Grandview Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, Pennsylvania.
- Location
- 78 Woodbine Lane, Danville, Pennsylvania 17821
- CMS Provider Number
- 395623
- Inspections on file
- 53
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 25 (1 serious)
Citation history
Health deficiencies cited at Grandview Nursing And Rehabilitation during CMS and state inspections, most recent first.
Multiple cognitively intact residents reported ongoing delays in call bell response times, with waits exceeding 30 minutes and sometimes up to two hours. Despite documented grievances and interviews, the facility did not demonstrate effective resolution or follow-up regarding these complaints, impacting residents' timely access to assistance.
Insufficient staffing in the dietary department resulted in delayed meal service and meals not served at palatable temperatures for residents. Multiple residents and staff reported frequent late and cold meals, with one visitor expressing concern for a resident's insulin management. Observation confirmed significant delays in meal delivery and suboptimal food temperatures, and review of staffing schedules showed unfilled dietary aide positions and the dietary manager covering cooking duties.
The facility did not ensure meals were served at palatable temperatures and flavors, with delayed meal cart delivery resulting in food being served cold and unappetizing. Multiple residents reported receiving cold, bland, or inedible food, and observations confirmed that hot food items were below the required temperature standard.
A resident with multiple medical conditions was observed with numerous medications and a prepared respiratory treatment at the bedside, with staff sometimes leaving medications for independent administration. Staff could not confirm that the required self-administration assessment, physician order, or care plan was completed, resulting in a deficiency for not following facility policy and regulatory requirements regarding medication self-administration.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall, persistent pain, increased confusion, and refusal of medications and food. Despite ongoing decline and documentation of symptoms, the attending physician was not notified of these significant changes prior to the resident's hospital transfer, in violation of facility policy.
A resident with severe dementia and a known history of forgetting to use her walker did not have individualized fall-prevention interventions included in her care plan. Despite staff awareness of her impulsivity and cognitive deficits, the care plan failed to specify actions to keep her walker within reach or address her behavior, resulting in a fall that caused injury and required hospitalization.
A resident with severe cognitive impairment and multiple health issues developed a pressure ulcer that worsened after staff failed to perform weekly skin assessments, did not implement wound care consultant recommendations to remove the resident's brief while in bed, and did not update the care plan to reflect the worsening wound. Documentation was lacking for both the required interventions and regular skin checks, leading to the progression of the wound from an abrasion to an unstageable pressure ulcer.
A resident with multiple mental health and medical diagnoses did not receive several prescribed medications as ordered due to delays in obtaining medications from the pharmacy and lack of timely administration by staff. Facility records showed missed or delayed doses for medications including Lamotrigine, Olanzapine, Clonazepam, Lithium, Simethicone, and Cefepime, with documentation indicating medications were not available or were administered late. This occurred despite facility policy requiring timely medication administration.
A deficiency occurred when a hazardous sanitizing chemical was mistakenly served as a beverage to ten residents after a cook, lacking documented training, used a drink pitcher to mix the chemical and left it unlabeled in the kitchen. The solution was then served by another staff member, who assumed it was pink lemonade. Several residents with chronic illnesses and cognitive impairment were affected, and required monitoring and assessment were not documented as completed. Staff interviews and personnel file reviews revealed a lack of formal training and orientation regarding chemical safety and labeling procedures.
A resident with a history of falls, cervical fracture, and on anticoagulation experienced multiple falls, including an unwitnessed fall with possible head impact. Despite physician orders for 15-minute safety checks and neurological assessments, these were not consistently performed or communicated to staff. The resident was not promptly evaluated or transferred for diagnostic imaging, and was later found unresponsive with a large subdural hematoma, resulting in death. The facility failed to provide care in accordance with professional standards, including post-fall monitoring and timely assessment.
Surveyors identified multiple sanitation failures in the dietary department, including improper use of the three-compartment sink, lack of sanitizer test strips, dirty kitchen and storage areas, and widespread issues with unlabeled and undated food items. Additional deficiencies were found in resident dining and pantry areas, with dirty equipment, food debris, and improper storage of cleaning chemicals. Facility leadership confirmed these conditions as food safety and sanitation issues.
Surveyors found that the facility did not maintain a clean and sanitary environment in one care unit, with soiled floors, dirty equipment, and a resident left in a soiled condition for over fifteen minutes after a bowel incontinence episode. Staff shortages contributed to delays in care, and multiple rooms were observed with visible dirt and stains.
Facility administration failed to ensure resident safety when the dietary department served a hazardous cleaning chemical during meal service, resulting in ten residents ingesting the substance and placing all residents in the affected wing at risk. Staff interviews revealed that dietary personnel had not received effective training or competency evaluation on safe handling, storage, and labeling of hazardous chemicals, and administrative oversight was lacking in monitoring departmental operations and implementing facility policies.
A resident with multiple joint replacements and chronic conditions, who required two-person assistance with a Hoyer lift for transfers, was transferred by a single nurse aide who was aware of but did not follow the care plan and physician's orders. During the transfer, the resident sustained a left tibial periprosthetic fracture, resulting in pain, immobilization, and the need for frequent pain medication.
Surveyors found that the facility failed to maintain sanitary food storage and service practices, including unlidded trash near food prep areas, dishware and paper products stored directly on the floor with open packaging, and supplies stored close to the ceiling, all of which increased the risk of contamination in the dietary department.
Surveyors identified that the facility did not develop or implement individualized care plans for two residents: one requiring oxygen therapy and another dependent on staff for hydration. The care plan and Kardex for a resident with chronic respiratory failure did not match the physician’s order for oxygen administration, while another resident’s care plan failed to address full staff dependence for hydration, resulting in delays in fluid provision.
Licensed nursing staff administered Novolog insulin to a resident with type 2 diabetes on several occasions when the resident's blood glucose levels were below the physician-ordered threshold, contrary to the prescribed parameters. The DON confirmed that these administrations did not follow the physician's orders.
A resident with Alzheimer's disease and muscle atrophy, who required significant assistance with mobility, was discharged from physical therapy with recommendations for a ROM Restorative Nursing Program. The program was not included in the care plan or implemented as recommended, and there was no documentation or staff awareness of the omission.
A resident dependent on hemodialysis did not have the required emergency kit at the bedside, despite physician orders and care plan interventions mandating its presence. Observation and interviews confirmed the absence of emergency supplies for the resident's AV fistula site, and staff acknowledged the supplies were not available as required.
Nursing staff did not consistently follow established procedures for counting and verifying controlled substances on a medication cart, as required by facility policy. Required signatures from both on-coming and off-going nurses were missing on several occasions, and this was confirmed through record review, observation, and staff interviews.
A resident with moderately impaired cognition and a history of hypertension and muscle weakness was given multiple medications not prescribed to him after an LPN, unfamiliar with the unit, failed to verify the resident's identity. The medications administered belonged to the resident's roommate, and the error was discovered after the resident exhibited low blood pressure and was sent to the emergency room for evaluation.
Surveyors found that expired and improperly labeled medications and supplements were present in a medication storage room, including items such as Multi-Vitamin with Iron, Aspirin, and Glucosamine and Chondroitin. An LPN confirmed the presence of these items, which had not been removed in accordance with facility policy and manufacturer guidelines.
A resident refused the pneumococcal vaccine, but there was no documented evidence that the resident or their representative received education about the vaccine's benefits and side effects, as required by facility policy. This lack of documentation was confirmed by the Infection Preventionist.
A resident with quadriplegia and COPD, assessed as cognitively intact and able to smoke independently, was found keeping smoking materials in their room, contrary to facility policy requiring all smoking supplies to be secured by staff. The facility was unable to provide evidence of staff monitoring or securing the resident's smoking materials, resulting in noncompliance with established procedures.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall from bed due to the left-side bed wedge not being in place and a nonfunctional bed alarm, despite care plan interventions requiring these safety measures. The facility's investigation determined that the fall resulted from failure to follow the individualized plan of care.
A resident with severe cognitive impairment and chronic medical conditions was not provided with an individualized incontinence management plan, despite being always incontinent of urine and frequently incontinent of bowel. The care plan lacked a structured toileting schedule or specific interventions, and documentation showed the resident was not on a toileting program. The resident was consistently found incontinent, and a family grievance reported the resident was soaked with urine. The DON confirmed there was no documented plan for incontinence management.
Multiple residents reported that their meals were frequently served cold or lukewarm, and a test tray analysis confirmed that hot foods were below the required temperature and cold foods were above the safe limit. The Dietary Manager and NHA acknowledged that meals were not consistently served at palatable temperatures or in line with resident preferences, in violation of facility policy and federal regulations.
Multiple residents experienced significant delays in staff response to call bells due to a malfunctioning notification system on one unit. Visual indicators were present, but without audible alerts or fully functioning pagers, staff were often unaware of active calls unless physically present in the hallway. In contrast, another unit with an upgraded system had faster response times.
The facility failed to follow its planned menus, resulting in food omissions for four residents during breakfast. The Dietary Manager confirmed that biscuits were not served due to being overbaked, but no substitutions were made. The facility could not provide required Meal Substitution Records and lacked a system to monitor food omissions or substitutions, leading to non-compliance with its policies.
