Garvey Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Hollidaysburg, Pennsylvania.
- Location
- 1037 South Logan Boulevard, Hollidaysburg, Pennsylvania 16648
- CMS Provider Number
- 395050
- Inspections on file
- 23
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Garvey Manor during CMS and state inspections, most recent first.
A resident who was cognitively intact and able to communicate reported that eggs served for breakfast were unpalatable, and direct observation confirmed that several food items, including eggs, French toast, and milk, were served at temperatures below facility standards. Staff acknowledged the difficulty in maintaining proper temperatures during tray delivery, resulting in food that was not appetizing or safe.
A dietary aide was observed working in the kitchen with uncovered facial hair, contrary to facility policy requiring hair and beard restraints. The Dietary Director confirmed that the staff member should have been wearing a beard restraint.
The facility did not ensure a clean, homelike environment on the D1 wing, as repeated observations found large brown and black stains on the hallway and lounge carpeting. Staff confirmed that housekeeping was unable to remove the stains and that the carpet needed replacement.
A resident with dementia and other serious conditions, who required total assistance and was known to be resistive to care, was subjected to verbal abuse by a physical therapist during a therapy session. The therapist became impatient, raised her voice, and made derogatory remarks about the resident in the presence of other staff, despite the resident's refusal to participate. Multiple staff witnessed the incident, which was found to be a violation of abuse prevention policies.
The facility did not complete required license checks before hiring two RNs, as personnel files showed both began work before their licenses were verified. Staff interviews confirmed that license verifications were not done prior to employment, in violation of facility policy on background checks and screening.
A resident with a hip fracture and requiring maximum assistance was found on the floor after the required motion sensor alarm was not present or activated as specified in the care plan. Facility policy required the alarm for safety, but staff failed to ensure it was in place, as confirmed by the DON.
The facility did not obtain Pennsylvania Nurse Aide Registry checks before two nurse aides began employment, as required by policy and state regulations. Personnel files and staff interviews confirmed that the registry checks were completed after the aides had already started working.
The facility failed to assess a resident for safety in a chair after a history of falls, leading to a fracture, and did not follow fall prevention protocols for another resident with a history of falls. Despite incidents, there was no documented evidence of safety assessments or adherence to care plans requiring hourly safety checks.
A resident's needs were not reasonably accommodated as her call bell was not within reach, despite her care plan requiring it. She was observed attempting to ambulate without supervision, and her call bell was found on the floor behind her nightstand. Staff interviews confirmed the call bell should have been accessible.
The facility failed to accurately complete MDS assessments for two residents, omitting the indication of oxygen therapy use as required by the RAI User's Manual. Despite physician orders for oxygen therapy due to respiratory conditions, the assessments did not reflect this, as confirmed by the LPN responsible for the documentation.
The facility failed to develop individualized care plans for two residents, one with diabetes mellitus and another requiring comfort care. A resident receiving insulin had no care plan for diabetes management, while another's care plan lacked comfort care measures despite physician orders. These deficiencies were confirmed by the DON.
The facility failed to update care plans for two residents to reflect discontinued medications, as confirmed by the DON. One resident's care plan still included Keppra despite a physician's order to discontinue it, and another's included Eliquis, which was also discontinued. The facility policy requires care plans to be revised with changes in condition, which was not followed.
The facility failed to obtain physician orders for pacemaker checks for two residents and did not ensure a registered nurse assessed a resident after an elopement incident. Both residents with pacemakers lacked documented orders, and a resident who eloped was not assessed upon return, as confirmed by the DON.
A resident with Parkinson's disease experienced an unwitnessed fall, and the facility failed to complete the required neurological checks as per their policy. The checks were initiated but not fully documented, as confirmed by the DON.
A resident at risk for pressure injuries did not have a physician-ordered left elbow splint in place, despite it being necessary for skin integrity. The resident, with cognitive impairment and medical conditions like stroke, was observed without the splint, which was found in the room. Interviews confirmed the splint's importance and lack of documented refusal by the resident.
A facility failed to follow physician's orders for tracheostomy care for a resident with chronic respiratory failure. Despite orders for daily care and sponge application, records showed no evidence of care on specific days, confirmed by the ADON. This constituted a deficiency in nursing services.
The facility did not complete annual performance evaluations for two nurse aides, despite being hired over a year ago. This was confirmed through personnel file reviews and an interview with the DON, who could not provide documentation of the evaluations.
