed to the deficiency.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for four out of five nurse aides reviewed. The personnel documentation for Employees 11, 12, 13, and 15 did not contain evidence of annual performance reviews, despite their respective hire dates being August 20, 2001, November 28, 2005, April 7, 2010, and January 11, 2022. During an interview, the Nursing Home Administrator acknowledged the absence of documentation for these evaluations and confirmed that he expected them to be completed annually around the employees' hire dates.
Deficiencies in Food Service Safety and Temperature Logging
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in both the main kitchen and five pantry areas. Observations revealed several deficiencies, including the use of expired test strips by the Food Service Director to test sanitizer concentration, and a heavily soiled floor with black and grey sludge next to the three-compartment sink. Additionally, food storage bins for sugar and rice were not labeled or dated, and the flour bin was improperly dated. These actions indicate a lack of compliance with the facility's policy on general food preparation and handling, which requires cleanliness and proper labeling of food service equipment. Further deficiencies were noted in the temperature logging of refrigerator/freezer units across multiple pantry areas. Temperature logs were incomplete, with several days missing both AM and PM recordings. Additionally, there were spills of a red substance in the refrigerator and freezer of two pantry areas. Interviews with the Food Service Director and the Nursing Home Administrator confirmed the expectation for proper labeling, dating, and cleanliness of food storage bins and kitchen equipment, as well as consistent temperature logging, which were not met.
Infection Control Deficiencies in EBP Implementation
Penalty
Summary
The facility failed to maintain a safe and sanitary environment that supports infection prevention and control for three residents. Resident 15, diagnosed with ESBL colonization in October 2022, did not have signage indicating enhanced barrier precautions (EBP) were in place, which was acknowledged by the Nursing Home Administrator (NHA) as a lapse in protocol. Similarly, Resident 171, who was admitted with a suprapubic catheter, did not have EBP signage until it was corrected during the survey, with the NHA admitting that EBP should have been implemented upon admission. For Resident 32, who had orders for EBP related to wound care, staff members failed to don gowns during a dressing change, contrary to the facility's policy. Employee 16 mistakenly believed that only gloves were necessary, despite the resident being on EBP. The NHA confirmed that the expectation was for staff to wear appropriate PPE, highlighting a gap in staff adherence to infection control protocols.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to implement resident-directed care and treatment consistent with the physician's orders and plan of care for a resident diagnosed with bipolar disorder and diabetes mellitus. The resident had specific physician orders for insulin administration based on a sliding scale, with instructions to notify the physician if blood sugar levels exceeded 400. The clinical record review revealed that the resident's blood sugar levels were greater than 400 on three separate occasions. Despite these elevated blood sugar readings, there was no documentation indicating that the physician was notified as required by the orders. During an interview, the Regional Director of Clinical Services confirmed the absence of documentation and acknowledged the expectation that physician orders should be followed. This deficiency highlights a failure in adhering to prescribed medical protocols for the resident's care.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and services to promote healing and prevent infection for pressure ulcers. The facility's policy on Skin and Wound Management System, last reviewed in August 2024, mandates appropriate interventions for residents with skin impairments. However, observations revealed that the resident, who was at risk for skin integrity issues, was not wearing the prescribed heel lift suspension boots while in bed. These boots were intended to reduce pressure and were found in the corner of the resident's room during multiple observations over several days. The resident's clinical record indicated a task for the use of heel lift suspension boots, which was marked as being in use daily for the past 30 days, despite the observations to the contrary. The resident had diagnoses of hypertension and bradycardia, which could complicate their condition. During an interview, the Nursing Home Administrator acknowledged the issue and mentioned that they were in the process of getting an order for the heel boots validated, indicating a lapse in ensuring the resident's care plan was properly implemented.