The facility failed to serve meals at safe and appetizing temperatures, affecting three residents. Meals were consistently cold, with a test tray evaluation confirming food temperatures below required standards. The dietary manager acknowledged the deficiency, which impacted resident satisfaction and increased the risk of foodborne illness.
The facility failed to provide adaptive dining equipment for two residents, one with cerebral infarction and dysphagia, and another with dementia and polyosteoarthritis. Despite physician orders for specific adaptive cups to prevent dehydration and address nutritional deficits, the dietary staff did not provide the required equipment during breakfast, as confirmed by staff interviews.
Two residents in the facility, both with severe cognitive impairments, did not receive scheduled showers over a three-month period. Despite being dependent on staff for assistance with activities of daily living, the facility failed to provide or document the showers as planned. The Nursing Home Administrator and DON confirmed the oversight but could not explain the lack of compliance.
The facility failed to provide meals accommodating the dietary needs and allergies of two residents. A resident with a dairy allergy was served yogurt containing milk, and both residents did not receive the prescribed honey-thickened juice. Staff interviews and observations revealed systemic issues in dietary service, with aides needing to retrieve missing items from the kitchen.
The facility failed to provide timely responses to residents' requests for assistance, impacting their quality of life and dignity. Several residents reported long wait times for care, with one resident waiting over an hour and a half for staff to respond to her call bell. Another resident, dependent on staff due to Parkinson's disease, was left exposed in bed for 20 minutes. The Nursing Home Administrator and DON acknowledged the issue but could not explain the delays.
A resident with Parkinson's disease was left exposed in bed with pants pulled down and no privacy curtains drawn, visible from the hallway for twenty minutes. The resident, who is cognitively intact and dependent on staff for personal care, expressed anger and frustration over the situation. The DON confirmed the lapse in maintaining the resident's dignity and the need for proper personal care.
A resident with chronic kidney disease and traumatic brain injury was discharged from an LTC facility without a safe discharge plan, particularly regarding medication administration. Despite recommendations for significant supervision due to cognitive impairment, the facility did not document the availability of necessary support or provide self-medication training. The resident was hospitalized shortly after discharge due to the lack of a safe plan.
A facility failed to ensure proper nursing practices for IV medication administration via a central venous catheter. A resident with bacterial meningitis required IV antibiotics through a PICC line, but LPNs administering the medication lacked the necessary education and supervision. The facility did not have a policy for LPNs providing care through central catheter lines, as confirmed by the DON.
A facility failed to document the administration of an antibiotic for a resident with bacterial meningitis. The resident had a PICC line and was prescribed Penicillin G Potassium in Dextrose intravenously every four hours. The Medication Administration Record showed missing documentation on multiple occasions, and the DON confirmed the uncertainty of administration.
A facility failed to implement a comprehensive care plan for a resident with a PICC line, omitting critical interventions such as monitoring for infection, measuring the line, and ensuring emergency supplies were available. The resident, admitted with bacterial meningitis and severe cognitive impairment, required specific care that was not documented in the care plan, as confirmed by the DON.
The facility failed to maintain a comprehensive infection prevention and control program. The infection control data lacked an operational system to monitor and investigate infections, with incomplete logs from September 2023 to September 2024. Clinical records showed a resident treated for cellulitis and two residents for UTIs. Interviews confirmed the absence of complete logs and a comprehensive program.
The facility did not provide dementia management training for five newly hired employees, as required by their policy. A review of records showed no evidence of such training for Employees 12, 13, 14, 15, and 16, hired between July and September 2024. The DON confirmed the lack of training, violating several state codes.
The facility experienced delays in meal service due to insufficient staffing in the dietary department. The FSD was observed cooking meals herself, and residents reported receiving meals late, with one resident noting supper was served at 7:45 PM. The nursing home administrator could not provide evidence of consistent staffing to ensure timely meal delivery.
The facility failed to maintain proper food storage and sanitation practices, increasing the risk of food-borne illness. Observations revealed meat stored directly on the floor, expired milk in a resident pantry, and a soiled ice machine. Additional sanitation issues included a dirty food delivery cart, soiled kitchen equipment, and improper broom storage. The foodservice director confirmed the need for sanitary maintenance and disposal of expired items.
The facility did not inform residents about the grievance process, including how to file grievances and the location of submission boxes for anonymous grievances. Five residents reported being unaware of these procedures, and observations confirmed the absence of postings about the grievance policy. The Nursing Home Administrator and DON could not provide evidence that residents were informed about the grievance process.
The facility failed to follow proper storage and use-by dates for multi-dose medications. Insulin vials on a medication cart and Aplisol vials in storage rooms were used beyond recommended discard dates. Staff interviews confirmed the oversight, and the Nursing Home Administrator acknowledged the failure to comply with guidelines.
The facility failed to provide sufficient nursing staff, resulting in unmet care needs for several residents. Residents reported infrequent showers and delayed call bell responses, attributing these issues to staff shortages. Facility records confirmed insufficient nursing care hours on multiple dates, and the administrator could not provide evidence that shower schedules were based on resident preferences.
The facility failed to accommodate resident food preferences and ensure the availability of meal components, leading to dissatisfaction. A resident reported missing milk and sugar, and limited meal options. A group of residents confirmed frequent shortages of preferred items. Another resident did not receive the planned vegetable, and an alternate was not offered until prompted. The FSD acknowledged the need for adequate food supply and offering alternates.
The facility failed to honor the drink preferences of several residents by discontinuing soda as a beverage option without prior notice. Residents expressed dissatisfaction, citing high vending machine prices and lack of family support to provide soda. The decision was made by corporate due to cost and nutritional concerns, but no alternative options were documented, leading to a deficiency in resident rights.
The facility failed to provide a fully functioning call system across three nursing units, as staff were not equipped with the required pagers to respond to residents' call bells. Observations and staff interviews revealed a lack of available pagers, with some staff unaware of the requirement to carry them. This deficiency was previously cited, indicating ongoing issues with the call system's utilization.
A resident with end-stage renal disease and dependent on dialysis was admitted to the facility, but their baseline care plan failed to include necessary information about their dialysis schedule and related needs. The care plan lacked goals, objectives, and interventions for dialysis, as confirmed by the DON.
Failure to Resolve Resident Complaints About Delayed Call Bell Response
Penalty
Summary
The facility failed to resolve ongoing resident complaints regarding delayed call bell response times, as evidenced by multiple grievances and interviews with residents who were cognitively intact. Four residents reported waiting more than 30 minutes, and in some cases up to two hours, for staff to respond to their call bells. These concerns were documented both in written grievances and during interviews, with residents consistently stating that delays occurred on all shifts and affected their ability to receive timely assistance with basic needs such as toileting, mobility, and safety. Despite the facility's grievance policy, which requires prompt and adequate follow-up on resident concerns, there was no evidence that the facility effectively addressed or resolved these repeated complaints. The Nursing Home Administrator was unable to provide documentation showing that corrective actions taken in response to the grievances were successful or that follow-up with residents occurred to ensure their concerns were resolved.
Insufficient Dietary Staffing Leads to Delayed and Unpalatable Meal Service
Penalty
Summary
The facility failed to maintain sufficient staffing in the dietary department, resulting in delayed meal service and meals not served at palatable temperatures for residents on the East unit. Multiple residents reported that meals were often late by thirty minutes to over an hour and were served cold and unpalatable. One resident's visitor expressed concern for timely nutritional intake due to the resident's insulin use, noting that delays in meal service could impact blood sugar management. Nursing staff also reported that meal carts were consistently delivered late to the units. Observation of the lunch tray pass confirmed that the meal cart arrived fifty-three minutes past the scheduled time, and test tray temperatures for hot foods were below expected levels, resulting in lukewarm and bland meals. A review of the dietary department's staffing schedule revealed that two dietary aides were not replaced during their scheduled shifts, and the dietary manager was covering as the PM cook. The facility census was 168 residents at the time, and the administrator acknowledged ongoing staffing shortages in the dietary department.