The facility's QAPI committee failed to address recurring deficiencies effectively, resulting in repeated issues with assessment coding, care plan development and revision, professional standards, and quality of care. Despite having plans of correction, the facility was unable to maintain compliance, as evidenced by repeated citations in consecutive surveys.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing and safe temperatures, as required by their policy and regulatory standards. According to the facility's policy, food temperatures are to be checked prior to service, with hot foods reheated if they fall below 165°F. During a breakfast meal service observation, it was noted that food trays were delivered to residents' rooms over a span of more than 20 minutes. Temperature checks of a test tray revealed that several items, including scrambled eggs, French toast, fried eggs, and milk, were not at palatable or safe temperatures. Specifically, scrambled eggs were 121.7°F, French toast was 112.6°F, fried eggs were 108°F, and milk was 56.1°F, all below the expected standards for serving. A resident who was cognitively intact and able to communicate clearly reported that the eggs tasted like plastic, indicating dissatisfaction with the food quality. Staff interviews confirmed that maintaining proper temperatures for certain items, especially eggs, during room delivery was challenging. The Dietary Supervisor and Dietary Director acknowledged that the milk, French toast, and fried eggs should have been served at palatable temperatures, but this was not achieved during the observed meal service.
Failure to Ensure Proper Use of Hair Restraints in Kitchen
Penalty
Summary
The facility failed to comply with professional standards for food service safety by not ensuring that all dietary staff wore appropriate hair restraints while working in the kitchen. Specifically, during an observation in the kitchen, a dietary aide was seen working with uncovered facial hair, which was in direct violation of the facility's dietary operations policy requiring hair and beard restraints. This observation was confirmed by the Dietary Director, who acknowledged that the staff member should have been wearing a beard restraint as per policy.
Failure to Maintain Clean and Homelike Environment Due to Stained Carpeting
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the D1 wing. Multiple observations over several days revealed that the carpeting in the D1 hallway and lounge had large brown and black stains. Staff interviews confirmed that, despite housekeeping efforts, the carpet remained stained in multiple areas and required replacement.
Resident Subjected to Verbal Abuse by Physical Therapist During Therapy Session
Penalty
Summary
The facility failed to protect a resident from verbal abuse during a therapy session. The resident, who had dementia, encephalopathy, sepsis, and required total assistance for daily care, was known to exhibit physical and verbal aggression and was resistive to care. Her care plan required staff to explain procedures, use diversional conversation, and stop care if the resident became combative, with a re-approach after a cooling-off period. During a therapy session, the physical therapist became impatient and verbally abusive when the resident resisted participation, raising her voice and making derogatory remarks about the resident to another staff member. Multiple staff members witnessed the therapist's escalating tone and frustration during the incident. The physical therapist insisted that the resident participate in therapy, citing insurance requirements, despite the resident's refusal and distress. The therapist's actions included increasing her volume, insisting the resident stand, and making inappropriate comments about the resident's behavior and her own frustration. The incident was reported by other therapy staff who were present and overheard the interaction, confirming the abusive behavior. The facility's failure to ensure the resident was free from abuse constituted a deficiency in compliance with abuse prevention policies.
Failure to Complete License Checks Prior to RN Hire
Penalty
Summary
The facility failed to ensure that license checks were obtained prior to hire for two Registered Nurses. Review of personnel files showed that both nurses began employment before their licenses were verified, with one starting work on June 9, 2025, and the license check completed on July 23, 2025, and the other starting on May 27, 2025, with the license check completed on June 6, 2025. There was no documented evidence that license checks were conducted before either nurse's start date. Staff interviews confirmed that the required license verifications were not completed prior to employment, contrary to the facility's policy on preventing abuse, neglect, or mistreatment, which includes protocols for employment background checks and screening.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement an individualized care plan for fall prevention for one resident. According to facility policy, safety alarms are to be used for residents with a history of unassisted transfers when staff assistance is necessary for safety. The resident in question was alert and oriented, required maximum assistance for daily care, had a diagnosis of hip fracture, and was assessed to require a motion sensor alarm at the foot of the bed at all times when in bed. However, a nursing note documented that the resident was found on the floor, and a witness statement confirmed that the alarm was not present at the time of the incident. The Director of Nursing verified that the alarm was not in place and activated as required by the care plan.
Failure to Complete Nurse Aide Registry Checks Prior to Hire
Penalty
Summary
The facility failed to ensure that Pennsylvania Nurse Aide Registry checks were obtained prior to the hire of two nurse aides. Review of personnel files showed that one nurse aide began employment on May 27, 2025, but the registry check was not completed until June 10, 2025. Another nurse aide started on April 7, 2025, with the registry check not performed until July 23, 2025. There was no documented evidence that the required registry checks were conducted before these staff members began working. Staff interviews confirmed that the registry checks should have been completed prior to the start dates, but this was not done, which was not in accordance with the facility's policy and state regulations.
