Glen Brook Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Berwick, Pennsylvania.
- Location
- 801 East 16th Street, Berwick, Pennsylvania 18603
- CMS Provider Number
- 395421
- Inspections on file
- 43
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Glen Brook Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not maintain clear exit access as required by NFPA 101 standards. A wooden pallet and vacuum cleaner were found obstructing the exit corridor near a resident's room, affecting one smoke compartment. This was confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain smoke barrier walls, with unsealed penetrations found in the North Hall and near the Generator room, affecting multiple smoke compartments. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
The facility failed to maintain smoke barrier separation doors in the North Wing A-Hall, as they did not latch into the frame when released from the hold open device. This issue affected two of ten smoke compartments and was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain its HVAC system ductwork through fire-rated walls, as 14 out of 59 fire/smoke dampers were found to be faulty due to deficient parts. This issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain the automatic sprinkler system in five locations on one floor. Observations revealed an unsealed penetration of a ceiling tile in the soiled utility area, missing ceiling tiles in a storage room, and missing escutcheons in a resident room, a lounge, and a dietary walk-in freezer. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
The facility failed to maintain a portable fire extinguisher, as observed when the kitchen 'K' fire extinguisher lacked a current annual inspection tag, with the last tag from 2022. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to properly secure and separate oxygen cylinders as required by NFPA 101 standards. An observation revealed an oxygen 'E' cylinder stored on the ground inside the outdoor oxygen empty storage cabinet, which was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain a corridor door in the main lobby, which did not close and latch properly due to hitting the frame. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager, indicating non-compliance with NFPA 101 standards and CMS regulations.
The facility failed to accurately account for and administer controlled medications for two residents. A resident had Morphine Sulfate signed out without documentation in the MAR, and another had Oxycodone HCL signed out without corresponding MAR entries. The DON confirmed these discrepancies, indicating procedural failures in managing controlled medications.
Residents in the facility experienced significant delays in receiving assistance, impacting their dignity and quality of life. Multiple residents reported waiting times ranging from 20 minutes to over two hours for help, with issues more frequent during night shifts. Specific cases included residents left in soiled conditions and others waiting excessively for medication or bedpan assistance. The facility's administration acknowledged the problem but could not explain the ongoing delays.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately indicated a psychotic disorder diagnosis without supporting documentation, while another resident's discharge status was incorrectly recorded as a transfer to a hospital instead of a discharge to home. The DON confirmed these discrepancies during interviews.
A facility failed to develop a comprehensive care plan for a resident with schizoaffective disorder experiencing involuntary movements. Despite an AIMS assessment indicating moderate severity and distress, the care plan did not address these issues. Observations showed the resident displaying erratic movements, and facility leadership confirmed the oversight.
A resident with congestive heart failure had a physician's order for oxygen at 2 L/min via nasal cannula, but observations revealed the oxygen concentrator was set to 3 L/min. This inconsistency was confirmed by an LPN and the DON, indicating a failure to follow the prescribed oxygen administration policy.
A resident reported missing lower dentures for months, with no timely follow-up from the facility to replace them. Despite repeated complaints and an X-ray, the facility failed to provide necessary dental services until prompted by surveyors. The resident experienced difficulty eating and expressed frustration over the lack of action.
A resident with chronic atrial fibrillation and severe cognitive impairment did not receive the influenza vaccine despite consent being given by their representative. The DON confirmed the facility's failure to administer the vaccine, violating state regulations.
A resident with hemiplegia and hemiparesis required two-person assistance for transfers, as per their care plan. However, a nurse aide attempted a transfer alone, resulting in the resident being lowered to the floor. The facility's policy on preventing neglect was breached, as confirmed by the NHA.
A facility failed to implement adequate safety measures and supervision for a high-risk resident, resulting in multiple falls. Despite a care plan with interventions like frequent checks and alarms, the resident experienced numerous falls, some unwitnessed, leading to injuries. The facility's responsibility to ensure safety was confirmed by the NHA and DON.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident's care plan did not include interventions for incontinence, while another's lacked necessary communication interventions for a Spanish-speaking resident with dementia. A third resident's care plan also failed to address communication needs despite the provision of translation services.
A resident with end-stage renal disease did not receive timely administration of Amlodipine Besylate and Aspirin as per physician's orders. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, but the resident's medications were delayed on 11 occasions, with delays ranging from over an hour to more than five hours. The DON confirmed the failure to adhere to the scheduled administration times.
The facility failed to provide restorative nursing services for two residents, one with dorsopathy and morbid obesity, and another with ALS. Despite discharge recommendations for range of motion programs, there was no documented evidence of implementation, confirmed by the NHA and DON.
The facility failed to respond promptly to residents' call bells, leading to prolonged wait times for assistance. Multiple grievances and resident interviews revealed that staff often turned off call bells without providing care, resulting in wait times of 20 minutes to over an hour. The NHA and DON acknowledged the issue but could not explain the delays.
A resident with cognitive impairment mistakenly ingested denture tablets due to inadequate supervision and storage practices, while unsecured oxygen cylinders were found on two nursing units, highlighting deficiencies in hazard prevention and safety measures.
The facility failed to ensure nursing staff had the necessary competencies for medication administration, leading to a medication error where an LPN administered the wrong drug to a resident. Another LPN was observed pre-pouring medications, a practice not aligned with professional standards. The facility lacked documentation of staff orientation and competency evaluations, indicating systemic issues in staff training and compliance.
A resident with diabetes did not receive timely administration of insulin as per physician's orders. The facility's MAR indicated multiple instances of late administration, and one instance where the morning dose was not given at all. The resident expressed concerns about the consistent lateness, and the DON confirmed the failure to administer the medication as ordered.
The facility failed to date multi-dose diabetes medications when opened, as observed on two medication carts. Several opened medications, including insulin pens and vials, were found without dates, belonging to multiple residents. LPNs confirmed the oversight, and the DON acknowledged the failure to ensure acceptable storage times.