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident diagnosed with schizoaffective disorder, bipolar type, abnormal posture, and muscle weakness. The incident occurred when the resident was found on the floor in a supine position in front of her wheelchair, holding her neck and head up, but not in acute distress. The resident had been returned to her room shortly before the incident, and her wheelchair was positioned close to the door, away from the call light, which was not within her reach. The wheels on the wheelchair were locked, and the resident was wearing appropriate footwear. The care plan for the resident, which included ensuring the call light was within reach, was not followed, contributing to the incident. The report indicates that the resident was left unattended inappropriately, as she should have been positioned closer to the call bell or placed in bed. The facility's documentation noted that the resident was left in her chair without access to the call bell, which was a deviation from her care plan. The Nursing Home Administrator did not provide additional written information or comprehensive staff education documentation related to the incident, despite being asked by the surveyor. The deficiency was identified under the Pennsylvania Code regulations for management and nursing services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD and major depressive disorder. The resident, who had a history of trauma related to verbal abuse by a former male roommate, had a known trigger of raised voices. Despite this, the resident's care plan did not include any comprehensive strategies or interventions to address her PTSD or identified triggers. This oversight was discovered during a review of the resident's clinical records and interviews with facility staff. Interviews with facility staff, including a Licensed Practical Nurse and the Regional Director of Clinical Services, revealed a lack of awareness regarding the resident's trauma history and triggers. The Regional Director acknowledged that a care plan should have been developed to address the resident's PTSD, but it was not, leading to staff being uninformed about her needs. The Social Worker admitted that the admission assessment for the resident was likely missed due to other assignments, contributing to the lack of a trauma-informed care plan.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not maintaining a detailed system of records for the receipt and disposition of controlled drugs, which is necessary for accurate accounting and to identify possible drug diversion. This deficiency was identified during a review of the facility's documentation, policies, clinical records, and staff interviews. Specifically, the medication disposition record form for a resident, who had diagnoses including Alzheimer's disease and hypertension and who passed away in the facility, was found to be incomplete. The form, which was supposed to include entries for each medication, reasons for disposition, and signatures of the person completing the form and a witness, lacked any signatures. The medications listed on the incomplete form included Trazadone, Fluoxetine, Lisinopril, and Risperidone. The Nursing Home Administrator, when interviewed, acknowledged the absence of signatures on the form and expressed an expectation that the form should have been signed. This oversight indicates a failure in the facility's process for managing controlled substances, as the medication disposition form is a critical component in ensuring that medications are properly accounted for and returned to the pharmacy, as per the facility's policy.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident was free of unnecessary psychotropic medications, as evidenced by the lack of monitoring for side effects of an antipsychotic medication prescribed to the resident. The facility's policy on antipsychotic medication use, which was last revised in December 2016, requires nursing staff to monitor and report any side effects or adverse consequences of such medications to the attending physician. However, a review of the clinical record for a resident with diagnoses including dementia, delusional disorder, and unspecified psychosis revealed an order for risperidone, an antipsychotic medication, without corresponding documentation of side effect monitoring. The resident's care plan did not reflect the use of the antipsychotic medication, and there was no evidence in the clinical record that the resident was being monitored for potential side effects associated with the medication. During an interview, the Nursing Home Administrator confirmed that monitoring for side effects should have been implemented when the antipsychotic medication was ordered. This oversight indicates a failure to adhere to the facility's policy and ensure the resident's safety regarding the use of psychotropic medications.
Failure to Monitor Resident Weight
Penalty
Summary
The facility failed to adequately monitor and document the weight of a resident, identified as Resident 124, who experienced a significant weight loss of 34 pounds, equating to a 15.32% decrease, over a one-month period from July 17, 2024, to August 17, 2024. The facility's policy required weekly weight measurements for the first four weeks after admission and monthly thereafter unless otherwise directed by a dietician or physician. However, the resident's weight was not recorded in June 2024, and as of September 22, 2024, no weight had been documented for September. The resident had diagnoses of psychosis and dementia, which could impact their nutritional intake and weight stability. The dietician had previously noted on June 26, 2024, that the resident required routine snacks twice a day due to poor intake at meals, indicating a need for close monitoring. Despite this, the facility did not document any refusals of weight checks in June or September 2024, although staff statements later indicated the resident often refused to be weighed. The Nursing Home Administrator confirmed that the resident was not care planned for these refusals, and the clinical record did not reflect them. A pending physician order for weekly weights was noted but had not yet been implemented. The Regional Director of Clinical Services suggested that the weight loss might be related to the use of diuretics, but this was not documented in the resident's care plan.