Failure to Conduct Safety Assessments and Follow Fall Prevention Protocols
Penalty
Summary
The facility failed to assess a resident for safety in a chair after a known history of falls, resulting in a fall with a fracture. Resident 2, who required extensive assistance for ambulation and transfers, was found on multiple occasions on the floor near her recliner. Despite these incidents, there was no documented evidence of a safety assessment for the use of her recliner. The resident suffered a fracture to her right shoulder after a fall on January 14, 2024, and was later provided with a motion alarm for her recliner. Additionally, the facility did not follow fall prevention interventions for Resident 5, who had a history of falls and was cognitively impaired. The resident's care plan required hourly safety checks, but there was no documented evidence that these checks were conducted. The resident experienced falls on May 13, 2024, and June 17, 2024, with the latter incident involving a fall from a recliner footrest, resulting in a bump to the head. Interviews with facility staff, including the Director of Nursing, confirmed the lack of documented safety assessments and adherence to fall prevention protocols. The facility's policy required assessments by a registered nurse supervisor if a fall was involved, but this was not consistently followed for the residents in question.
Failure to Ensure Call Bell Accessibility for a Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of Resident 57 by not ensuring that her call bell was within reach. According to the quarterly Minimum Data Set (MDS) assessment dated April 30, 2024, Resident 57 was able to understand and be understood by others and required minimal assistance from staff for care. Her care plan, dated January 9, 2024, specified that staff should encourage her to use her call bell for assistance and ensure it was within reach when she was in her room. A therapy note from July 28, 2024, indicated that she required supervision with ambulation and transfers. However, on July 29, 2024, at 11:03 a.m., an observation revealed that Resident 57 was sitting on her bed attempting to ambulate, and her call bell was found behind her nightstand on the floor, out of reach. Interviews with Nurse Aide 1 and the Director of Nursing confirmed that the call bell should have been accessible to Resident 57.
Inaccurate MDS Assessments for Oxygen Therapy
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) User's Manual. The manual specifies that Section O0100C should be completed to indicate the use of oxygen therapy. For Resident 45, who had a history of aspiration and sleep apnea, the care plan included an order for oxygen therapy. However, the quarterly MDS assessment did not reflect this, as column (2) of Section O0100C was not marked to indicate the use of oxygen. Similarly, Resident 89, who had a history of congestive obstructive pulmonary disease, also had a physician's order for oxygen therapy. Yet, the MDS assessment for this resident also failed to indicate the use of oxygen in the same section. An interview with the LPN responsible for completing the MDS assessments confirmed the inaccuracies in the documentation for both residents, acknowledging that the assessments should have indicated the residents' use of oxygen therapy.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 69, who was cognitively intact and dependent on staff for care, had a diagnosis of diabetes mellitus and was receiving daily insulin injections. However, there was no documented evidence of a care plan for managing the resident's diabetes, which was confirmed by the Director of Nursing during an interview. Similarly, Resident 88, who was also cognitively intact and required extensive assistance for daily care, had a diagnosis of cerebrovascular disease and was under physician orders to receive comfort care. Despite this, the resident's care plan did not include the necessary comfort care measures as ordered by the physician. This oversight was also confirmed by the Director of Nursing, indicating a failure to update the care plan to reflect the resident's current needs.
Failure to Update Care Plans for Medication Changes
Penalty
Summary
The facility failed to update and revise care plans for two residents, which led to deficiencies in reflecting the residents' current care needs. For one resident, the care plan was not updated to reflect the discontinuation of Keppra oral solution, a medication used to control seizures, despite a physician's order to discontinue it. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have been revised to reflect the change in medication. Similarly, another resident's care plan was not updated to reflect the discontinuation of Eliquis, an anticoagulant, as per the physician's order. The care plan still included the anticoagulant, which was no longer prescribed. This was also confirmed by the Director of Nursing during an interview. The facility's policy requires care plans to be evaluated and revised every 90 days, annually, and when there is a change in a resident's condition, which was not adhered to in these cases.