Failure to Serve Palatable and Timely Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable, attractive, and at safe and appetizing temperatures during a lunch meal service on the East Unit. Observations revealed that the meal cart, scheduled to arrive at 11:30 AM, was delayed and did not reach the unit until 12:23 PM, resulting in meal trays being distributed significantly later than planned. A test tray obtained after the last resident was served showed that hot food items, including beef tips, garden rice, and mixed vegetables, were served at temperatures below the facility's standard of 120 degrees Fahrenheit, with recorded temperatures ranging from 108.5 to 118.2 degrees Fahrenheit. The food was described as lukewarm, unpalatable in temperature and flavor, with the rice being hard and bland, and the vegetables unseasoned and bland. Only the brownie was found to be palatable. Resident and staff interviews, as well as a review of food committee meeting minutes and grievance forms, indicated ongoing concerns about meals being served cold and unpalatable, with residents attributing these issues to dietary department staffing shortages and delayed meal cart deliveries. One cognitively intact resident specifically reported receiving burnt and inedible food, and others consistently noted that meals arrived late and were frequently cold. The facility's own documentation and interviews confirmed that meals were not served at the expected times or at palatable temperatures and flavors.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and determine a resident's capability to self-administer medications as required by its own policy. The policy mandates that residents who wish to self-administer medications must undergo an assessment by the interdisciplinary team to determine their ability to do so safely, including evaluating their understanding of medication labels, dosages, administration times, and safe storage. In this case, a resident with multiple diagnoses, including aftercare following abdominal surgery, asthma, anxiety, and depression, was observed with a medication cup containing 22 pills and a prepared nebulizer treatment at the bedside. The resident reported that nursing staff sometimes left medications at the bedside and sometimes stayed during administration. Interviews with staff revealed that medications and respiratory treatments were left at the resident's bedside without confirmation of a completed or approved self-administration assessment. The staff member involved considered the resident cognitively intact but could not verify that the required assessment had been performed. Further review by the Director of Nursing confirmed that the clinical record lacked a current physician order for self-administration, a self-administration assessment, and a care plan documenting self-administration. This failure to follow policy and regulatory requirements resulted in a deficiency related to pharmacy services, resident care policies, and nursing services.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the attending physician of a significant change in condition for one resident, as required by facility policy. The policy mandates prompt identification, assessment, intervention, and communication with the resident, family, and healthcare providers when there is a sudden or significant deterioration in a resident's baseline health status. In this case, the clinical record review showed that the resident, who was severely cognitively impaired and had multiple complex diagnoses, experienced an unwitnessed fall with head injury, followed by persistent head and neck pain, increased confusion, and changes in mental status. Despite ongoing documentation of the resident's worsening symptoms—including repeated complaints of pain, increased confusion, refusal of medications and food, and elevated blood glucose—there was no evidence that the attending physician was notified of these changes prior to the resident's transfer to the hospital. While a physician assistant and a certified registered nurse practitioner were involved at various points, and the resident's responsible party was contacted, the attending physician was not informed as required by policy. The resident's condition continued to decline, ultimately resulting in hospital admission for trauma. Interviews with facility leadership confirmed that there was no documentation verifying physician notification before the hospital transfer. The deficiency was cited under state regulations for nursing services and resident care policies, as the facility did not follow its own protocols for managing and communicating significant changes in a resident's condition.
Failure to Individualize Fall-Prevention Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized fall-prevention interventions for a resident with severe cognitive impairment and a history of forgetting to use her walker. The resident, diagnosed with dementia and requiring supervision and assistance for transfers and ambulation, was known to be impulsive and easily distracted, with a BIMS score of 00 indicating severe cognitive deficits. Despite these documented needs and behavior patterns, the care plan did not include specific interventions to ensure the resident's walker was kept within reach or address her tendency to ambulate without it. As a result of this omission, the resident was left unattended without her walker after being assisted to her room, during which time she attempted to follow her cousin and fell. This incident led to the resident sustaining a head laceration and a right hip fracture, requiring hospitalization and surgery. Staff interviews confirmed awareness of the resident's impulsivity and forgetfulness regarding her walker, yet the care plan lacked tailored strategies to mitigate these risks.
Failure to Implement and Document Pressure Ulcer Interventions
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including polyosteoarthritis and osteomyelitis, developed a pressure ulcer that worsened due to the facility's failure to implement and document required interventions. The resident was assessed as being at high risk for pressure injuries and had a care plan in place that included frequent repositioning, use of specialized support surfaces, and regular skin assessments. However, between mid-July and mid-August, there was no documentation of weekly skin assessments, during which time the resident developed an open area in the left gluteal fold. Despite recommendations from the wound care consultant to remove the resident's brief while in bed to relieve pressure on the wound, facility records, including Treatment Administration Records and nurse aide documentation, did not show evidence that this intervention was implemented. The wound progressed from an abrasion to an unstageable pressure ulcer, with the wound consultant repeatedly noting that pressure from the brief contributed to the worsening condition. The care plan was not updated to reflect the new wound or the consultant's recommendations, and the facility did not follow its own pressure ulcer prevention and treatment policy. Interviews with facility leadership confirmed the absence of documentation verifying implementation of the recommended interventions and weekly skin checks. The lack of timely assessment, failure to update the care plan, and non-implementation of wound care recommendations directly contributed to the deterioration of the resident's pressure ulcer.
Failure to Ensure Timely Acquisition and Administration of Prescribed Medications
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of twelve sampled residents. Facility policy required medications to be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. For a resident admitted with diagnoses including bipolar disorder and major depressive disorder, multiple physician orders for medications such as Lamotrigine, Olanzapine, Clonazepam, Lithium, Simethicone, and Cefepime were not followed as prescribed. Medication Administration Records (MAR) showed blank entries or notes indicating medications were not available and were awaiting pharmacy delivery on several occasions. There were also instances of delayed administration, such as a four-hour delay in administering Cefepime. The resident involved was cognitively intact, as indicated by a BIMS score of 13, and had several mental health and medical conditions requiring consistent medication management. Interviews and record reviews confirmed that the facility did not ensure medications were obtained and administered as ordered, due to misunderstandings between nursing staff and the pharmacy regarding medication availability. This resulted in missed or delayed doses for multiple prescribed medications, in violation of facility policy and state regulations.
Improper Chemical Labeling and Storage Leads to Residents Being Served Sanitizer
Penalty
Summary
A deficiency occurred when the facility failed to implement safe and sanitary food handling practices in the kitchen, specifically by not ensuring that hazardous chemical cleaning and sanitizing solutions were properly labeled, stored, and used according to manufacturer instructions and facility policy. A cook, who had not received any documented orientation or training, used a clear plastic drink pitcher to mix a red sanitizing chemical solution due to a lack of available sanitation buckets. After cleaning, the cook left the pitcher containing the chemical in the sink, and it was later mistaken for pink lemonade by another staff member, who then served it to residents on the East unit. Ten residents were served the chemical solution, and the facility could not determine how much was consumed by each individual. The affected residents included individuals with chronic kidney disease, dementia, cerebral infarction, COPD, and cerebral palsy, with varying levels of cognitive impairment. One resident experienced vomiting after lunch, and all affected residents were assessed for symptoms, with physicians and poison control notified. However, clinical record reviews revealed that the ordered monitoring, fluid administration, and oral assessments were not documented as completed at the time of the incident for any of the residents involved. Interviews with dietary staff and review of personnel files showed that most kitchen staff were newly hired and had not received formal education or training regarding their job responsibilities, chemical safety, or labeling procedures. The contracted dietary company did not provide written job descriptions or documented orientation for the staff. The lack of proper labeling, storage, and staff training directly led to the accidental serving of a hazardous chemical to residents, resulting in Immediate Jeopardy to resident health and safety.
Plan Of Correction
Investigation was completed on 9/22/2025. Root cause determined to be isolated staff member improperly using a drink pitcher to store a cleaning sanitizer. Medical team made aware. Poison Control Center consulted. East Unit residents were assessed, and additional orders were implemented for the 10 residents found to have ingested some of the diluted sanitizer. These orders included vital sign monitoring, additional fluids, and oral assessments. Resident Representatives notified. Completed on 9/22/2025. DON/designee to complete follow-up clinical needs determined by post-incident evaluations of affected residents. Completed on 9/23/2025. The chemicals in the kitchen were reviewed for proper storage and labeling; sanitizing solutions were secured. Dietary staff are to store drink pitchers on the shelf under the beverage preparation station. Open chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Chemicals that are in current use are to be stored under the 3-compartment sink. All other chemicals are to be stored in a remote storage area. Dietary staff are to complete pH testing on diluted 3-compartment sink chemicals and keep a log. Chemicals are only to be used for intended purposes and in labeled containers. Completed on 10/3/2025. DON/designee to complete chemical safety education for nursing staff for specifics on chemical storage and container labeling. Date of completion 10/3/2025. Dietary policies for labeling and storing of chemicals were reviewed and updated. Dietary Manager/designee to complete chemical safety training for dietary staff to include Food and Chemical Storage (NO chemicals can be in food storage containers), Sanitation Bucket Use, Labeling and Dating, Hazardous Chemicals, Food Storage, SDS, and Hazard Communications. Dietary Manager/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue. DON/designee to complete post-education audits to ensure compliance with remediation. Audits to be completed 5 times weekly for 4 weeks. Audit findings to be reviewed at the facility QAPI. Audits initiated on 10/3/2025 and continue.
Removal Plan
- A root-cause analysis determined that a staff member had improperly used a drink pitcher to mix and store a sanitizing chemical in the kitchen.
- All residents on the East Unit were reassessed for injury or adverse effects, and physician orders were implemented for care and monitoring.
- All chemicals in the kitchen were reviewed for proper labeling and storage.
- Education was provided to all dietary and nursing staff regarding chemical safety, labeling, and segregation of food and cleaning supplies.
- All chemicals not in active use were removed from the kitchen area and placed in a secure, designated chemical-storage area.
- Facility dietary policies regarding chemical labeling, storage, and use were reviewed and revised.
- Post-education audits were initiated to verify continued staff compliance with labeling and storage procedures.