The facility failed to provide consistent evening snacks to residents, as per their policy. Residents reported that snacks, including sugar-free options, were not always available or distributed by staff. Interviews revealed dissatisfaction among residents, with some stating they were not regularly offered snacks in the evening. The NHA and DON could not explain the discrepancy between the facility's policy and residents' experiences.
The facility failed to implement an antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident received Doxycycline without a confirmed urinary tract infection due to a failure to collect a urine sample. Another resident was given Ciprofloxacin for hallucinations, despite urine test results suggesting contamination. The infection preventionist did not use required criteria to identify infections, contributing to these deficiencies.
The facility failed to communicate necessary resident-specific information to the receiving health care provider for two residents transferred to the hospital. There was no documented evidence of communication regarding advance directives, special instructions, or care plan goals. This was confirmed by the DON and NHA.
A facility failed to ensure accurate MDS assessments for a resident with cerebral infarction and left-sided hemiplegia. The resident's Quarterly MDS assessment inaccurately indicated no impairment in range of motion, despite the resident's report of minimal to no use of his left side. This discrepancy was confirmed by the RNAC and DON.
A resident with Parkinson's disease and constipation did not receive the prescribed bowel regimen, including MOM, Dulcolax, and Fleet Enema, on multiple occasions. The facility failed to administer these medications as ordered, resulting in extended periods without bowel movements. This deficiency was confirmed by the DON and Nursing Home Administrator.
A resident with dementia and other disorders had medication regimen irregularities identified by a pharmacist, including inappropriate antipsychotic use. The attending physician failed to act on these recommendations, and instead, a consultant psychiatric CRNP responded. The facility could not provide evidence of the physician's response, violating regulatory requirements.
Two residents in an LTC facility received unnecessary antibiotics due to inadequate urine sample collection and improper clinical justification. One resident, with chronic kidney disease, was given Doxycycline without a urine analysis, while another with dementia received Ciprofloxacin despite a contaminated urine sample. The DON confirmed the lack of clinical justification for these treatments.
A facility failed to attempt non-pharmacological interventions before administering a PRN antipsychotic medication to a resident with cerebral infarction and anxiety. Despite having a plan for interventions like activities and redirection, the medication was given without documented attempts of these measures. The DON could not provide evidence of these interventions being tried prior to medication administration.
The facility failed to maintain proper food storage practices in two resident pantries, leading to potential food-borne illness risks. Observations revealed undated and expired opened containers of nectar-thickened juice and water, contrary to manufacturer guidelines. The Nursing Home Administrator confirmed the requirement for proper dating and disposal of food items.
The facility failed to resolve grievances timely and adequately for two residents. One resident's complaint about staff not answering call bells and using phones was unresolved, and another resident's concern about a knife found in her bed was not followed up. Both residents were not informed of the outcomes.
The facility failed to provide timely care and necessary supplies for effective incontinence management for a resident with significant medical conditions, leading to the resident sitting in a soiled brief for over two hours due to the unavailability of properly sized bariatric briefs. Staff and the DON confirmed frequent shortages and lack of a system to ensure consistent availability of supplies.
The facility failed to adhere to expiration dates on pharmacy products stored in the central supply room. Expired items included Glucerna tube feeding, Nova Source Renal tube feeding formula, and hand sanitizer. A clinical consultant confirmed the expiration.
A resident with significant medical conditions and bilateral leg amputations did not receive scheduled showers due to the unavailability of a specialized bariatric amputee shower sling required for safe transfers. The resident received only a portion of the planned showers over two months, and the Director of Nursing was unaware of the missing equipment.
The facility failed to ensure the consistent availability of prescribed insulin for a resident with diabetes, leading to repeated shortages and reliance on the resident's son to provide the medication. Staff did not follow the policy for reordering medications, as confirmed by the DON and an LPN.
The facility failed to store resident care supplies in a sanitary environment. Observations revealed litter, dirt, and debris on the floor of the central supply room, with various personal care supplies and medical kits found directly on the floor. Interviews confirmed that the supplies were not stored appropriately and that the central supply room should be maintained in a sanitary manner.
Obstruction in Exit Corridor
Penalty
Summary
The facility failed to maintain exit access in accordance with NFPA 101 standards, specifically in one of the ten smoke compartments. During an observation on March 31, 2025, at 12:11 pm, it was noted that a wooden pallet and a vacuum cleaner were stored in the exit corridor near Resident Room 53. This obstruction in the exit corridor was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 1:15 pm.
Plan Of Correction
1. A wooden pallet and vacuum cleaner were being stored near resident room 53, in the exit corridor. 2. The wooden pallet and vacuum cleaner were immediately removed from the exit corridor near resident room 53. 3. The Maintenance manager/Designee will audit the affected area and other potential areas to ensure the facility maintains a proper means of egress. 4. Corrective Action Date: April 17, 2025
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain the integrity of a smoke barrier separation wall, which affected two out of ten smoke compartments. During an observation on March 31, 2025, at 12:32 pm, it was noted that the smoke barrier wall in the North Hall had an unsealed penetration above the ceiling around black and blue wires. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day. Additionally, another smoke barrier wall near the Generator room was found to have an unsealed penetration above the ceiling, affecting two out of six smoke compartments. This observation was made on the same day and time as the previous finding. The unsealed penetration was also confirmed during the exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
1. The North Hall, smoke barrier wall had an unsealed penetration above the ceiling around a black and blue wire. 2. The area above the ceiling in the North Hall has been sealed. Point to reference is that the facility is currently installing wires to upgrade the current phone system. 3. The Maintenance manager/Designee will audit other areas of the facility to ensure smoke barrier walls are sealed. 4. Corrective Action Date: April 17, 2025 1. The smoke barrier wall near the generator room had an unsealed penetration above the ceiling. 2. The area above the ceiling near the generator room has been sealed. 3. The Maintenance manager/Designee will audit other areas of the facility to ensure smoke barrier walls are sealed. 4. Corrective Action Date: April 17, 2025
Smoke Barrier Door Latching Deficiency
Penalty
Summary
The facility failed to maintain the smoke barrier separation doors in compliance with NFPA 101 standards. During an observation on March 31, 2025, at 12:37 pm, it was noted that the smoke barrier separation doors in the North Wing A-Hall did not latch into the frame when released from the hold open device. This deficiency affected two out of ten smoke compartments within the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 1:15 pm.
