Green Home, Inc, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Wellsboro, Pennsylvania.
- Location
- 37 Central Avenue, Wellsboro, Pennsylvania 16901
- CMS Provider Number
- 395318
- Inspections on file
- 16
- Latest survey
- December 30, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Green Home, Inc, The during CMS and state inspections, most recent first.
The facility did not maintain stair tower enclosures as required by NFPA 101 standards. A plastic storage tote was observed under the stairs at the 1st floor, North Exit, affecting two floors. This was confirmed during an exit interview with facility administrators.
The facility did not maintain a proper hazardous area enclosure on the second floor, as observed in the Mechanical Room, which had two unsealed penetrations in the concrete ceiling. This was confirmed during an exit interview with facility representatives.
The facility failed to maintain the automatic sprinkler system, with deficiencies observed in three locations across both floors. Issues included an unsealed penetration in a ceiling tile, a missing escutcheon, and a missing ceiling tile. These deficiencies were confirmed during an exit interview with facility representatives.
The facility failed to maintain proper latching of corridor doors, as observed in several locations on both floors. Doors in the Living Room, Resident Room B-17, Dr's Office, and Shower Room did not latch into their frames, with the Dr's Office door also not being smoke-tight. These deficiencies were confirmed during an exit interview with facility representatives.
The facility failed to provide quarterly personal fund statements to two residents, despite holding their funds and having agreements in place. Both residents and their families confirmed the lack of statements, and the facility had no evidence of compliance until questioned by surveyors.
The facility failed to provide physician-ordered mobility and range of motion (ROM) programs for three residents. One resident did not receive the prescribed ambulation and exercise program, another experienced a decline in ROM without intervention, and a third did not receive promised exercises post-stroke. The facility lacked evidence of implementing these programs as recommended.
A facility failed to ensure a resident's medication regimen was free from unnecessary medications, as the resident was prescribed Ativan in various dosages, including PRN orders, without documented justification or attempts at non-pharmacological interventions. Despite behaviors such as restlessness and chanting, the facility's antianxiety monitoring did not reflect noted anxiety, and pharmacy reviews did not address the PRN Ativan order or request a physician review for dose reduction.
A resident's medication administration records were found to be incomplete and inaccurate due to an LPN's failure to document timely and correctly. The LPN pre-documented the effectiveness of PRN Ativan and Morphine doses and recorded administration times hours after the actual events, leading to discrepancies in the resident's clinical records.
The facility failed to provide required immunization education for four residents who received the influenza vaccination for the 2024-2025 season. There was no documented evidence of education regarding the risks and benefits of the vaccination in their clinical records. An interview with the infection control preventionist confirmed these findings.
The facility did not screen, educate, or offer the COVID-19 vaccine to four newly hired staff members, including nurse aide trainees and an LPN, as required by CMS guidelines. An interview confirmed the lack of documentation and actions regarding the vaccination process.
The facility failed to provide a resident with the required Notice of Medicare Non-Coverage (NOMNC) when their Medicare A coverage ended. Despite a planned discharge and known end date of coverage, there was no evidence that the CMS-10123 form was given to the resident, as confirmed by interviews with the Nursing Home Administrator and the DON.
A facility failed to ensure accurate MDS assessments for a resident, leading to discrepancies in documenting a Stage 3 pressure ulcer. Initially, the ulcer was noted as present on admission, but later assessments incorrectly indicated it was not. An interview confirmed the error in coding the resident's pressure ulcer status.
The facility failed to maintain or improve the ability of two residents to perform activities of daily living. One resident with a prosthetic leg was not using it due to the absence of parallel bars and lack of staff training, despite therapy recommendations. Another resident did not consistently receive a restorative nursing program to maintain strength, with documentation showing frequent non-completion of the program.
A resident with chronic respiratory failure and COPD received supplemental oxygen at an incorrect flow rate of three liters per minute, contrary to the physician's order of two liters per minute. An LPN mistakenly believed she could adjust the flow based on oxygen saturation levels, leading to a discrepancy in care. The issue was reviewed with the facility's administration.
The facility failed to provide adequate nursing staff, resulting in delayed call bell responses for two residents. One resident, who requires assistance to use the bathroom, experienced wait times exceeding 15 minutes, with the longest being 34 minutes. Another resident faced similar delays, with one instance over an hour, impacting their toileting needs. These issues were discussed with the facility's administration.