Failure to Provide Post-Fall Monitoring and Timely Assessment for Anticoagulated Resident
Penalty
Summary
A resident with a history of falls, cervical fracture, and on anticoagulation therapy was admitted to the facility and identified as a high fall risk. The care plan included interventions such as keeping the call bell within reach, ensuring non-skid footwear, and encouraging the resident to request assistance for mobility. Despite these interventions, the resident experienced multiple falls during their stay, including unwitnessed incidents and falls resulting in injury. After each fall, documentation shows that only minor or previously implemented interventions were added, and there was no evidence of significant revision to the care plan to address the ongoing pattern of falls. Following an unwitnessed fall with possible head impact, the resident, who was on anticoagulation therapy, was not transferred for immediate medical evaluation or diagnostic imaging as recommended by professional standards and facility policy. Although a physician ordered 15-minute safety checks and neurological assessments after the fall, documentation revealed that these were not consistently performed or communicated to all staff. The neurological assessment flow sheet showed gaps in monitoring, and the facility could not provide evidence that the required 15-minute safety checks were completed. The DON confirmed that staff were unaware of the order for increased monitoring due to a lack of communication. Subsequently, the resident was found unresponsive approximately 13 hours after the fall, with no documented neurological assessments in the five hours prior. Emergency services were called, and the resident was transferred to the hospital, where diagnostic imaging revealed a large subdural hematoma and multiple areas of brain bleeding. The resident was pronounced deceased following further evaluation. The facility failed to ensure that treatment and care were provided in accordance with professional standards of practice, including prompt evaluation and monitoring after a fall in an anticoagulated resident, as well as proper implementation and documentation of physician-ordered interventions.
Plan Of Correction
1. Unable to retro correct deficient practice for Resident CR1. 2. Facility will review residents on anticoagulation therapy who have had a fall in the past 48 hours. Physician will be contacted with post fall assessment findings including neurological evaluation to determine whether residents need to be transferred to the hospital for evaluation. 3. Nursing Educator/ designee will provide education to licensed staff facility on post fall protocols including MD notification to include anticoagulant use and neurological evaluation. 4. Director of Nursing / designee to complete audits on 5 falls weekly to ensure that interventions are initiated to address risk for falls and interventions to prevent reoccurrence. Audits will also include neurological evaluations on unwitnessed falls and q 15-minute checks if applicable, and MD notification if the resident is on anticoagulation therapy. Audits will continue x 8 weeks and findings will be reviewed by the facility QAPI committee. F 0684
Widespread Food Service Sanitation Failures in Dietary and Resident Areas
Penalty
Summary
The facility failed to maintain food service sanitation practices in accordance with professional standards for safe preparation, handling, and service of food. During a tour of the kitchen, surveyors observed multiple sanitation concerns, including improper use and maintenance of the three-compartment sink system. All three sink compartments contained food debris, and no sanitizer test strips were available to verify sanitizer concentration. The surrounding area was dirty, with paper debris, liquid stains, and a sticky residue on the floor. A mop bucket filled with dirty water and cleaning equipment was stored adjacent to the sink, creating a risk of contamination. The Corporate Dietary Manager confirmed that sanitizer test strips could not be located and that there was no documentation verifying that sanitizer concentrations were checked as required by facility policy. He also stated that most dietary staff were recently hired and had not been trained on proper three-compartment sink use. Additional environmental observations revealed widespread sanitation issues throughout the kitchen, maintenance, storage, and service areas. Unlabeled drink pitchers were stored upside-down on a dirty windowsill, and an unlabeled bucket containing a rag in chemical solution was stored next to food items. The kitchen maintenance room contained unidentified machines, an open bottle of degreaser, and electrical extension cords strewn across the machines and floor. A metal cart was visibly soiled, and the floor had visible dirt, paper, and a black sticky substance. In the storage room, uncovered shelving held pans and utensils with standing water and water stains, and the area was cluttered with dust, dirt, cobwebs, and open containers of paper dining products. The kitchen's meal tray delivery cart and open food carts in resident hallways had visible food and liquid stains. Further deficiencies were noted in the Pavilion resident dining area and pantry. Clean coffee cups had a white film inside, and there were open, undated, and unlabeled food items in both the refrigerator and freezer. The refrigerator and pantry areas were dirty, with food debris, paper waste, and dirt accumulation. Dirty dishes, a microwave with dried food residue, and sticky countertops were observed. The cabinet under the sink contained dirty trays and an unlocked bag of dishwasher pods. The Corporate Dietary Manager confirmed that dietary staff were responsible for cleaning and maintaining these areas, and the Nursing Home Administrator acknowledged that the observed conditions constituted food safety and sanitation issues.
Plan Of Correction
1. Three compartment sinks were emptied, cleaned, and sanitizer test strips were obtained. Area around the 3-compartment sink was cleaned, and the dirty mop bucket was emptied and cleaned. Cleaning equipment stored by the 3-compartment sink was moved to avoid possible contamination of food-contact areas. Log obtained for documentation of sanitizer concentrations. Unlabeled drink pitchers were removed from the window sill and cleaned. The window sill was cleaned of dirt and lint. The cleaning bucket was moved away from the spice shelf with cooking products. The kitchen maintenance room was checked for contamination and hazards, and all equipment and cleaning products were removed and/or relocated. The floor of the maintenance storage room was cleaned, and detergent was stored. The 3-tier metal shelving unit in the storage room was cleaned. The floor of the storage room was cleaned of dirt and debris. All meal delivery carts have been cleaned. Kitchen refrigerator fans have been cleaned, as well as the ceiling. Unlabeled and use-by date deli meat has been discarded. Coffee cups with white film in Pavillon dining room have been discarded, as well as an open cereal bag in a box. Metal banquet pans have been cleaned. The refrigerator has been cleaned, and outdated sandwiches and unmarked peaches have been discarded. Resident Pavillon pantry has been cleaned; all outdated, outdated, or opened food items have been discarded. Dirty dishes have been removed for cleaning. The refrigerator and freezer have been cleaned. 2. Corporate Dietary Service manager will complete a detailed and thorough audit of the main kitchen, maintenance storage area, food storage area, walk-in refrigerator and freezer areas, as well as all pantries on nursing units, and ensure areas are compliant. 3. Dietary Manager/designee will educate dietary staff on regulation requirements for food procurement, storage, preparation, serving, and maintaining a sanitary environment. 4. Corporate Dietary Service manager or designee will complete visual inspections and audits of kitchen areas as well as pantries twice a week for eight weeks. Results of audits will be reviewed by the QAPI committee.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment in the West Resident Unit. In Room W-16, a large amount of a white substance from an incontinent brief was found strewn under and around a bed, with the floor showing liquid stains, visible dirt, and paper debris. A fall mat was propped against the bathroom door frame and was visibly soiled with dark liquid stains and dirt. Additional rooms, W-9 and W-11, were also noted to have dried liquid stains and dirt on the floors. A resident was observed seated in a wheelchair outside her room with a brown liquid substance on her clothing, wheelchair seat, and tires. Multiple large puddles of the same brown liquid were present under the wheelchair and extended along the floor. The resident reported having a bowel incontinence episode, activating her call bell, and waiting more than fifteen minutes for assistance. Staff interviews revealed that the nurse aide assigned to the resident had to leave due to an emergency, and other aides were occupied with their assigned tasks. The DON confirmed that all resident care and common areas are required to be kept clean and sanitary.
Plan Of Correction
1. Rooms W 8, 9, 11, & 16 including floors and any fall mats, were deep cleaned. Incontinence care was provided to Resident # 12 on 10/4/25. Resident # 12 w/c seat and wheels were cleaned. 2. EVS supervisor to complete an initial audit of all resident rooms, fall mats, and wheelchairs to ensure cleanliness. Any items identified as not clean will be cleaned. 3. EVS supervisor with provide education to housekeeping staff on room cleanliness standards. 4. EVS Supervisor or designee will complete room audits 3 x week for cleanliness of flooring, fall mats and chairs. Audits will be completed 3 x week x 4 weeks, then weekly x 4 weeks. Results of audits will be reviewed at facility QAPI committee.
Immediate Jeopardy: Hazardous Chemical Served to Residents Due to Administrative Oversight
Penalty
Summary
The facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents. Specifically, the administration did not ensure resident safety when the dietary department served a hazardous cleaning chemical to residents during meal service. As a result, ten out of fifty-seven residents ingested the chemical, placing all residents in the East Wing at risk of consuming a hazardous substance and resulting in an immediate jeopardy to resident health and safety. A review of the job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that their responsibilities include overseeing the safety and cleanliness of the facility, ensuring hazardous conditions are addressed, and monitoring departmental operations. The facility failed to carry out these administrative responsibilities, as evidenced by the lack of effective oversight in the safe handling, storage, and labeling of hazardous chemicals within the dietary department. Interviews with staff confirmed that dietary personnel had not received effective training or competency evaluation regarding the safe handling, storage, and labeling of hazardous chemicals in accordance with facility policy and procedure. This lack of oversight and resource utilization by the Administrator and DON contributed to the immediate jeopardy situation, as they did not monitor departmental operations, identify systemic risks, or ensure the implementation of facility policies to maintain resident safety.