Plan Of Correction
1. The North Wing, A hall smoke barrier separation doors failed to latch into frame. 2. The North Wing, A hall smoke barrier separation door has been adjusted to ensure the door latches to the frame. 3. The Maintenance manager/Designee will audit other facility doors to ensure the doors are properly adjusted. 4. Corrective Action Date: April 17, 2025
HVAC System Deficiency Due to Faulty Fire/Smoke Dampers
Penalty
Summary
The facility failed to maintain its Heating, Ventilating, and Air Conditioning (HVAC) system ductwork through fire-rated walls throughout the facility. During an observation on March 31, 2025, it was revealed that a fire/smoke damper report from March 12, 2025, indicated that 14 out of 59 fire/smoke dampers failed due to deficient parts. At the time of the survey, this deficiency had not been addressed. An exit interview with the Facility Administrator and the Facilities Manager confirmed that the condition remained unresolved.
Plan Of Correction
1. The fire/smoke damper report from March 12, 2025, stated 14 of 59 fire/smoke dampers failed because of deficient parts. 2. A contract was signed with a vendor and scheduled to be completed the week of 04-28-2025. 3. Corrective Action Date: April 17, 2025.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in five locations on one floor. Observations made on March 31, 2025, revealed several deficiencies: an unsealed penetration of a ceiling tile in the soiled utility area of Willow Hall, two missing ceiling tiles in the storage room of Spruce Hall, and missing escutcheons in Resident Room 233, the 200 Hall lounge, and the dietary walk-in freezer. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
1. The facility failed to maintain the automatic sprinkler system in the following areas: a. unsealed penetration of a ceiling tile in the soiled utility hall of Willow unit. b. missing ceiling tiles within storage room of Spruce Hall. c. missing escutcheon within room 233, of Spruce Hall. d. missing escutcheon within 200 hall lounge area. e. missing escutcheon within Dietary Walk-in freezer. 2. Areas listed in the preceding statement have all been resolved. 3. The Maintenance manager/Designee will audit the affected areas and other potential areas to ensure the automatic sprinkler system is monitored appropriately. 4. Corrective Action Date: April 17, 2025.
Fire Extinguisher Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a portable fire extinguisher on the only floor within the component. During an observation on March 31, 2025, at 11:51 am, it was noted that the kitchen 'K' fire extinguisher did not have a current annual inspection tag, with the last tag dated from 2022. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 1:15 pm.
Plan Of Correction
K 0355 1. The Kitchen "K" fire extinguisher lacked a current annual inspection tag. 2. The Kitchen "K" fire extinguisher has been inspected with appropriate tag attached. 3. The Maintenance manager/Designee will audit other areas with portable fire extinguishers to ensure the devices are properly inspected. 4. Corrective Action Date: April 17, 2025
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to properly secure and separate oxygen cylinders, which is a requirement under NFPA 101 standards for gas equipment storage. During an observation on March 31, 2025, at 11:05 am, it was noted that an oxygen 'E' cylinder was stored on the ground inside the outdoor oxygen empty storage cabinet. This storage method did not comply with the necessary safety protocols for securing oxygen cylinders. The deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 1:15 pm. The interview verified that the oxygen cylinders were not properly secured, which is a violation of the established guidelines for the safe storage of gas equipment. The report does not mention any specific residents or patients involved, nor does it provide details on any immediate consequences of this deficiency.
Plan Of Correction
1. One oxygen "E" cylinder in the outdoor oxygen storage cabinet was stored on the ground. 2. The oxygen "E" cylinder in the outdoor oxygen storage cabinet was immediately removed and stored appropriately. 3. The Maintenance Manager/Designee will audit oxygen storage areas to ensure oxygen "E" tanks are stored correctly. 4. Corrective Action Date: April 17, 2025
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain a corridor opening, specifically the single door in the main lobby leading to the main dining room. During an observation on March 31, 2025, at 12:22 pm, it was noted that the door did not close and latch properly because it was hitting the frame. This deficiency affects the entire floor within the component where the door is located. An exit interview with the Facility Administrator and the Facilities Manager confirmed the issue with the door. The door's inability to close and latch as required by the NFPA 101 standards and CMS regulations indicates a failure to ensure that corridor doors resist the passage of smoke and maintain proper latching mechanisms. This deficiency was observed and documented by the surveyors during their assessment.
Plan Of Correction
1. The Main dining room, single door, in the main lobby failed to close and latch. 2. The Main dining room, single door, in the main lobby has been adjusted and closes appropriately. 3. The Maintenance manager/Designee will audit other areas of the facility to ensure doors are latching correctly. 4. Corrective Action Date: April 17, 2025
Discrepancies in Controlled Medication Administration
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting and administration of controlled medications for two residents. For Resident 92, there was a physician's order for Morphine Sulfate 15 mg to be administered as needed for severe pain. However, the controlled substance record indicated that doses were signed out by nursing staff on several occasions, but there was no corresponding documentation in the Medication Administration Record (MAR) to confirm that the medication was administered to the resident on those dates and times. Similarly, for Resident 64, there was a physician's order for Oxycodone HCL 5 mg to be administered as needed for moderate pain. The controlled substance record showed that doses were signed out on specific dates, but the administration of the medication was not recorded in the resident's MAR. The Director of Nursing confirmed these discrepancies during an interview, indicating a failure in the facility's procedures for managing controlled medications.