A resident refused Metoprolol during a medication pass, and the LPN left the unsecured tablet on top of the medication cart. The LPN then left the cart unattended while administering medications to another resident, leaving the Metoprolol tablet unsecured and out of view.
A resident with natural teeth did not receive routine dental services for over a year. The last dental service was from a dentist over two years ago and from a hygienist about one and a half years ago. The facility confirmed the lack of routine dental care in accordance with the State plan.
Stair Tower Enclosure Deficiency
Penalty
Summary
The facility failed to maintain the stair tower enclosures in accordance with NFPA 101 standards. During an observation on December 30, 2024, at 11:36 am, a plastic storage tote was found stored under the stairs at the 1st floor, North Exit. This issue affected two of two floors in the facility. The presence of the storage tote was confirmed during an exit interview with the Facility Administrator, Facility Assistant Administrator, and a Facility Representative on the same day at 12:30 pm.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The plastic storage tote, located under the stairs in the of the first-floor north exit, was removed and the work was documented in work order #20321918. The Facilities Manager or his designee will maintain compliance through monthly safety rounding to identify and correct issues related to stairways and exits. 2. This corrective action was completed on the day of the survey. The Facilities Manager is responsible to ensure that corrections are completed and documented in the maintenance work order program.
Hazardous Area Enclosure Deficiency on Second Floor
Penalty
Summary
The facility failed to maintain a proper hazardous area enclosure on the second floor. During an observation on December 30, 2024, at 11:01 am, it was noted that the Mechanical Room had two unsealed penetrations in the concrete ceiling. This deficiency was confirmed during an exit interview with the Facility Administrator, Facility Assistant Administrator, and Facility Representative #1 on the same day at 12:30 pm.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. The penetrations in the concrete ceiling of the second-floor mechanical room were repaired and the work was documented in work order #20321914. The Facilities Manager or his designee will maintain compliance through monthly safety rounding to identify and correct issues related to hazardous area enclosures. 2. This corrective action was completed on the day of the survey. The Facilities Manager is responsible to ensure that corrections are completed and documented in the maintenance work order program.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in three specific locations, affecting both floors of the building. During an observation on December 30, 2024, it was noted that there was an unsealed penetration in a ceiling tile in the janitor's closet near Resident Room B-24 on the second floor. Additionally, the transportation garage on the first floor was missing an escutcheon in the ceiling, and the janitor's closet near the East Exit on the first floor was missing a ceiling tile. These deficiencies were confirmed during an exit interview with the Facility Administrator, Facility Assistant Administrator, and a Facility Representative.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. a. The penetration in the ceiling tile in the second-floor janitor's closet, near resident room B-24 was repaired and the work was documented in work order #20321912. b. The escutcheon in the ceiling of the first-floor transportation garage will be replaced and the work will be documented in work order #20321923. c. The ceiling tile in the first-floor janitor's closet was replaced and the work was documented in work order #20321924. The Facilities Manager or his designee will maintain compliance through monthly safety rounding to identify and correct issues related to automatic sprinkler systems. All four of the corrective actions will be completed by February 4, 2025. The Facilities Manager is responsible to ensure that corrections are completed and documented in the maintenance work order program.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor openings in compliance with NFPA 101 standards, as observed during a survey on December 30, 2024. The survey revealed that several doors on both the first and second floors did not latch into their frames, compromising their ability to resist the passage of smoke. Specifically, the Living Room doors on the second floor, the Resident Room B-17 door, the Dr's Office door on the first floor, and the Shower Room door all failed to latch properly. Additionally, the Dr's Office door was noted to be not smoke-tight. These deficiencies were confirmed during an exit interview with the Facility Administrator, Assistant Administrator, and a Facility Representative. The failure of these doors to latch properly and maintain smoke-tight conditions indicates a lapse in maintaining the required fire safety standards, potentially affecting the safety of the facility's environment.