Plan Of Correction
Unable to retro correct deficient practice. 2. NHA/ designee will direct and lead and direct the overall operations of the facility and ensure that the Corporate Dietary Service manager provided education to all dietary staff on proper use and storage of kitchen chemicals. NHA will ensure that Corporate Dietary Service manager/ designee is present in the facility to inspect, direct and oversee the dietary personnel to ensure regulatory compliance. In the absence of the NHA, DON will assume these responsibilities. 3. Regional Director of Operations/ designee will provide education to the NHA and DON on Administrative Duties and responsibilities. 4. Regional Director of Operations/designee will follow-up weekly by reviewing audits to ensure the NHA and DON are providing effective and efficient administrative oversight. Audit findings will be reviewed at facility QAPI meeting.
Failure to Follow Care Plan for Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with chronic heart failure and polyosteoarthritis, who required assistance with activities of daily living, was not provided the required level of staff support during a transfer. The resident's care plan and physician's orders specifically mandated the use of a Hoyer lift with two staff members for all transfers. Despite this, a nurse aide performed a transfer alone, citing the absence of available staff at the time. During the transfer, the nurse aide attempted to reposition the resident's legs and heard a crack. The resident, who was cognitively intact, later reported pain and swelling in her left knee. Subsequent assessment and hospital evaluation confirmed a left tibial periprosthetic fracture, requiring immobilization and pain management. The resident experienced significant pain, necessitating frequent administration of oxycodone for relief. The incident was corroborated by witness statements, clinical documentation, and interviews with the resident and staff. The nurse aide admitted to being aware of the two-person requirement for Hoyer lift transfers but proceeded alone due to staffing constraints. This failure to follow the individualized care plan and physician's orders resulted in actual harm to the resident in the form of a serious fracture.
Improper Food Storage and Sanitation in Dietary Department
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food storage and service practices in the dietary department, leading to unsanitary conditions. Specifically, unlidded garbage cans containing trash were found near the tray line and cook's preparation areas, which increased the risk of contamination in food preparation zones. In both the First Floor East and Ground Floor dry storage areas, multiple cases of disposable dishware and paper products were stored directly on the floor, with some packaging open and unsealed, exposing the contents to potential contamination from floor debris, cleaning solutions, and pests. Additionally, in the Ground Floor dry storage/equipment area, cases of dishware, supplies, and dietary-related materials were stored close to the ceiling, which limited air circulation and increased the risk of contamination from overhead surfaces, dust, or ceiling-based hazards. A review of the facility's policy on food receiving and storage indicated that all foods and goods should be stored in a manner that maintains the integrity of the packaging until use, and bulk food should be removed from original packaging, placed in bins, and labeled with a use-by date. These practices were not followed as observed during the survey. During an interview, the Nursing Home Administrator acknowledged that the dietary department should be maintained in a sanitary condition to prevent contamination and reduce the risk of foodborne illness.
Failure to Develop and Implement Individualized Care Plans for Oxygen Therapy and Hydration
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with specific and individualized interventions for two residents. For one resident with chronic respiratory failure, quadriplegia, and a tracheostomy, there was a discrepancy between the physician’s order for oxygen therapy and the interventions listed in the care plan and Kardex. The physician’s order specified oxygen at 10 liters per minute via nasal cannula or tracheostomy collar, but the care plan and Kardex indicated oxygen at only 2 liters per minute. Observation confirmed the resident was receiving oxygen at 10 liters per minute, but the care plan and Kardex had not been updated to reflect this, resulting in a lack of alignment between the physician’s order and the documented plan of care. For another resident with Parkinson’s disease, hemiplegia, and hemiparesis following a stroke, the care plan addressed several nutritional concerns and included general interventions for monitoring hydration. However, the care plan did not identify that the resident was fully dependent on staff for hydration or include individualized interventions to ensure the resident’s fluid needs were proactively assessed and met. The resident, who was cognitively intact but required total staff assistance with eating and drinking, reported that fluids were only offered at meals and that he had to use the call bell to request drinks at other times, often experiencing long delays due to his inability to provide himself with fluids. These deficiencies were confirmed through clinical record reviews, staff interviews, and resident interviews, which revealed that the care plans did not contain specific, individualized interventions to address the residents’ needs for oxygen therapy and hydration, as required by regulatory standards.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
Licensed nursing staff failed to follow physician orders for the administration of insulin to a resident with type 2 diabetes mellitus and a long-term insulin regimen. The facility's policy required verification of a physician's medication order, including specific parameters for administration. The physician's order specified that Novolog insulin should be administered subcutaneously with meals, but only if the resident's blood glucose level was 100 mg/dl or higher. Despite these instructions, the resident's Medication Administration Records showed that nursing staff administered Novolog insulin on multiple occasions when the resident's blood glucose levels were below the prescribed threshold. Specifically, insulin was given when blood glucose readings were 78 mg/dl, 92 mg/dl, and 96 mg/dl, all of which were below the physician's specified parameter. The Director of Nursing confirmed that these administrations were outside the prescribed parameters.
Failure to Implement Restorative Nursing Program for Resident with Limited Mobility
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned for a resident with Alzheimer's disease and muscle atrophy. The resident was admitted with significant cognitive impairment and required substantial to maximal assistance for mobility. After a period of physical therapy, the resident was discharged with recommendations for a Range of Motion (ROM) Restorative Nursing Program (RNP) to reduce contractures in the lower extremities. However, there was no evidence that the RNP was included in the resident's care plan or that the program was implemented as recommended. A review of the resident's clinical record, care plan, and nursing documentation revealed no documentation of the restorative program being carried out. Additionally, there was no indication that licensed staff were aware that the RNP was not being implemented as planned. During an interview, the Nursing Home Administrator was unable to provide evidence that the facility had consistently implemented the restorative nursing program to maintain the resident's functional abilities and prevent decline.
Failure to Provide Required Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident who required hemodialysis. The resident, who had end-stage renal disease and was dependent on hemodialysis, had a physician's order and care plan intervention requiring an emergency kit to be present at the bedside. This kit, intended to address complications such as bleeding from the arteriovenous (AV) fistula site, was not found at the resident's bedside during an observation, despite documentation on the Medication Administration Record indicating it was present. The resident, who was cognitively intact, confirmed the absence of the emergency supplies after returning from dialysis. Staff interviews further confirmed that the emergency supplies were not available in the resident's room as required. An LPN acknowledged that the supplies should have been at the bedside and typically are kept on the back of the resident's headboard. The Nursing Home Administrator also confirmed the failure to ensure the emergency dialysis access supplies were available as ordered and required by the resident's care plan. This deficiency was identified through observation, record review, and staff and resident interviews.
Failure to Follow Controlled Substance Reconciliation Procedures
Penalty
Summary
The facility failed to implement its established pharmacy procedures for the reconciliation of controlled substances on one of five medication carts reviewed. According to facility policy, nursing staff are required to count controlled medications at the end of each shift, with both the on-coming and off-going nurses participating in the count and signing the verification sheet. A review of the controlled medication count sheet for Pavilion cart #2 revealed that on several occasions, the required signatures were missing during shift changes, specifically on multiple dates in July 2025. Observation of the medication cart and interviews with staff confirmed that licensed nurses did not consistently sign the count verification at the change of shift as required by policy. This failure to follow established procedures prevented timely identification of any discrepancies in controlled substance counts. The deficiency was identified through review of facility policy, controlled substance records, direct observation, and staff interviews.
Failure to Verify Resident Identity Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a nurse administered medications to the wrong resident. The facility's policy required staff to verify resident identity using methods such as checking identification bands, photographs, or confirming with other personnel before administering medications. However, a Licensed Practical Nurse (LPN) who was unfamiliar with the unit and the residents failed to verify the identity of a resident before giving medications. As a result, the resident received multiple medications, including Keppra, Remeron, Lyrica, Trazodone, and Warfarin, which were not prescribed to him but were intended for his roommate. The resident was not scheduled to receive any nighttime medications at that time and did not have diagnoses requiring those medications. The affected resident had a history of hypertension, muscle weakness, and moderately impaired cognition, as indicated by a BIMS score of 11. After receiving the incorrect medications, the resident's blood pressure was recorded as low, and the physician was notified. The resident was sent to the emergency room for evaluation due to the medication error and a recent unwitnessed fall earlier that day. Upon return from the hospital, the resident was noted to be lethargic. Interviews with facility leadership confirmed that the LPN failed to follow proper identification procedures, resulting in the administration of another resident's medications.
Expired and Improperly Labeled Medications Found in Storage Room
Penalty
Summary
Surveyors identified that the facility failed to store medications and pharmaceutical products in accordance with expiration date guidelines in one of three medication storage areas, specifically the Pavilion medication storage room. During an observation, ten medication and supplement items were found to be either expired or had illegible expiration dates. These included bottles of Multi-Vitamin with Iron, Aspirin, Sodium Bicarbonate, Glucosamine and Chondroitin, Meclizine, Vitamin E, Guaifenesin Liquid, and Copper Glycinate. The expiration dates on these items ranged from February 2024 to June 2025, with one item having an illegible expiration date. A review of the facility's policy on Storage of Medications indicated that all medications should be stored according to manufacturer recommendations and regularly inspected for expiration and labeling by the consultant pharmacist. However, the presence of expired and improperly labeled medications was confirmed by an LPN during an interview, demonstrating that the facility did not ensure the timely removal of these items as required by both policy and regulatory standards.