Delayed Response to Resident Needs
Penalty
Summary
The facility failed to provide timely assistance to residents, impacting their quality of life and dignity. During Resident Council meetings, multiple residents expressed concerns about delays in receiving help, particularly with getting out of bed and responding to call bells. Residents reported waiting times ranging from 20 minutes to over two hours, with some instances of staff turning off call bells without providing assistance. These delays were noted to be more frequent during night shifts. Specific cases highlighted include Resident 49, who waited over two hours for medication assistance, and Resident 142, who was left in soiled conditions for an hour after her call bell was silenced. Resident 10 reported daily occurrences of waiting 20 to 30 minutes for help, causing frustration. Resident 72 and his roommate also experienced 30-minute wait times, leading to feelings of neglect. Resident 31 frequently waited over 30 minutes for care, with staff sometimes turning off his call bell without assisting him. Additional concerns were raised by Resident 140's Responsible Party, who reported that Resident 140 was often found soiled due to delayed assistance, particularly during evening and night shifts. Resident 48 experienced excessive wait times for bedpan assistance, sometimes waiting up to 1.5 hours. Resident 47 also reported long wait times, especially in the mornings. The Nursing Home Administrator and Director of Nursing acknowledged the issue but could not explain the continued delays in response times and unmet care needs.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For Resident 2, the MDS assessment indicated a diagnosis of a psychotic disorder other than schizoaffective and schizophreniform disorders. However, a review of the clinical records revealed no documented evidence supporting this diagnosis. The Director of Nursing (DON) confirmed the inaccuracy of Resident 2's MDS assessment, acknowledging the absence of documentation for the stated psychotic disorder. For Resident 183, the discharge return not anticipated MDS inaccurately recorded the discharge status. The MDS indicated that the resident was discharged to a short-term general hospital, while a progress note confirmed that Resident 183 was actually discharged to their home with belongings and medications. The DON confirmed this discrepancy, acknowledging that the resident was discharged to home and not to a hospital. These inaccuracies in the MDS assessments were identified during a review of clinical records and staff interviews.
Failure to Address Involuntary Movements in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with schizoaffective disorder, who was experiencing involuntary movements. The resident was admitted with a diagnosis that included schizoaffective disorder and was on multiple medications, including Quetiapine Fumarate, Hydroxyzine HCI, and Lorazepam. An Abnormal Involuntary Movement Scale (AIMS) assessment conducted on September 23, 2024, indicated the resident had a moderate level of severity of abnormal movements and mild incapacitation, causing moderate distress. Despite these findings, the facility did not document a care plan addressing the involuntary movements or the psychosocial distress resulting from them. During an observation on March 19, 2025, the resident was seen displaying erratic and jerky movements, indicating a lack of control over these involuntary actions. The Director of Nursing and Nursing Home Administrator confirmed that the facility's responsibility is to ensure each resident's care plan includes identified problems and services to assist the resident in maintaining their highest practicable well-being. However, they acknowledged that the resident's care plan did not identify the problem with medication-induced involuntary movements or the associated psychosocial distress before the survey inquiries.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to consistently administer oxygen as ordered for Resident 14, who was admitted with a diagnosis of congestive heart failure. The resident had a physician's order for oxygen at 2 liters per minute (L/min) via nasal cannula for shortness of breath, dated December 16, 2024. However, observations on March 19 and March 21, 2025, revealed that the resident's oxygen concentrator was set to 3 L/min, which was not consistent with the physician's orders. This discrepancy was confirmed by an LPN and the director of nursing, indicating a failure to follow the prescribed oxygen administration policy.
Failure to Provide Timely Dental Services for Resident
Penalty
Summary
The facility failed to provide timely dental services for a resident who was missing his lower dentures. The resident, who is cognitively intact and receives Medicaid benefits, reported his dentures missing for two months, and a room search confirmed they were not found. Despite the resident's repeated complaints and a representative's contact with the facility, there was no documented evidence of further assistance provided to replace the dentures until the survey week. The resident expressed difficulty eating without the dentures and frustration that the facility staff had discarded them. An X-ray was performed, but no further action was taken to address the issue until the surveyors' inquiries. The Director of Nursing and Nursing Home Administrator acknowledged the facility's responsibility to ensure residents receive necessary dental services but could not provide evidence of compliance in this case.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to offer and/or provide the influenza immunization to a resident, unless the immunization was medically contraindicated or the resident had already been immunized. This deficiency was identified for one of the five residents sampled, specifically Resident 58. The clinical record review revealed that Resident 58 was admitted with diagnoses including chronic atrial fibrillation and dementia. The resident was severely cognitively impaired, as indicated by a BIMS score of 03. Despite the resident's representative providing informed consent for the influenza vaccine on January 29, 2025, there was no documented evidence that the vaccine was administered. During an interview, the Director of Nursing confirmed that the facility did not administer the influenza vaccination to Resident 58, acknowledging the facility's responsibility to ensure residents are offered and/or provided the immunization unless contraindicated or already received. This oversight was a violation of several Pennsylvania Code regulations, including those related to the responsibility of the licensee, management, resident care policies, and nursing services.
Failure to Prevent Resident Fall Due to Inadequate Assistance
Penalty
Summary
Glen Brook Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding the prevention of abuse and neglect. The deficiency involved a failure to provide necessary care and services to prevent a fall for a resident identified as Resident B1. This resident, who was admitted with conditions including hemiplegia and hemiparesis following a stroke, required substantial assistance for transfers. Despite a care plan and physician's order specifying the need for two-person assistance during transfers, a nurse aide attempted to transfer the resident alone, resulting in the resident being lowered to the floor. The incident was documented in a nurse's note and confirmed by the facility's Nursing Home Administrator. The facility's policy on abuse, neglect, and exploitation, which was last reviewed in April 2024, mandates the provision of protections for residents' health and rights. However, the incident on December 9, 2024, revealed a breach of this policy. The nurse aide involved admitted awareness of the two-person transfer requirement but proceeded alone, leading to the resident's fall. Although the resident did not sustain visible injuries, the action posed an unnecessary risk. The Nursing Home Administrator acknowledged the failure to adhere to the care plan, which could have resulted in potential harm to the resident.