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. a. The closer of the second floor living room doors was adjusted to ensure latching and the work was documented in work order # 20321910. b. The door to resident room B-17 was adjusted to ensure latching and the work was documented in work order #20321911. c. The door to the Doctor's office on the first floor was repaired and adjusted to ensure that it latched and was smoke-tight. The work was documented in work order # 20321916. d. The door to the first-floor shower room was adjusted to ensure latching and the work was documented in work order #20321917. The Facilities Manager or his designee will maintain compliance through monthly safety rounding to identify and correct issues related to door closure and integrity. All four of the corrective actions were completed by January 2, 2025. The Facilities Manager is responsible to ensure that corrections are completed and documented in the maintenance work order program.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to two residents, which is a requirement for managing residents' personal funds. Resident 19 was aware of the approximate amount in her personal funds account but did not receive a written statement at least quarterly. The clinical record for Resident 19 included a Resident Personal Fund Authorization form with an undated signature that did not specify the facility's obligation to provide quarterly statements or designate a recipient for the statement. Interviews with the Nursing Home Administrator and the Director of Nursing revealed that no staff could confirm the provision of personal fund statements to Resident 19. Similarly, Resident 40 and her mother confirmed that they did not receive quarterly statements of her personal funds, despite the facility holding money for her. The clinical record for Resident 40 included a signed Resident's Personal Fund Agreement, which stated that the facility would maintain a record of all transactions and provide an itemized quarterly statement. However, the Nursing Home Administrator confirmed that the facility had not provided these statements to Resident 40. The facility had no evidence of providing quarterly statements to either resident until questioned by surveyors.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Residents 19 and 40 received a copy of their most recent quarterly statement during survey. 2. All residents who signed a Resident's Personal Fund Agreement have been received a copy of their most recent quarterly statement. 3. Education will be provided to the business office manager to provide and document receipt of quarterly statements for all residents who have signed a Resident's Personal Fund Agreement. 4. Quarterly audits will be completed x4 to ensure residents received quarterly statement with results presented in QAPI. 5. Compliance date: January 28, 2025.
Failure to Implement Physician-Ordered Mobility and ROM Programs
Penalty
Summary
The facility failed to provide physician-ordered services to maintain a resident's mobility and range of motion for three residents. Resident 71, who was planning to return home, had completed 12 weeks of therapy and was placed on a restorative nursing program for ambulation and lower extremity exercises. However, the facility did not consistently follow through with the prescribed ambulation program, as evidenced by incomplete documentation and insufficient ambulation distances recorded. There was no evidence that the recommended standing exercises were ordered or completed, and no communication was provided to indicate any issues with completing the program. Resident 11 was readmitted from a hospital stay with a physician's order for therapy screens to determine her care needs. The facility did not complete these screens, and her range of motion declined without any documented interventions. Initially assessed as having no range of motion limitations, subsequent assessments showed limitations in both upper and lower extremities, yet the facility did not implement any interventions to address this decline. Resident 14, who had a stroke resulting in left-sided weakness, reported not receiving the promised exercises from the nursing staff. Her care plan included participation in therapy and a restorative nursing program for range of motion, but there was no evidence that these programs were implemented. The facility confirmed the lack of evidence for the implementation of the recommended range of motion program for Resident 14.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Residents 11, 14 and 71 have been evaluated by therapy to provide needed services and identify appropriate restorative program. 2. Whole house audit of residents discharged from therapy in the last 2 months with an ambulation and ROM program to ensure programs are on Kardex. Audit of previous month of MDSs to review for any residents with a decline in ROM and ensure appropriate intervention occurred. 3. Education to Restorative Nurse Coordinator about ensuring all RNPs are added to Kardex. Education to RNACs to elevate any coded declines of ROM to IDT. 4. Random audit of 3 residents coming off therapy caseload weekly x4 then monthly x2 to confirm ordered RNP on Kardex. Random audit of 3 MDS weekly x4 then monthly x2 to monitor for any decline in resident ROM. 5. Compliance date: January 28, 2025.