Failure to Document Vaccine Education for Pneumococcal Immunization
Penalty
Summary
The facility failed to provide required education to a resident or the resident's representative regarding the benefits and potential side effects of the pneumococcal immunization. According to the facility's policy, all residents must be offered the pneumococcal vaccine and have the right to refuse, with documentation of both the offer and any refusal, including education provided. A review of the clinical record for one resident showed that the pneumococcal vaccine was refused, but there was no documented evidence that education about the vaccine's benefits and side effects was given to the resident or their representative. This was confirmed by the Infection Preventionist during an interview, who acknowledged the lack of documentation in the resident's medical record.
Failure to Secure Smoking Materials per Facility Policy
Penalty
Summary
The facility failed to follow its established policy and procedures regarding safe smoking practices for one resident. According to the facility's Resident Smoking Policy, all smoking supplies for both supervised and independent smokers are to be kept in a locked nursing medication room, and residents are not permitted to keep smoking supplies in their possession. A review of the clinical record for a resident with quadriplegia and chronic obstructive pulmonary disease showed that the resident was assessed as cognitively intact and able to smoke independently, with the understanding that smoking materials must be returned to staff when not in use. During an observation, the resident was found in their room with smoking materials, including two lighters and a pack of cigarettes, which were not secured by staff as required by policy. The resident stated that they kept their smoking supplies in a locked drawer in their bedside cabinet. The Nursing Home Administrator confirmed that the facility policy requires all smoking supplies to be secured by staff, regardless of independent smoking status, and was unable to provide evidence that staff were monitoring the resident's storage of smoking materials. This failure to follow policy was identified through review of records, interviews, and direct observation.
Failure to Consistently Implement Fall Prevention Measures
Penalty
Summary
A resident with severe cognitive impairment, generalized muscle weakness, difficulty walking, and a history of falls was identified as being at high risk for falls. The resident's care plan included specific fall prevention interventions such as bilateral fall mats, triangular wedges on both sides of the bed, a tab alarm while in bed, and maintaining the bed in a low position. Physician's orders also required triangular wedges to be positioned at the upper bilateral bed rails while the resident was in bed. Despite these interventions, the resident experienced an unwitnessed fall from bed, resulting in a minor injury. Review of the incident revealed that at the time of the fall, the left-side bed wedge was not in place as required and was found on the window frame, while the right-side wedge was in place. Additionally, the bed alarm was nonfunctional, and it was noted that the resident had a known history of disabling the alarm. The facility's investigation concluded that the fall occurred due to failure to follow the resident's plan of care, specifically the improper placement of the bed wedge and the nonfunctional bed alarm.
Failure to Implement Individualized Incontinence Management Plan
Penalty
Summary
The facility failed to develop and implement an individualized plan to meet the toileting needs of a resident with severe cognitive impairment, dementia, and chronic kidney disease. Despite the resident's care plan identifying issues such as overactive bladder, frequent urinary and bowel incontinence, hemorrhoid pain, urinary pain, recurrent UTIs, and atrophic vaginitis, the plan did not include a structured toileting schedule or individualized incontinence program. The resident required substantial assistance for bed mobility, transfers, and toileting, and was always incontinent of urine and frequently incontinent of bowel. Documentation showed the resident was not on a toileting program, and the nursing information system lacked instructions for timely toileting or incontinence care. A quarterly toileting review noted a decline in continence and the need for extensive assistance, but did not specify individualized interventions such as scheduled toileting. The resident was documented as being incontinent of urine 100% of the time during every shift, and a family grievance reported the resident was found soaked with urine. The Director of Nursing confirmed there was no documented evidence of a planned incontinence management program for the resident, indicating a failure to provide timely and individualized care as required by facility policy and state regulations.
Failure to Serve Meals at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at palatable and safe temperatures, as required by both federal regulations and the facility's own policy. Observations and interviews revealed that five out of nine residents interviewed reported their meals were often served cold, lukewarm, or unappetizing. A review of a resident concern form and direct interviews confirmed that multiple residents experienced meals that were not at a palatable temperature. During a lunch service observation, the last tray delivered to a resident was found to have hot food items below the required 135°F, with temperatures ranging from 113°F to 126.1°F, and cold items above the required 41°F, with a fruit drink at 59.9°F. A taste analysis confirmed the food was lukewarm and unappetizing. The facility's policy, last reviewed in January 2025, required hot foods to be held and served at or above 135°F and cold foods at or below 41°F. Despite this, the Dietary Manager incorrectly stated that a hot food temperature of 126.1°F was acceptable, which contradicted both policy and regulatory requirements. The Nursing Home Administrator acknowledged that the facility had not ensured meals were consistently served at palatable temperatures or in accordance with resident preferences. These findings were based on direct observation, resident and staff interviews, and review of facility documentation.
Delayed Response Due to Malfunctioning Call Bell System
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system that ensured direct and timely communication between residents and caregivers for three of nine sampled residents. According to the facility's policy, all staff are responsible for responding to call bells, and nurse aides, charge nurses, and RN supervisors are required to carry pagers to receive notifications. However, interviews with residents revealed that staff response to call bells could take up to an hour, with multiple reports of delays exceeding 30 minutes. Observations on the second floor showed that while visual call bell indicators were present above hallway doors, there was no audible alert to notify staff unless they were physically present in the hallway. This resulted in active call bell requests going unnoticed for extended periods. Further investigation found that some pagers used by staff were malfunctioning, with issues such as non-working screens that prevented identification of which resident had activated their call bell. Staff confirmed that when pagers were not functioning, the only way to identify an active call bell was by visually checking the hallway indicators, as there was no alternative notification system. In contrast, another unit in the facility had an upgraded call bell system with both visual and audible alerts, leading to faster response times. The Nursing Home Administrator confirmed that the second floor call bell system was not functioning as intended, resulting in delayed responses to resident calls.
Failure to Follow Planned Menus and Document Substitutions
Penalty
Summary
The facility failed to adhere to its written planned menus, resulting in food omissions for four residents during a breakfast meal. The planned menu included hot cereal, an egg, cheese and ham biscuit, banana, milk, and coffee or tea. However, observations revealed that the meal trays for four residents were missing hot cereal and biscuits. One resident expressed that such omissions occurred frequently, and the Dietary Manager confirmed that biscuits were not served due to being overbaked, but no substitutions were made. The facility's policy required that any menu substitutions be discussed with the director of food and nutrition services and documented, but the facility was unable to provide the Meal Substitution Records for the months of December 2024, January 2025, and February 2025. Interviews with the Nursing Home Administrator and the Dietary Manager confirmed the absence of these records and the failure to follow the planned menus. The facility did not have a system in place to monitor food omissions or substitutions, nor did it ensure the required documentation of menu changes, leading to non-compliance with its own policies regarding meal service.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable and maintained at a safe and appetizing temperature for three residents. Observations and interviews revealed that meals were consistently served cold, with residents expressing dissatisfaction with the temperature and palatability of their food. Resident 3 reported never receiving a hot meal and lacking condiments, while Resident 4 and Resident 5 also complained about the cold temperature of their meals, specifically mentioning cold eggs and insufficient food portions. A test tray evaluation conducted on the East Wing Nursing Unit confirmed these concerns, with food temperatures recorded below the required standards. The ziti with meat sauce and Italian blend vegetables were served at temperatures significantly below the required 135 degrees Fahrenheit, and the vanilla pudding was served above the required 41 degrees Fahrenheit. The dietary manager acknowledged that the test tray results did not meet the facility's policy or regulatory requirements, confirming the deficiency in maintaining appropriate food temperatures, which affected resident satisfaction and increased the risk of foodborne illness.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment as required and prescribed for two residents. Resident 7, who was admitted with cerebral infarction and dysphagia, had a care plan indicating the use of a two-handled adapted cup with a lid for beverages at all meals to prevent dehydration and malnutrition. Despite this, an observation on February 26, 2025, revealed that the dietary staff did not provide the adaptive cup during breakfast, as ordered by the physician. Similarly, Resident 8, diagnosed with dementia with behavioral disturbance and polyosteoarthritis, was prescribed a Kennedy cup for all meals and bedside use to address a nutritional deficit. However, during the same breakfast observation, the dietary staff failed to provide the Kennedy cup. Interviews with a nurse aide and the Dietary Manager confirmed that the dietary staff frequently forget to include the necessary adaptive equipment on meal trays, causing interruptions in care as nursing staff must retrieve the equipment from the kitchen.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living were consistently provided showers as planned. Resident 1, who was admitted with diagnoses including hypertension and atrial fibrillation, required substantial assistance for showering due to severe cognitive impairment, as indicated by a BIMS score of 00. Despite being scheduled for showers on Mondays and Thursdays, Resident 1 missed multiple showers from December 2024 through February 2025, with no documentation of the showers being provided or refused. Similarly, Resident 2, admitted with osteoarthritis and dementia, also required assistance for showering and was scheduled for showers on Tuesdays and Fridays. However, Resident 2 missed several scheduled showers from December 2024 through February 2025, again with no documentation of the showers being provided or refused. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the residents should have received their showers as scheduled but could not explain the failure to provide or document the showers.