Plan Of Correction
1. Resident B1 had no adverse effect related to the incident. 2. A review of fall incidents in the last 7 days will be completed to assure that plan of care was followed to prevent a fall and provide services in order to prevent abuse/neglect. 3. The RN Staff Educator will educate nursing staff on following plan of care to prevent resident falls and policy on abuse and neglect. 4. The Unit Manager/Designee shall complete a random observational audit to verify resident transfers are being completed based on plan of care in order to prevent abuse/neglect. The audits shall be completed weekly x4 then monthly x2 or until sustained compliance is achieved. Results of audits will be reviewed by the QAPI committee. 5. POC Due Date: 01/20/2025
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to implement adequate safety measures and provide sufficient staff supervision for a resident identified as high risk for falls, leading to multiple incidents of falls. The facility's Falls Prevention Program policy, last reviewed in April 2024, mandates that residents be assessed for fall risk and receive care according to their individualized risk level. Despite this, Resident 115, who was admitted with a history of falling and severe cognitive impairment, experienced nine falls within her first month at the facility and seven additional falls over the following months. Resident 115's care plan included interventions such as checking the resident every 15 minutes, using motion alarms, and placing bilateral floor mats and position alarms to alert staff of unsafe transfers. However, these measures were not effectively implemented, as evidenced by the resident's repeated falls, many of which were unwitnessed. The resident's falls occurred in various locations, including her room and near the nurse's station, and resulted in injuries such as skin tears and abrasions. The facility's failure to provide adequate supervision and implement effective interventions was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. They acknowledged the facility's responsibility to ensure each resident receives adequate safety measures to prevent falls. The deficiency was identified under the Pennsylvania Code sections related to the responsibility of the licensee, management, and nursing services.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident 103, who was admitted with Type 2 diabetes and difficulty walking, was found to be incontinent of urine and feces. Despite being on a two-hour check and change program, the resident's care plan did not include interventions for bowel and bladder incontinence. Similarly, Resident 58, admitted with dementia and other conditions, required Spanish-speaking staff for effective communication due to behavioral disturbances. However, the care plan did not include necessary interventions for communication, relying instead on family members and translation devices. Resident 401, diagnosed with Alzheimer's disease and depression, was identified as a Spanish-speaking resident. Although the facility provided Spanish-speaking staff and translation services, the care plan did not address the resident's communication needs. Interviews with staff and the Nursing Home Administrator confirmed the lack of comprehensive care plans tailored to the residents' specific needs, resulting in a failure to meet regulatory requirements.
Medication Administration Delay for a Resident
Penalty
Summary
The facility failed to administer medications timely in accordance with physician's orders for a resident diagnosed with end-stage renal disease. The resident had a physician's order for Amlodipine Besylate and Aspirin, both scheduled for administration at 8:00 AM. However, a review of the Medication Administration Audit Report revealed that these medications were administered late on 11 occasions between October 1, 2024, and October 24, 2024. The delays ranged from 1 hour and 20 minutes to 5 hours and 31 minutes past the scheduled time. The facility's policy on Medication Administration, last reviewed in April 2024, requires medications to be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician or resident preference. During an interview, the Director of Nursing confirmed that the nursing staff failed to administer the resident's medication timely, which was not in accordance with the physician's orders. This deficiency was identified through a review of clinical records, facility policy, and interviews with residents and staff.
Failure to Implement Restorative Programs for Residents
Penalty
Summary
The facility failed to provide appropriate services and assistance to maintain or improve mobility for two residents, leading to deficiencies in their care. Resident 145, who was admitted with diagnoses including dorsopathy and morbid obesity, was recommended a restorative range of motion program upon discharge from physical therapy. However, from September 1, 2024, through October 22, 2024, there was no documented evidence of any restorative nursing services being provided. During an interview, Resident 145 expressed frustration and sadness over not receiving the necessary services to improve her mobility, which was confirmed by the Nursing Home Administrator (NHA) and Director of Nursing (DON). Similarly, Resident 180, diagnosed with ALS and other conditions, was recommended a restorative program for assisted active and passive range of motion to the bilateral lower extremities. Despite these recommendations, there was no documented evidence that the program was implemented from June 1, 2024, through October 18, 2024. The NHA and DON confirmed the lack of implementation of the restorative nursing program as per the physical therapy recommendations, failing to maintain the resident's highest practicable function.
Delayed Response to Resident Call Bells
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, negatively impacting their quality of life. Multiple grievances were filed by residents, indicating that staff either did not respond to call bells or took an excessive amount of time to provide care. Specific incidents included a resident waiting for over an hour for assistance after activating the call bell, and another resident being left in soiled conditions for two hours because staff prioritized other tasks. Resident Council Meeting Minutes from March and April 2024 highlighted ongoing concerns about the responsiveness of nursing staff to call bells. Residents reported that staff often turned off call bells without providing the necessary care, leading to prolonged wait times. Interviews with residents corroborated these grievances, with reports of wait times ranging from 20 minutes to over an hour, particularly during shift changes and meal times. The Nursing Home Administrator and Director of Nursing acknowledged that residents should be treated with dignity and respect but could not explain the delays in staff response times. The deficiency was documented under several Pennsylvania Code regulations, emphasizing the facility's failure to uphold residents' rights and provide adequate nursing services.