Failure to Justify PRN Ativan Administration
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications. Specifically, Resident 12 was prescribed Ativan in various dosages, including routine and PRN (as needed) orders, which could result in the resident receiving up to 9 mg of Ativan in a 24-hour period. Despite the high potential dosage, there was no documentation justifying the need for the PRN Ativan, nor were non-pharmacological interventions attempted prior to administering the PRN doses. Clinical records and staff interviews revealed that Resident 12 exhibited behaviors such as rambling, restlessness, and chanting, but there was no significant change in her condition noted by her physician. The hospice social worker and staff documented instances of restlessness and anxiety, yet the facility's antianxiety monitoring did not reflect any noted anxiety or anxiousness. Despite this, PRN Ativan was administered multiple times without documented justification or attempts at non-medicinal interventions. The facility's pharmacy medication regimen reviews for November and December 2024 did not address the PRN Ativan order or request a physician review for a potential gradual dose reduction. This oversight was discussed with the Director of Nursing, highlighting a failure in the facility's processes to ensure appropriate medication management and documentation for Resident 12.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 12's physician reviewed Ativan orders. 2. All residents with PRN Ativan orders written for greater than 14 days were reviewed to confirm appropriate documentation, timeframe, and dosing. 3. Consultant pharmacist will review regulation on gradual dose reductions and limitations for timeframes of PRN Ativan use. 4. Audits of new PRN Ativan orders documentation, timeframes and total dose ordered will be completed weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025.
Inaccurate Medication Documentation by LPN
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for a resident, identified as Resident 12, as evidenced by discrepancies in the medication administration records (MAR) maintained by an LPN, referred to as Employee 9. The clinical record review revealed that Resident 12 had several physician orders for Ativan and Morphine, with specific dosages and administration times. However, the MAR for October, November, and December 2024 showed multiple instances where Employee 9 documented medication administration and its effectiveness either significantly after the actual administration time or pre-documented the effectiveness before it could be accurately assessed. This included instances where the documentation was completed hours after the medication was administered or where the effectiveness was recorded before the time it was supposed to be evaluated. The discrepancies in documentation included pre-documenting the effectiveness of PRN Ativan and Morphine doses, as well as failing to timely document the administration of these medications. For example, on several occasions, Employee 9 documented the administration of Ativan and Morphine hours after they were given, and in some cases, recorded the effectiveness of the medication before the time it was supposed to be assessed. These actions led to incomplete and inaccurate clinical documentation, which was confirmed during an interview with the Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Interview with employee 9 reveals resident 12 received medications as ordered. 2. Employee 9 was coached on medication documentation at time of administration. 3. All licensed staff were educated to document at time of administration of ordered medications. 4. A random audit of documented medication administration times for five residents will be completed weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025.
Failure to Provide Immunization Education
Penalty
Summary
The facility failed to provide required immunization education for four out of five residents reviewed for influenza immunizations. Specifically, Residents 11, 15, 46, and 59 received the influenza vaccination for the 2024-2025 season without documented evidence of education regarding the risks and benefits of the vaccination being provided to them or their responsible parties. The vaccinations were administered on various dates in October and November 2024, but the clinical records lacked documentation of the necessary educational information. An interview with Employee 6, the infection control preventionist, confirmed these findings. The absence of documented education for these residents constitutes a failure to comply with the regulatory requirements for immunization education. This deficiency was identified during a review of select facility policies and procedures, clinical record reviews, and staff interviews, highlighting a gap in the facility's adherence to mandated educational protocols for vaccinations.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Residents 11, 15, 46, and 59 or their responsible party have acknowledged they received education at the time of consenting/declining the influenza immunization. 2. The Infection Preventionist will review all current residents to ensure documentation of influenza education of risks and benefits of vaccination was provided to resident or responsible party. 3. Education for the Infection Preventionist regarding documentation requirement for provided education of the influenza immunizations. 4. Audits for documented education for influenza and pneumococcal to residents or families will be conducted weekly x4 then monthly x2 with results reported in QAPI. 5. Compliance date: January 28, 2025.