Failure to Accommodate Dietary Needs and Allergies
Penalty
Summary
The facility failed to provide meals that accommodated the dietary needs and allergies of two residents. Resident 7, who has a documented allergy to dairy/milk, was served a Yoplait original harvest peach yogurt, which contains milk, during breakfast. Additionally, Resident 7 was supposed to receive 4 ounces of honey-thickened juice due to swallowing difficulties, but this was not provided on the breakfast tray. Similarly, Resident 9 was supposed to receive 8 ounces of honey-thickened juice with lunch, but this was also missing from the tray. Interviews and observations revealed systemic issues in the dietary service. A nurse aide reported that dietary staff consistently failed to include thickened liquids on residents' trays, requiring aides to interrupt meal service to retrieve them from the kitchen. The dietary manager confirmed the failure to provide meals that met residents' dietary orders. Observations of the kitchen and storeroom showed a lack of honey-thick juice in the kitchen, although it was available in the storeroom, indicating a failure in the distribution process.
Facility Fails to Respond Timely to Residents' Requests for Assistance
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, impacting their quality of life and dignity. Resident 5, who is cognitively intact, reported waiting over an hour and a half for staff to respond to her call bell. Similarly, Resident 1, also cognitively intact, experienced wait times of about 20 minutes, with instances extending over 40 minutes. Both residents expressed concerns about the lack of staff to provide timely care. Resident 2, who is cognitively intact and suffers from osteomyelitis, reported waiting up to an hour and thirty minutes for assistance, often resulting in sitting soiled due to incontinence. Resident 4, with COPD, experienced similar delays, waiting an hour for care after being incontinent. These residents highlighted the facility's staffing shortages as a reason for the delays, which they had communicated to the staff without resolution. Resident 3, who has Parkinson's disease and is dependent on staff for care, was observed lying in bed with his pants down, exposed to the hallway, for 20 minutes before receiving assistance. He expressed feelings of frustration and neglect due to the long wait times for care. The Nursing Home Administrator and Director of Nursing acknowledged the importance of treating residents with dignity and respect but could not explain the untimely responses to residents' needs.
Plan Of Correction
1. Facility staff unable to retroactively correct past call bell and dignity issues mentioned for R 1,2,3,4, & 5. 2. DON/designee to perform an audit of cognitively intact residents to determine if they feel as if they are treated with respect and dignity and that their call bells are answered timely. 3. ADON educator/designee to provide education to staff on resident rights and dignity to include not leaving residents exposed in view of others and timely answering of call bells. 4. Department Heads/designee to perform call bell audits for 10 cognitively intact residents 5X per week X 2 weeks then 3X per week X 2 weeks, then weekly X 2 weeks to ensure call bells answered timely. Department Heads/designee to perform observation audits for 10 residents 5X per week X 2 weeks then 3X per week X 2 weeks, then weekly X 2 weeks to ensure dignity and respect is maintained by not leaving them exposed in view of others. 5. Audit findings to be reported and reviewed at facility QAPI monthly X 3 to evaluate process improvement.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide care and services in a manner respectful of each resident's personal dignity, as evidenced by the situation involving a resident with Parkinson's disease. This resident, who is cognitively intact and dependent on staff for assistance with personal care, was observed lying in bed with his pants pulled down to his thighs and his stomach exposed. The privacy curtains were not drawn, leaving the resident visible from the hallway. This situation persisted for twenty minutes while other residents and staff walked past the room. The resident expressed feelings of anger and frustration, describing himself as feeling like a piece of furniture due to the lack of assistance from the staff. The Director of Nursing confirmed that the resident should not have been left in such a state without privacy curtains drawn and acknowledged the facility's responsibility to ensure residents receive care that promotes their dignity and respect. Additionally, the resident's fingernails were observed to be dirty, with a yellow-orange film and debris under the tips, indicating a lack of attention to personal hygiene needs. This incident highlights a failure in maintaining the resident's dignity and respect, as well as a lapse in providing necessary personal care.
Plan Of Correction
1. Facility nursing staff provided nail care to Resident 3. 2. DON/designee to perform an audit of cognitively intact residents to determine if they feel as if they are treated with respect and dignity and have sufficient nail care performed to promote dignity. 3. ADON/educator/designee to provide education to staff on resident rights and dignity, on not leaving residents exposed in view of others, and to include nail care. 4. Department Heads/designee to perform observation/interview audits for 10 residents 5X per week X 2 weeks then 3X per week X 2 weeks, then weekly X 2 weeks to ensure they feel treated with dignity and respect, that no residents were left exposed in view of others, and that nail care has been performed. 5. Audit findings to be reported and reviewed at facility QAPI monthly X 3 to evaluate process improvement.
Failure to Ensure Safe Discharge Plan for Resident
Penalty
Summary
The facility failed to develop and implement a safe discharge plan for a resident, identified as Resident CR1, who was admitted with chronic kidney disease and traumatic brain injury. The resident was moderately cognitively impaired, as indicated by a BIMS score of 8. A progress note highlighted the need for 30 hours a week of caregiver support, and physical therapy discharge recommendations included significant supervision and assistance due to impaired cognition and safety. However, the clinical record lacked documentation of the total amount of supervision and assistance available upon discharge. The interdisciplinary team discharge summary indicated that Resident CR1 was to be discharged home with occupational and physical therapy home health services. However, there was no documented evidence ensuring safe medication administration upon discharge, nor was there evidence of self-medication training or education provided to the resident. The Director of Nursing and Director of Social Services confirmed the absence of a documented plan for safe medication administration, despite the resident's moderate cognitive impairment and the discharge plan not being against medical advice. Upon discharge, Resident CR1 was sent home with 24 medications, including insulin, without a plan for safe administration. The resident's representative confirmed that CR1 lived alone and was hospitalized two days after discharge due to the need for continued care. The facility's failure to ensure a safe discharge plan, including medication administration, led to the resident's hospitalization shortly after discharge.
Plan Of Correction
1. Facility staff unable to retroactively correct as resident has been discharged. 2. DON/designee to perform an audit of current short-term residents to determine that a discharge plan has been initiated and includes measures to promote safe discharge. 3. DON/designee to provide education to IDT members on the process for initiation and coordination for safe resident discharges. Facility to incorporate an evaluation of resident specific discharge needs during the initial assessment period. 4. Facility to audit discharge plans for 3 residents per week X 4 weeks then 2 residents per week X 2 weeks to ensure safe discharge plans have been initiated and include measures to promote safe discharge. 5. Audit findings to be reported and reviewed at facility QAPI monthly X 3 to evaluate process improvement.
Failure to Ensure Proper IV Medication Administration by LPNs
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not implementing proper nursing practices for the administration of intravenous medication via a central venous catheter for one resident. According to the Pennsylvania Code Title 49, Professional and Vocational Standards, LPNs are required to have the necessary education and supervision to perform IV therapy functions safely. However, the facility did not have a policy available regarding LPNs providing care and administering medications through a central catheter line. The clinical record review revealed that a resident was admitted with bacterial meningitis and had a PICC line for intravenous medication administration. Physician's orders required the administration of Penicillin G Potassium in Dextrose intravenously every four hours. Between specific dates, three LPNs signed the Medication Administration Record as administering the IV antibiotic through the PICC line. However, there was no evidence that these LPNs received the necessary education or supervision for administering IV antibiotics through a PICC line. The Director of Nursing confirmed that LPNs did not receive education regarding this procedure.
Failure to Document Antibiotic Administration
Penalty
Summary
The facility failed to implement proper pharmacy procedures for medication administration and documentation for a resident diagnosed with bacterial meningitis, a serious infection. The resident was admitted with a PICC line and had physician's orders for Penicillin G Potassium in Dextrose to be administered intravenously every four hours for 27 days. However, the Medication Administration Record for October 2024 showed that the antibiotic was not documented as administered on several occasions, specifically on October 8, 10, 19, and 21. During an interview, the Director of Nursing confirmed that it could not be determined if the doses were administered on those dates.
Failure to Implement Comprehensive Care Plan for PICC Line Management
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who required intravenous medication administration through a central venous line (PICC catheter). The resident, admitted with bacterial meningitis and a PICC line, was severely cognitively impaired and required extensive staff assistance for activities of daily living. Despite the resident's critical condition and the need for careful management of the PICC line, the care plan did not include specific and individualized interventions to ensure the safe delivery of antibiotic medications and the care of the line. The care plan lacked essential interventions such as monitoring the PICC site every shift for infection, line fracture, breakage, dislodgement, pain, or swelling, and documenting findings in progress notes. Additionally, it did not include measuring the PICC line and arm circumference at specified intervals, changing IV tubing every 72 hours, ensuring an emergency kit was at the bedside, and changing PICC dressing and clave caps every seven days. These omissions were confirmed during an interview with the Director of Nursing, who acknowledged the failure to ensure that comprehensive care plans were fully developed and implemented.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program. A review of the facility's policy indicated that the program should identify, investigate, control, and prevent infections, while maintaining a record of incidents and corrective actions. However, the facility's infection control data did not reflect an operational system to monitor and investigate causes of infection or the manner of spread. There was no evidence of a system to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. The facility's infection control logs from September 2023 through September 2024 were incomplete, with no accurate tracking of infections for several months. Clinical records showed that a resident was treated for cellulitis in September 2023, and two residents were treated for urinary tract infections in November 2023. Interviews with the Director of Nursing and the Infection Preventionist confirmed the absence of complete infection control logs and a comprehensive program. The facility did not demonstrate a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors, as required by accepted standards and guidelines.