Deficiencies in Hazard Prevention and Safety Measures
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards, as evidenced by the accidental ingestion of denture tablets by Resident 88. Resident 88, who was moderately cognitively impaired, was found with green debris on her mouth, which was determined to be from a denture cleaning tablet she mistook for candy. The resident did not have dentures, and the tablets belonged to her roommate, Resident 45, who also had moderate cognitive impairment. The facility's failure to ensure that denture cleaning supplies were not accessible to Resident 88, who had a history of rummaging through other residents' belongings, contributed to this incident. Additionally, the facility did not ensure the safe storage of oxygen cylinders on two nursing units. Observations revealed unsecured oxygen cylinders standing upright in resident rooms on both the North and East Nursing Units. Interviews with staff confirmed that oxygen cylinders should be stored securely to prevent accidents, yet this was not adhered to, posing a potential hazard. The Director of Nursing and the Nursing Home Administrator acknowledged the deficiencies, confirming that treatments, including denture cleaning tablets, should not be left in residents' rooms without physician orders and proper safety measures. The facility's policy on oxygen safety also mandates that cylinders be properly secured, which was not followed, leading to the identified deficiencies.
Medication Administration Deficiency Due to Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to administer prescribed medications according to professional standards of nursing practice. This deficiency was identified through observations, clinical record reviews, and interviews with staff. Specifically, an agency LPN administered the wrong medication to a resident due to confusion over similar last names. The resident, who was severely cognitively impaired and diagnosed with dementia, GERD, and anxiety, received Tramadol instead of the prescribed Oxycodone. The error was discovered during a shift change, and the resident's vitals remained stable. Further investigation revealed that another LPN was observed pre-pouring medications for multiple residents, a practice that is not in line with professional standards. This LPN admitted to using this shortcut during the morning medication pass. The medications were stored in unlabeled cups, which poses a risk of medication errors. The residents involved were prescribed various medications, including aspirin, carbidopa-levodopa, Lexapro, and others, which were prepared in advance without proper labeling. The facility was unable to provide documentation of orientation, skills checks, or competency evaluations for the involved nursing staff. This lack of documentation was confirmed by the Nursing Home Administrator, indicating a systemic issue in ensuring that nursing staff are adequately trained and competent in medication administration. The absence of these records suggests a failure in maintaining proper personnel records and ensuring compliance with nursing service regulations.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the timely administration of insulin. The resident, who is cognitively intact and has a diagnosis of diabetes mellitus, had a physician's order to receive Novolin insulin at specific times in the morning and evening. However, the facility's medication administration record (MAR) showed that the resident's morning dose was not administered on one occasion, and there was no documented explanation for this omission. Additionally, there were multiple instances where the insulin was administered late, ranging from over an hour to more than three hours past the scheduled time. The resident expressed concerns about the consistent lateness of her diabetes medication, recalling several recent instances of late administration. The Director of Nursing (DON) confirmed the facility's failure to administer the insulin as ordered and was unable to provide an explanation for the missed dose on one specific date. This deficiency was identified through a review of clinical records, facility policy, and interviews with staff and the resident.
Failure to Date Multi-Dose Diabetes Medications
Penalty
Summary
The facility failed to adhere to acceptable storage and use-by dates for multi-dose diabetes medications on two of the four medication carts observed. During an observation of the Spruce 400 hall medication cart, several opened multi-dose diabetes medications were found without being dated when initially opened. These included a Novolin N Flex Pen, two Insulin Lispro vials, a Fiasp vial, a Fiasp Kwik pen, a Novolog flex pen, a Lantus Solo Star flex pen, an Insulin Aspart pen, an Insulin Degludec pen, and a Humalog Kwik pen. The medications belonged to various residents, including Residents 107, 6, 27, 147, 34, and 57. Employee 3, an LPN, confirmed these findings and acknowledged that the medications should have been dated when opened. Similarly, an observation of the [NAME] 800 hall medication cart revealed an opened Humalog vial that was not dated when initially opened, belonging to Resident M1. Employee 4, another LPN, confirmed this finding. The Director of Nursing (DON) also confirmed that the facility failed to date multi-dose medications when opened, which is necessary to ensure acceptable storage times. The facility's policy requires that once opened, vials should be stored in the refrigerator, dated, and used within 30 days.
Failure to Provide Consistent Evening Snacks
Penalty
Summary
The facility failed to consistently provide snacks as desired by residents, as evidenced by a review of Resident Council and Food Committee Meeting minutes, scheduled facility mealtimes, and interviews with residents and staff. The facility's policy, last reviewed on April 17, 2024, states that residents should be offered a nourishing snack at bedtime daily, in accordance with their needs, preferences, and requests. However, the time between dinner and breakfast exceeds fourteen hours, and residents have reported that snacks, including sugar-free options, are not always available or distributed by staff. Interviews with residents revealed dissatisfaction with the availability of evening snacks. A cognitively intact resident stated she is not always offered a bedtime snack, and a group of five alert and oriented residents reported not being regularly offered evening snacks, with some instances of no snacks being available upon request. The Nursing Home Administrator and Director of Nursing were unable to explain why residents indicated that the facility is not offering nutritious snacks, despite confirming the facility's policy to do so.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to fully implement an antibiotic stewardship program, as evidenced by the inappropriate use of antibiotics for two residents. Resident 50, who had chronic kidney disease and cerebral infarction, was prescribed Doxycycline for symptoms suggestive of a urinary tract infection without obtaining a urine sample to confirm the infection or determine the most effective antibiotic. Despite the physician's order for a urine analysis and culture, the sample was not collected due to the resident's incontinence, leading to the administration of 10 doses of the antibiotic without confirmed necessity. Similarly, Resident 18, who had dementia, was prescribed Ciprofloxacin for hallucinations without any symptoms of a urinary tract infection. A urine sample was obtained, but the results suggested contamination or colonization, not an infection. Despite this, the resident received 20 doses of the antibiotic. The facility's infection preventionist admitted to not using the McGeer or Loeb Minimum criteria to identify infections or determine the need for antibiotic treatment, as required by the facility's policy. This lack of adherence to established criteria and procedures contributed to the inappropriate use of antibiotics.