Failure to Screen and Educate New Hires on COVID-19 Vaccination
Penalty
Summary
The facility failed to comply with the CMS memo (QSO-21-19-NH) requirements regarding COVID-19 vaccination for newly hired staff. Specifically, the facility did not screen, educate, or offer the COVID-19 vaccine to four newly hired employees, including two nurse aide trainees, one licensed practical nurse, and one nurse aide. There was no documented evidence to show that these employees were medically screened for vaccine eligibility, educated on the risks and benefits of the vaccine, or offered the vaccine itself. An interview with the employee health staff confirmed the lack of documentation and actions regarding the COVID-19 vaccination process for these new hires. This deficiency was identified through a review of the facility's new hire list and was corroborated by the employee health staff, indicating a systemic failure to adhere to the required protocols for COVID-19 vaccination education and offering for new employees.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Employees 1, 2, 3, and 4 were provided COVID-19 vaccination education and a list of nearby providers of the COVID-19 vaccination. 2. All new hires in the last two months were provided COVID-19 vaccination education and nearby providers of the vaccination. 3. Education provided to SDC of requirements to document COVID-19 screening, providing education on the COVID-19 vaccination and a list of nearby COVID-19 vaccination providers. 4. Audit of all new hire documentation will be conducted weekly x4 then monthly x2 for screening, education and providing a list of nearby providers for the COVID-19 vaccination with results reported to QAPI. 5. Compliance date: January 28, 2025
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare A coverage was ending. According to the review of clinical records and staff interviews, Resident 76's last covered day of Medicare A services was June 27, 2024, and the resident was discharged to home/self-care. Despite the planned discharge and the known end date of Medicare A coverage, there was no evidence that the facility provided the CMS-10123 form to Resident 76, which is necessary to inform the resident of the termination of services and their right to appeal. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the facility had no documentation to show that the NOMNC was delivered to Resident 76. The facility also lacked evidence that Resident 76 had exhausted his available Medicare A covered days. The deficiency was identified during a review of the facility's compliance with regulations requiring notification to residents about changes in their payment coverage.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 76 was notified of remaining Medicare days. 2. Residents who discharged while still covered by Medicare A in the last two months were reviewed for issuance of CMS-10123 notice. 3. The RNACs were educated on providing notice to residents discharging with Medicare A days remaining. 4. Audits for CMS-10123 notice will be completed weekly x4 then monthly x2 with results presented in QAPI. 5. Compliance date: January 28, 2025.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident, identified as Resident 59. A review of the resident's clinical record revealed discrepancies in the documentation of a Stage 3 pressure ulcer. An MDS assessment dated July 11, 2024, indicated that the resident had a Stage 3 pressure ulcer present on admission, with no other skin issues noted. However, a subsequent MDS assessment indicated that the same pressure ulcer was not present on admission. An interview with the Administrator confirmed that the MDS dated October 11, 2024, was coded in error regarding the resident's pressure ulcer status. This discrepancy highlights a failure in accurately assessing and documenting the resident's condition as required by the facility's protocols.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 59's MDS was corrected at the time of survey to reflect the Stage 3 pressure ulcer was not facility acquired. 2. All MDS for residents with facility acquired pressure ulcers in the last 2 months were reviewed for accuracy. 3. The RNACs were educated on accurate MDS coding of facility acquired pressure ulcers. 4. Audits will be completed for MDS coding of facility acquired pressure ulcers weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025
Failure to Implement Restorative Programs for Residents
Penalty
Summary
The facility failed to maintain or improve the ability of two residents to perform activities of daily living. Resident 24, who had a left leg amputation and was provided with a prosthetic leg, was not using it because the facility did not have parallel bars, which he had used in a previous facility for gait training. The staff used a mechanical lift for transfers and did not incorporate the prosthetic leg into his care plan, despite recommendations from physical therapy for a restorative nursing program that included the use of the prosthetic. Interviews with Resident 24 and his wife, as well as a nurse aide, confirmed the lack of use of the prosthetic and the absence of training for staff on its application. Resident 40, who was discharged from skilled therapy with recommendations to continue a restorative nursing program to maintain lower extremity strength, did not consistently receive these services. Documentation showed that the program was not completed on numerous days, with staff citing the resident was resting as the reason. The Nursing Home Administrator and the Director of Nursing confirmed the inconsistency in completing the restorative nursing program and acknowledged the lack of oversight by licensed staff to ensure the program was carried out as planned.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Residents 24 and 40 are on therapy caseload to address needs and evaluate for appropriate restorative nursing program. 2. All residents with a prosthetic were reviewed to ensure documented use of prosthetic. All residents on a RNP for ADLs were reviewed for completion of program and elevation to IDT for recommendations for those not completing their program requirements. 3. The Restorative Nursing Coordinator was educated on reviewing program completion of RNP for ADLs and elevating to IDT for recommendations of any programs not completed. 4. Random audit of 5 RNP for ADLs will be completed weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025.