Failure to Obtain Physician Orders and Conduct Post-Elopement Assessment
Penalty
Summary
The facility failed to obtain physician orders for pacemaker checks for two residents, which is a requirement according to the facility's policy and the residents' care plans. One resident, who was cognitively intact and had diagnoses including congestive heart failure and atrial fibrillation, did not have documented evidence of a physician's order for pacemaker checks. Similarly, another resident, also cognitively intact with coronary artery disease and a history of stroke, lacked documented physician orders for pacemaker checks. Interviews with the Director of Nursing confirmed the absence of these orders, which were necessary as per the facility's policy. Additionally, the facility did not ensure that a registered nurse completed an assessment after an elopement incident involving another resident. This resident, who was cognitively intact and required maximum assistance for daily care tasks, was found outside the facility without a coat. Upon returning, there was no documented evidence that the resident was assessed by a registered nurse, as required by the facility's policy for missing residents. The Director of Nursing confirmed that the assessment was not conducted as per the policy.
Failure to Complete Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that neurological checks were completed following an unwitnessed fall for one of the residents reviewed. According to the facility's policy for unwitnessed falls, neurological checks should be conducted to assess sensory neuron and motor responses to determine if the nervous system is impaired. The policy specifies that these checks should be performed every 15 minutes for two hours, every 30 minutes for two hours, every hour for four hours, and then every eight hours until 72 hours have passed. However, for Resident 99, who had an unwitnessed fall on July 10, 2024, the neurological checks were not completed as required by the policy. Resident 99, who has a diagnosis of Parkinson's disease and requires substantial assistance with daily care needs, experienced an unwitnessed fall at her recliner. The nurse's note indicated that neurological checks were to be completed, and the flow sheet for these checks was initiated. While the checks were completed per policy until the second shift on July 11, 2024, there was no further documentation of the 8-hour checks being completed. An interview with the Director of Nursing confirmed that these checks should have been conducted after the unwitnessed fall, indicating a lapse in following the established protocol.
Failure to Implement Physician-Ordered Pressure Relief Devices
Penalty
Summary
The facility failed to ensure that pressure relief devices were in place as ordered by the physician for a resident identified as at risk for pressure injuries. The resident, who was cognitively impaired and required assistance for daily care tasks, had medical diagnoses including stroke, coronary artery disease, and high blood pressure. The care plan specified the use of an E-Z flex splint on the left hand and a left elbow comfy splint for four hours per shift to prevent skin breakdown. However, during observations, it was noted that the resident was not wearing the left elbow splint as ordered, although it was present in the room. Interviews with the Director of Therapy and the Director of Nursing confirmed that the splints were necessary to promote skin integrity and should have been in place according to the physician's orders. The Director of Therapy mentioned that the resident sometimes refused to wear the splints, but there was no documented evidence of refusal in this instance. This oversight was a violation of the facility's policy on pressure injury care and treatment, as well as a failure to comply with the physician's orders.
Failure to Document and Provide Tracheostomy Care
Penalty
Summary
The facility failed to ensure that physician's orders for tracheostomy care were followed for a resident, leading to a deficiency. The facility's policy required tracheostomy care to be provided as per physician's orders and documented in the electronic Medication Administration Record (eTAR) Treatment Page. However, a review of the records for a resident with a tracheostomy and chronic respiratory failure revealed that there was no documented evidence of tracheostomy care being provided on specific dates in March and April 2024. Additionally, there was no documentation of the application of a tracheostomy sponge as ordered by the physician. The resident involved was cognitively intact and required limited assistance with daily care needs. The resident had a tracheostomy related to diphtheria and chronic respiratory failure, with physician's orders for daily tracheostomy care and sponge application. Despite these orders, the facility's records did not show that the care was provided on certain days, which was confirmed by the Assistant Director of Nursing. This lack of documentation and adherence to physician's orders constituted a failure in providing necessary nursing services as per the regulations.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aide performance evaluations were completed at least annually for two of the five nurse aides reviewed. Specifically, Nurse Aides 5 and 6, who were hired over a year ago, did not have performance evaluations completed in the past year. This was confirmed through a review of personnel files and staff interviews. The Director of Nursing was unable to provide documentation to show that these evaluations had been conducted, confirming the deficiency during an interview.
Ineffective QAPI Committee Leads to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in consecutive surveys. The deficiencies included problems with assessment coding, developing and revising residents' care plans, adherence to professional standards, and overall quality of care. Despite having plans of correction in place from a previous survey, the facility was unable to maintain compliance with the cited nursing home regulations. The current survey revealed that the QAPI committee was ineffective in implementing and maintaining the necessary corrective actions. Specific deficiencies were noted under F641 for assessment coding, F656 and F657 for care plan development and revision, F658 for professional standards, and F684 for quality of care. These findings indicate that the audits and monitoring systems intended to ensure compliance were not successful, leading to repeated citations in these areas.
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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