Failure to Communicate Resident Information Upon Transfer
Penalty
Summary
The facility failed to ensure that necessary resident-specific information was communicated to the receiving health care provider upon transfer for two residents. Resident 124 was transferred to the hospital on February 10, 2024, and Resident 90 on February 22, 2024. Upon review of their clinical records, there was no documented evidence that the facility communicated essential information such as advance directives, special instructions, precautions for ongoing care, or comprehensive care plan goals to the receiving health care provider. This lack of communication was confirmed during an interview with the Director of Nursing and Nursing Home Administrator on June 6, 2024.
Inaccurate MDS Assessment for Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident. Resident 98, who was admitted with diagnoses including cerebral infarction and left-sided hemiplegia and hemiparesis, reported minimal to no use of his left side. However, a review of his Quarterly MDS assessment showed a discrepancy in Section GG - Functional Abilities and Goals, where it was inaccurately coded as having no impairment in range of motion for the upper and lower extremities. This inaccuracy was confirmed by both the RNAC and the Director of Nursing during interviews.
Failure to Follow Bowel Protocol for Resident with Constipation
Penalty
Summary
The facility failed to adhere to a physician-prescribed bowel protocol for a resident diagnosed with Parkinson's disease and constipation. The resident had specific orders for a bowel regimen that included Milk of Magnesia (MOM), Dulcolax suppository, and Fleet Enema to be administered sequentially if no bowel movement occurred within specified time frames. However, the facility did not follow these orders on multiple occasions in April and May 2024, resulting in the resident experiencing extended periods without a bowel movement. In April 2024, the resident did not have a bowel movement for six days, yet the facility did not administer MOM, Dulcolax, or Fleet Enema as ordered. Similarly, in May 2024, the resident went five days without a bowel movement, and again, the facility failed to administer the prescribed MOM and Dulcolax. This deficiency was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator, who acknowledged the failure to follow the physician's bowel protocol for the resident.
Failure to Address Pharmacist-Identified Medication Irregularities
Penalty
Summary
The deficiency involves the failure of the attending physician to act upon pharmacist-identified irregularities in the medication regimen of a resident diagnosed with dementia with agitation, major depressive disorder, and generalized anxiety disorder. The consultant pharmacist identified three irregularities in the resident's drug regimen during the December 2023 monthly pharmacy review. These included the use of Olanzapine and Brexpiprazole, which could trigger quality indicators for inappropriate antipsychotic use. The pharmacist recommended a 14-day length of therapy for Olanzapine and requested a review of the diagnosis for Brexpiprazole. However, the facility was unable to provide documented evidence that these recommendations were sent to the physician or that the physician responded to them. Further findings revealed that the consultant pharmacist identified additional irregularities in March and April 2024, involving the use of Quetiapine and Seroquel, which also triggered quality indicators for inappropriate antipsychotic use. The pharmacist requested a review of the diagnosis and consideration of a gradual dose reduction for Seroquel. Instead of the attending physician, the facility's consultant psychiatric CRNP responded to these recommendations, stating that the behavioral history benefits outweighed the risks. The Director of Nursing confirmed that the consultant psychiatric CRNP was responding to the pharmacy recommendations instead of the attending physician, as required by regulations.
Unnecessary Antibiotic Administration in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotic drugs for two residents. Resident 50, who was cognitively intact and had a history of chronic kidney disease and cerebral infarction, was prescribed Doxycycline for symptoms of dysuria without a urine analysis or culture and sensitivity being completed. Despite the resident's ability to occasionally hold urine and provide a sample with assistance, staff did not attempt to collect a urine sample before administering the antibiotic. The Director of Nursing could not provide evidence that the resident was free from unnecessary antibiotics or that attempts were made to collect a urine sample. Resident 18, who had dementia, was prescribed Ciprofloxacin for hallucinations and altered mental status, which were suspected to be symptoms of a urinary tract infection. However, the resident did not display any other signs or symptoms of a UTI, and the urine sample collected was contaminated, suggesting colonization rather than infection. Despite this, the physician advised continuing the antibiotic treatment, resulting in the resident receiving 20 doses of an unnecessary antibiotic. Interviews with the Director of Nursing confirmed that the administration of antibiotics to both residents was not clinically justified. The facility's failure to collect appropriate urine samples and the continuation of antibiotic treatment without proper justification led to the administration of unnecessary medications, violating regulations regarding residents' drug regimens.
Failure to Attempt Non-Pharmacological Interventions Before PRN Antipsychotic Use
Penalty
Summary
The facility failed to consistently attempt non-pharmacological interventions before administering an antipsychotic medication prescribed on an as-needed basis (PRN) for a resident. The resident, who had a diagnosis of cerebral infarction with left-side hemiplegia and anxiety, was moderately cognitively impaired with a BIMS score of 10. A physician's order dated May 30, 2024, prescribed Seroquel 25 mg as needed every 24 hours for anxiety, with planned non-pharmacological interventions including activities, redirection, repositioning, food/fluids, rest period, and a quiet environment. The resident's Medication Administration Record for June 2024 showed that the PRN antipsychotic medication was administered on two occasions for behaviors of restlessness and increased yelling out. However, there was no documented evidence that the planned non-pharmacological interventions were attempted before administering the medication. During an interview, the Director of Nursing was unable to provide documented evidence that these interventions were attempted prior to the administration of the PRN antipsychotic medication.
Improper Food Storage Practices in Resident Pantries
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness in two of four resident pantries. During an observation on June 5, 2024, at the Spruce Nursing Unit, it was found that a 46-ounce container of cranberry nectar-thickened juice inside the refrigerator was opened but not dated. The manufacturer's label indicated that the juice should be used within 10 days of opening, but without a date, it was unclear how long the juice had been stored. Similarly, at the North Nursing Unit, an opened 46-ounce container of lemon nectar-thickened water was found in the refrigerator, dated May 23, 2024. The manufacturer's label specified that the water should be kept under refrigeration for up to seven days after opening, indicating that the product was past its recommended usage period. An interview with the Nursing Home Administrator confirmed that all food items in the resident pantries should be properly dated upon opening and discarded according to manufacturer recommendations to ensure food quality and reduce the risk of food-borne illness.