Failure to Administer Physician-Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure the application of physician-ordered supplemental oxygen consistent with professional standards of practice for a resident. On two separate occasions, the resident was observed receiving supplemental oxygen at a flow rate of three liters per minute, despite having an active physician order for two liters per minute. The resident, who had a history of chronic respiratory failure and COPD, believed her oxygen was set correctly at three liters per minute. The plan of care required oxygen saturations to be checked and recorded every eight hours and as needed, with oxygen administered per the physician's order. A licensed practical nurse (LPN) mistakenly believed she was permitted to adjust the oxygen flow based on the resident's oxygen saturation levels, although the physician's order did not allow for such titration. Upon review, the LPN corrected the oxygen flow to align with the physician's directive. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the discrepancy between the physician's orders and the actual administration of oxygen to the resident.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 15's orders were changed by the physician to a titrate order. There was no harm to resident 15. 2. All residents with supplemental oxygen orders were reviewed and confirmed for wean vs titrate. 3. Education to licensed staff on titrate vs wean orders for supplemental oxygen. 4. Random audit of 5 residents on supplemental oxygen to ensure their oxygen setting follows their order. 5. Compliance date: January 28, 2025.
Insufficient Nursing Staff Leads to Delayed Call Bell Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically in relation to call bell response times. Resident 71 reported that she relies on staff assistance to use the bathroom due to her limited mobility and expressed frustration over long wait times after activating her call bell. The call bell activation logs for Resident 71 showed multiple instances where the response time exceeded 15 minutes, with the longest recorded wait being 34 minutes. Although no instance of a wait time over an hour was documented, the resident's concerns about delayed assistance were evident. Similarly, Resident 38 experienced significant delays in call bell responses, with several instances exceeding 15 minutes and one instance reaching over an hour. The resident reported having to wait for assistance with toileting and changing, sometimes resulting in sitting in a soaked bed. The call bell logs for Resident 38 corroborated these claims, showing multiple long wait times. The facility's staff acknowledged that the timing of nurse aide documentation might not align with the actual time of toileting, but the delays in response were still apparent. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Facility is meeting all DOH staffing ratio and PPD guidelines. Residents 38 and 71 will be interviewed weekly x4 weeks then monthly x2 months to monitor call bell response satisfaction. 2. The DON or designee will attend Resident Council monthly x3 to confirm satisfaction with call bell response time. 3. Staff was educated on responding to call bells within 15 minutes of activation. 4. Random audit of call bell reports for response times will be completed weekly x4 then monthly x2. Resident council response to call bell length and the random audit results will be reported to QAPI for review and recommendations. 5. Compliance date: January 28, 2025.
Medication Security Lapse During Administration
Penalty
Summary
The facility failed to ensure the secure storage of medications during a medication administration pass for a resident. During an observation on December 11, 2024, a licensed practical nurse (Employee 10) administered medications to a resident who refused to take her Metoprolol medication due to concerns about excessively lowering her blood pressure. Employee 10 removed the Metoprolol tablet from the medication cup and placed it in an open plastic cup on top of the medication cart, stating she would dispose of it later at the nurses' station. Subsequently, Employee 10 left the medication cart unattended in the hallway while administering medications to another resident in the same room. During this time, the unsecured Metoprolol tablet remained on top of the cart, out of Employee 10's view, from 8:54 AM to 8:58 AM. Upon returning to the cart, Employee 10 confirmed that the tablet was left unsecured. The surveyor discussed these concerns with the Nursing Home Administrator and the Director of Nursing later that day.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. No residents were harmed. 2. Employee 10 was immediately educated on proper storing of medications. 3. All licensed staff were educated on proper storing of medications. 4. A random audit of storing of medications will be conducted weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services for a resident, identified as Resident 40, who was reviewed for dental concerns. An interview with Resident 40 revealed that she had natural teeth but had not received dental services in the past year, such as routine prophylactic cleaning. A review of the clinical records showed that the last professional dental service Resident 40 received was from a dentist on October 4, 2022, and from a dental hygienist on April 26, 2023. This indicates that Resident 40 had not received routine dental care for over a year. The Nursing Home Administrator confirmed that the facility did not provide routine dental services for Resident 40 in accordance with the State plan.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 40 was seen by a dentist on December 13, 2024. 2. All residents were reviewed for required dental visits. 3. Education was provided to the medical records tech regarding required dental services. 4. Random audit of dental visits will be completed monthly x3 with results reported to QAPI. 5. Compliance date: January 28, 2025.
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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