Failure to Provide Dementia Management Training
Penalty
Summary
The facility failed to provide dementia management training for five newly hired employees, as required by their policy on abuse and dementia management. A review of the education records and personnel files for Employees 12, 13, 14, 15, and 16, who were hired between July and September 2024, showed no documented evidence of dementia management training. An interview with the Director of Nursing confirmed the lack of training for these staff members. This deficiency is in violation of 28 Pa. Code 201.19 (7) Personnel policies and procedures, 28 Pa. Code 201.18(b)(1) Management, and 28 Pa. Code 201.20 (b) Staff development.
Dietary Staffing Shortage Leads to Meal Delivery Delays
Penalty
Summary
The facility failed to maintain sufficient staffing in the dietary department, which led to delays in meal service delivery. The Food Service Director (FSD) was observed to be cooking meals herself due to a shortage of staff, as the department was in the process of hiring additional personnel. This staffing issue resulted in meal trays being delivered late, as confirmed by both residents and staff interviews. Specifically, a cognitively intact resident reported receiving supper at 7:45 PM on a past Sunday, which was significantly later than the scheduled time. Further observations and interviews revealed that the lunch meal service on the [NAME] Nursing Unit was delayed by 30 minutes, with the last cart of lunch trays arriving at 1:00 PM instead of the scheduled 12:30 PM. Another resident confirmed that meals were often late, and the FSD acknowledged that meal trays were frequently delayed due to insufficient dietary staff. The nursing home administrator was unable to provide documented evidence of consistent staffing to support timely meal delivery, highlighting a deficiency in the facility's management of food and nutrition services.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an observation of the kitchen, four cases of meat were found directly on the floor outside the walk-in freezer, which the foodservice director confirmed should have been placed on a pallet. Additionally, in a resident pantry, 12 containers of milk were found with a sell-by date that had passed. The facility's ice machine had a heavy build-up of a black and pink substance on the condensation hose, and a food delivery cart was visibly soiled with dirt and debris. Further observations in the kitchen revealed several sanitation concerns, including a rag in the handwashing sink, a pan labeled as clean that was visibly soiled and greasy, and a rusted and soiled two-tiered shelf under the steamer. The stovetop's metal backsplash was heavily scorched, and the kitchen floors had a build-up of debris. Stained ceiling tiles were noted above the dishwasher, and a chemical bucket lid had a build-up of dirt. Brooms were improperly stored in direct contact with the floor. The foodservice director confirmed that the dietary department and resident pantries were to be maintained in a sanitary manner and that expired food items should be discarded.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process, including how to file a grievance, both written and verbal, and anonymously. During a group interview with five alert and oriented residents, all participants reported being unaware of the grievance filing procedures and the location of submission boxes for anonymous grievances. This lack of awareness was corroborated by observations conducted on the facility's three nursing units, which revealed no postings regarding the grievance policy. Additionally, during an interview with the Nursing Home Administrator and Director of Nursing, they were unable to provide evidence that residents had been given the necessary details of the grievance process. This includes the identification of the grievance official and the procedures for filing grievances. The facility's policy, reviewed in July 2024, states that all grievances will be investigated and corrective actions taken, yet the facility did not ensure that this information was accessible or communicated to the residents.
Failure to Adhere to Medication Storage Guidelines
Penalty
Summary
The facility failed to adhere to proper storage and use-by dates for multi-dose medications, as observed during a survey. On one of the medication carts and in two medication storage rooms, several vials of insulin and Aplisol were found to be used beyond the manufacturer's recommended discard dates. Specifically, vials of Lantus, Insulin Aspart, and Fiasp were observed on a medication cart with dates indicating they were opened and used beyond the 28-day period recommended by the manufacturer. Additionally, a vial of Aplisol in the medication storage room was found to be in use beyond the 30-day period recommended for use after opening. Interviews with the nursing staff confirmed the observations, acknowledging that the medications were not discarded within the recommended time frames. Furthermore, a vial of Aplisol in another medication room was found to be opened but not dated, which is against the facility's policy that requires dating upon opening. The Nursing Home Administrator confirmed the facility's failure to comply with acceptable storage and use-by dates for these medications, as required by the facility's policy and manufacturer guidelines.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the experiences of four residents. Resident 68, who is cognitively intact and requires assistance with activities of daily living, reported receiving only one shower per week due to staff shortages, which was insufficient for his personal hygiene needs. Similarly, Resident 101, also cognitively intact, expressed concerns about delayed response times to call bells and insufficient shower frequency, attributing these issues to inadequate staffing levels. Resident 60, who requires assistance with a Hoyer lift, reported receiving only one shower in the past month, with bed baths substituting on other occasions. This was corroborated by documentation indicating a lack of showers as scheduled. Resident 135, with moderate cognitive impairment, also reported infrequent showers, sometimes going up to two weeks without one, which was supported by the facility's records. The facility's staffing records revealed that on several dates, the minimum required nursing care hours per resident were not met, with direct care hours falling below the mandated 3.2 hours. The administrator acknowledged the expectation for prompt call bell responses but could not provide evidence that the limited shower schedule was based on resident preference or that residents were being showered as required. This deficiency in staffing led to unmet clinical, safety, and care needs for the residents.
Failure to Accommodate Resident Food Preferences and Ensure Meal Component Availability
Penalty
Summary
The facility failed to accommodate individual food preferences and ensure the availability of meal components, leading to dissatisfaction among residents. Resident 48, who is cognitively intact, reported that milk or sugar were often not provided with meals, and alternate meal options were limited to peanut butter and jelly sandwiches. Additionally, there was no juice available for breakfast on a specific day. A grievance filed by Resident 48 highlighted the absence of bacon, milk, and sugar, with the facility's response only addressing the sugar issue. During a group interview, five alert and oriented residents confirmed that the facility frequently ran out of items they preferred, such as juice and sugar packets. Further observations revealed that Resident 128 did not receive the planned vegetable, green beans, with her lunch, and was not offered an alternate until prompted by the surveyor. The Food Service Director (FSD) confirmed that cooked tomatoes were available as an alternate but were not initially offered. Resident 101 expressed a desire for a double entree, but was told he had to wait until everyone was served to see if there was enough available. The FSD acknowledged that the food supply should be adequate to meet menu requirements and resident preferences, and that staff should ensure alternates are offered when necessary.
Facility Fails to Honor Resident Drink Preferences
Penalty
Summary
The facility failed to honor the drink preferences of seven residents, as identified in a review of the Menu Committee Minutes and through resident and staff interviews. The facility decided to stop offering soda as a beverage option, informing residents that soda would only be available in vending machines or as BINGO prizes. This decision was made without prior notice to the residents, and the vending machine prices were considered too high by the residents. As a result, residents who preferred soda, such as Residents 48, 101, 111, 134, 60, 135, and 46, were dissatisfied and felt their preferences were not respected. Interviews with the residents revealed their frustration with the facility's decision, as some residents had to rely on family members to provide soda, while others, like Resident 101, had no family support and could not afford the vending machine prices. The foodservice director and the administrator confirmed that the decision to remove soda was made by corporate due to its lack of nutritional value and cost. However, there was no documented evidence that the facility provided alternative drink options based on individual preferences, leading to a deficiency in meeting resident rights as per 28 Pa. Code 201.29(a).
Deficient Call System Utilization in Nursing Units
Penalty
Summary
The facility failed to consistently provide a fully functioning call system for direct communication between residents and caregivers across three nursing units. Observations revealed that when call bells were activated, resident room numbers would scroll across a screen, but staff were required to carry pagers to be alerted to these calls. However, there were no pagers available behind the nursing station for employees on the Pavilion Nursing Unit. Interviews with various staff members, including registered nurses, nurse aides, and licensed practical nurses, confirmed that they did not have the required pagers to be alerted to residents' call bells. Some staff were unaware of the requirement to carry a pager, and others reported that there were not enough pagers available for everyone on the unit. Similar issues were observed on the [NAME] Nursing Unit and the East Nursing Unit, where staff either did not have pagers or had pagers that were not functioning. The facility's regulatory compliance history indicated that the same deficient practice was cited during a previous survey, where the call bell system was not properly utilized, and staff were not adequately informed about the requirement to use pagers. The nursing home administrator confirmed the facility's failure to properly utilize the call bell system, which impacted the timely care and services provided to residents.
Failure to Include Dialysis Needs in Baseline Care Plan
Penalty
Summary
The facility failed to include essential healthcare information in the baseline care plan for a resident admitted with end-stage renal disease and dependent on renal dialysis. The resident was admitted with a physician's order to receive dialysis three times a week, but the baseline care plan did not reflect this critical need. The care plan also lacked goals, objectives, and interventions related to the resident's dialysis requirements. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the omission of necessary healthcare information to properly care for the resident immediately upon admission.
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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