Failure to Resolve Resident Grievances Timely and Adequately
Penalty
Summary
The facility failed to demonstrate timely and adequate efforts to resolve resident grievances for two residents. Resident 2 lodged a grievance on January 28, 2024, regarding staff not answering call bells in a timely manner and nurse aides using their phones while on duty. Although the facility noted the complaint was resolved on February 1, 2024, there was no documented evidence that the resident was informed of the outcome or that staff were educated on phone usage. An interview with Resident 2 on February 28, 2024, revealed that the resident's concerns were still unresolved, with wait times for call bell responses remaining problematic. The resident confirmed that he did not receive written details of the grievance outcome and was not asked if he was satisfied with the resolution. Resident 11's grievance, filed on January 29, 2024, involved a small box cutter type knife found in her bed. The grievance was marked as resolved on February 2, 2024, but there was no indication that the resident or her daughter was informed of the outcome. An interview with Resident 11 on February 28, 2024, confirmed that no one had followed up with her about the incident or the facility's corrective actions. The Nursing Home Administrator was unable to provide documented evidence of timely follow-up with the residents or their representatives to inform them of the grievance outcomes and assess the effectiveness of the resolutions.
Failure to Provide Timely Incontinence Care and Supplies
Penalty
Summary
The facility failed to provide timely care and necessary resident care supplies for effective incontinence management for one resident. Resident 2, who has significant medical conditions including diabetes, congestive heart failure, and amputations of both legs, reported sitting in a soiled brief with feces for over two hours due to the unavailability of properly sized bariatric briefs. The resident's care plan required checking every two hours and using appropriate briefs, but the facility frequently ran out of the necessary supplies, leading to discomfort and improper care for the resident. Interviews with staff and the Director of Nursing confirmed that the facility did not consistently have the correct sized incontinence briefs available for Resident 2. The staff often had to search the building or purchase supplies from local stores due to stock depletion. The Director of Nursing acknowledged the lack of a functioning system to ensure the consistent availability of incontinence briefs, resulting in the resident having to sit in feces and wear improperly fitting briefs.
Expired Pharmacy Products in Central Supply Room
Penalty
Summary
The facility failed to adhere to expiration dates on pharmacy products stored in the central supply room. During an observation on February 28, 2024, at 11:15 AM, it was found that a box containing 5 bottles of Glucerna tube feeding and another box containing 6 bottles had expired. Additionally, 2 bags of Nova Source Renal tube feeding formula and 16 bottles of hand sanitizer were also found to be expired. An interview with Employee 5, a clinical consultant, confirmed that these pharmacy products and enteral tube feeding formulas had indeed expired.
Failure to Provide Scheduled Showers Due to Missing Equipment
Penalty
Summary
The facility failed to consistently provide necessary services to maintain good personal hygiene for a resident dependent on staff for assistance with activities of daily living. Resident 2, who has significant medical conditions including diabetes, congestive heart failure, and bilateral leg amputations, was not provided with scheduled showers due to the unavailability of a specialized bariatric amputee shower sling required for safe transfers. The resident's care plan indicated the need for two-person assistance and the use of a mechanical Hoyer lift with the specialized sling for all transfers, including showers. However, the sling had been missing since early January 2024, leading to missed showers and the resident's inability to get out of bed as desired. Interviews with the resident and staff confirmed the unavailability of the specialized sling, which was often not returned from the laundry. The resident received only four out of eight planned showers in January 2024 and three out of eight planned showers in February 2024. The Director of Nursing was unaware of the issue and confirmed that the resident did not receive his planned showers due to the missing sling. This failure to provide the necessary equipment and services resulted in the resident not receiving adequate personal hygiene care as per the facility's policy.
Failure to Ensure Consistent Availability of Prescribed Medications
Penalty
Summary
The facility failed to implement pharmacy procedures to ensure the consistent availability of routine prescribed medications for Resident 8. Resident 8, who has been diagnosed with diabetes and hypertension, had a physician's order for Novolin 70/30 insulin to be administered twice daily. Despite this, the facility ran out of the prescribed insulin on three separate occasions, causing the resident to rely on her son to bring in insulin from home. On the date of the survey, the resident expressed concern and frustration about the repeated shortages and the facility's inability to order the medication from a local pharmacy. The resident reported that she no longer had any insulin at home because her son had already brought in all she had during previous shortages. During interviews, both a licensed practical nurse and the Director of Nursing confirmed that the facility staff failed to follow the policy for reordering medications through the electronic healthcare software provider, Point Click Care. The nurse confirmed that she administered the last dose of insulin available and had asked the resident to contact her son for more insulin. The Director of Nursing acknowledged that the staff should have reordered the medication when supplies were low and confirmed that the facility did not ensure the consistent availability of the prescribed medication for Resident 8.
Unsanitary Storage of Resident Care Supplies
Penalty
Summary
The facility failed to store resident care supplies in a sanitary environment and manner in the central supply room. Observations on February 28, 2024, at 11:15 AM revealed paper litter, dirt, and debris scattered on the floor of the central supply room. Boxes of personal care supplies, including bags of clean incontinence briefs and boxes of skin and hair cleanser, were found directly on the floor. Additionally, an oxygen tubing and mask kit, a skin stapler remover kit, a foam dressing kit, and a piston syringe were observed on the floor. Outside the central supply room, 20 boxes of clean incontinence briefs were also found on the floor. An interview with a clinical consultant confirmed that the supplies were not stored appropriately. The DON confirmed that the central supply room is supposed to be maintained in a sanitary manner.
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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