Failure to Maintain Comfortable Environment Due to Air Conditioning Issues
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment on the 1300 unit due to issues with the air conditioning system. The facility's policy on managing residents during hot weather requires regular monitoring of air temperatures and maintenance of air conditioning systems. However, during a survey, it was observed that the air conditioning on the 1300 unit was not functioning properly, leading to elevated room temperatures. Interviews with the Nursing Home Administrator confirmed the ongoing issues with the air conditioning, and it was noted that portable units were being used as a temporary measure. Residents on the 1300 unit expressed discomfort due to the heat, with some using personal fans to cope with the high temperatures. Specific temperature readings taken during the survey showed that rooms were as warm as 86 degrees Fahrenheit. The Maintenance Director acknowledged that one resident's in-room air conditioning unit was not working effectively. These findings indicate a failure to adhere to the facility's policy and ensure a comfortable environment for residents.
Delayed CT Scan Scheduling After Resident Fall
Penalty
Summary
The facility failed to provide timely care and services in accordance with professional standards for a resident who had a fall. The resident, diagnosed with Alzheimer's disease and a nontraumatic intracerebral hemorrhage, fell and subsequently complained of tenderness on the right side of her forehead. A physician ordered a CT scan of the head to assess potential injuries. However, the CT scan was not scheduled until over a month later, despite the order being placed shortly after the fall. This delay in scheduling the CT scan was not communicated to the physician, indicating a breakdown in communication within the facility. The nursing home administrator acknowledged the delay and the lack of communication regarding the scheduling of the CT scan. The deficiency was identified when the surveyor questioned the administrator about the scheduling delay and whether the physician was informed. The administrator admitted that the CT scan was not ordered as urgent and that there was a communication breakdown, which contributed to the delay in obtaining the necessary diagnostic imaging for the resident.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent infection of a pressure ulcer for a resident. The resident had an unstageable pressure ulcer of the sacral region and was recommended to use a wound vac and Aquacel non-silver dressing by a wound clinic. However, the facility did not have the wound vac supplies available from May 1 to May 6, and the wound vac was not applied until May 6. During this period, alternative treatments were ordered, including cleansing the wound with normal saline solution and applying a wet to dry dressing. The facility experienced difficulties in obtaining the required wound vac supplies from central supply and the pharmacy, and eventually had to reach out to a different wound care team to obtain them. The facility was unable to provide evidence of attempts to acquire the supplies or documentation of the pharmacy and central supply's lack of availability. The unit manager responsible for obtaining the supplies was no longer employed at the facility, and the wound vac supplies were eventually provided by the wound care team assessing the resident's wound.
Failure to Provide Appropriate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate suprapubic catheter care and monitoring for a resident, resulting in an active infection that required antibiotic treatment. The resident, who had a suprapubic catheter upon admission, did not receive the prescribed catheter care due to an error in transcribing the physician's orders into the electronic health record. This error led to the absence of the catheter care order in the Treatment Administration Record (TAR), and consequently, the resident did not receive the necessary catheter care since admission. Observations revealed a moderate amount of yellow-white drainage at the catheter site, indicating an infection that was not promptly addressed by the facility staff. Further review of the resident's clinical record showed that the resident was sent to the hospital with catheter-related complications and treated for a urinary tract infection. Despite recommendations from a urology specialist to start antibiotics, obtain a urine culture, and increase the frequency of catheter changes, these orders were not implemented by the facility. The resident reported voiding through the urethra and not receiving the prescribed antibiotics, further highlighting the facility's failure to follow through with the specialist's recommendations. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility did not have the urology consultation report from the resident's recent appointment and failed to follow up with the consultative service. This lack of follow-up and failure to implement the urology recommendations resulted in the resident not receiving the necessary treatment for the infection, demonstrating a significant lapse in care and monitoring by the facility.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents were free from neglect, specifically for one resident who was not provided timely incontinence care. Resident 4, who has diagnoses including hypertension and anxiety, was documented as having requested to be changed at 4:30 PM but was informed by a registered nurse that only two CNAs were available for the entire 800 and 900 hall. However, staffing records indicated that there were actually four nurse aides working in that area on the day in question. Resident 4 confirmed during an interview that she was left sitting in wet briefs for hours before being changed. The clinical record showed that incontinence care was not provided until 9:33 PM for bladder and 9:34 PM for bowel. The Director of Nursing and Nursing Home Administrator acknowledged the issue and confirmed that they would expect timely incontinence care and proper documentation in the resident's clinical record whenever such care is provided.
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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