Greene Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 119 Industrial Park Road, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395604
- Inspections on file
- 36
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Greene Health & Rehab Center during CMS and state inspections, most recent first.
Two residents who were cognitively intact and dependent on staff for ADLs, including one with MS and another with post-stroke hemiplegia/hemiparesis and diabetes, experienced excessively long call bell response times that did not align with facility policy or expectations. Call bell logs showed repeated delays ranging from many minutes to about an hour, and one resident reported being placed in bed and not checked on for several hours, with unanswered attempts to reach staff by phone. The ADON acknowledged that these call bell wait times were excessive and inconsistent with the expectation that call bells be answered within five minutes.
A resident with dementia and cognitive impairment, who required staff assistance for ADLs and had a care plan specifying twice-weekly showers on set days with bed baths as an alternative if refused, did not receive showers on numerous scheduled days over a two-month period. Facility policy required honoring bathing preferences and documenting refusals and alternatives, but bathing records showed repeated missed showers with no documentation that showers were offered, refused, or replaced with bed baths. The ADON confirmed the absence of documentation and that the resident should have received showers per her preferences and plan of care.
Staff failed to follow medication storage and supervision requirements when an LPN left a cup containing multiple unlabeled pills on an overbed table for a cognitively intact resident with heart failure, anxiety, and depression, without remaining to observe administration, and when prescription triamcinolone 0.1% cream ordered for dermatitis in another cognitively intact resident with gastroenteritis and colitis was found left unattended on the resident’s bed near the door. The facility’s own policy prohibited leaving medications or chemicals unattended, and leadership confirmed these medications should not have been left unsupervised.
A resident with an unstageable sacral pressure ulcer did not receive Triad cream every shift as ordered by the physician; instead, the treatment was only applied daily over several days, as confirmed by review of records and staff interview.
A resident with hemiplegia and hemiparesis was not provided with physician-ordered adaptive eating equipment, including a divided plate and specialized utensils, during a meal. Despite clear documentation and communication from therapy and dietary staff, the required devices were not supplied, and the resident and family confirmed their ongoing need.
The facility did not serve food and drink at appropriate temperatures, with hot items found to be lukewarm and cold items not sufficiently chilled during a lunch meal observation. A Dietary Technician confirmed that the foods were not served at the required temperatures, resulting in meals that were not palatable.
The facility did not ensure that refrigerated foods were properly labeled and dated, and failed to maintain cleanliness in key kitchen areas and equipment. Required cleaning tasks were not consistently documented as completed, and significant build-up of food debris and dust was observed on kitchen equipment and surfaces. The Dietary Technician confirmed these deficiencies.
A resident experiencing severe, uncontrolled pain was not assessed by an RN after a significant change in condition, despite facility policy and state regulations requiring such assessment. An LPN documented the pain and communicated with the physician, but there was no evidence of RN involvement or assessment during the episode, as confirmed by the DON.
A resident with cognitive impairment, incontinence, and diabetes did not receive scheduled showers as outlined in her care plan, and there was no documentation of showers given or refusals. Facility policy required at least two weekly showers or documentation of refusals, but records showed missing entries and unexplained 'did not occur' notations, as confirmed by the DON.
A resident with cognitive impairment and a physician's order for routine Naproxen did not receive multiple scheduled doses, as confirmed by MAR review and DON interview, despite the medication being available as a stock OTC item.
A resident with a history of DVT and ongoing pain was not provided adequate pain management when scheduled Tylenol failed to relieve her symptoms. Despite documentation of severe, uncontrolled pain and a request for stronger medication or comfort care, there was no evidence that the physician was promptly contacted for additional interventions. The DON confirmed that the resident's acute pain was not properly managed.
A resident with a history of falls and multiple medical conditions experienced several falls, after which the IDT implemented new interventions such as bed and wheelchair alarms. However, the care plan was not updated to reflect these changes, despite the alarms being in use and staff confirming their application.
A resident with dementia, dependent on staff for transfers, was left without access to her call bell and was not assisted out of bed after staff intentionally moved the call bell out of reach. Multiple staff, including an LPN and RN, were aware of the situation but did not report it promptly, resulting in a failure to protect the resident from abuse and neglect.
A resident with paraplegia and a Stage 4 pressure ulcer did not receive prescribed IV antibiotics as ordered, and there was no documentation that an air mattress recommended by a CRNP and requested by the resident was provided. The DON confirmed these omissions.
The facility did not maintain proper documentation for the administration of controlled medications for three residents with significant pain management needs. Although narcotic pain medications were signed out on controlled drug records, there was no evidence in the clinical records or MAR to confirm that these medications were administered as required by policy.
The facility did not maintain complete and accurate documentation for the administration of controlled substances, as required by policy and regulation. Multiple residents with chronic pain and various diagnoses received opioid medications, but staff failed to record these administrations on the controlled medication records, despite documenting them on the MAR. The DON confirmed the absence of required documentation for these medications.
A resident with severe cognitive impairment exhibited ongoing aggressive and combative behaviors, including refusal of care, verbal aggression, and inappropriate sexual comments. Despite these persistent behaviors and changes to the resident's antipsychotic medication regimen, there was no documented evidence that the physician or CRNP was notified on multiple occasions, resulting in a failure to communicate important changes in the resident's condition.
A resident with severe cognitive impairment displayed ongoing behavioral disturbances, including aggression and refusal of care, but did not receive a psychiatric evaluation as indicated in the care plan. The care plan was not updated to address the resident's persistent behaviors, and staff confirmed these omissions during interviews.
A resident with severe cognitive impairment exhibited ongoing verbal, physical, and sexually inappropriate behaviors, including aggression and refusal of care. Despite repeated documentation of these behaviors, staff did not assess or analyze the situation or attempt new interventions, and no psychiatric evaluation was scheduled, as confirmed by the DON.
Three residents with varying cognitive and physical needs did not receive showers according to their documented preferences and care plans, and there was no evidence that showers were offered, refused, or that alternative hygiene care was provided. The DON confirmed the lack of documentation and that showers should have been given as scheduled.
A resident with an unstageable heel pressure injury did not receive a timely change in wound care as recommended by a wound care CRNP. The new treatment order was not implemented until several days after the recommendation, as the LPN responsible was not present during the consultation and only updated the order upon return. The DON confirmed the delay in following the CRNP's recommendations.
A resident with chronic kidney disease did not receive their prescribed metoclopramide before breakfast as ordered. The medication was left unsupervised on the bedside table, and an LPN confirmed it should have been administered before meals. The DON acknowledged the error.
The facility failed to complete comprehensive admission MDS assessments within the required timeframe for seven residents, with delays ranging from 15 to 21 days. Additionally, an annual MDS assessment for a resident was completed 94 days late. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to complete quarterly MDS assessments within the required timeframe for four residents. The assessments were completed beyond the 14-day requirement after the ARD, with one resident's assessment completed 96 days after the ARD. The Nursing Home Administrator confirmed these delays.
The facility failed to accurately complete MDS assessments for several residents, as confirmed by clinical records and staff interviews. Errors included incorrect documentation of medication administration, such as anti-platelet and diuretic medications, and the omission of hospice services and influenza vaccine refusals. These inaccuracies were verified by the RN Assessment Coordinator.
The facility failed to provide adequate activities for residents with dementia on the Memory Impaired Unit. Observations showed residents were mostly inactive, and staff confirmed the lack of scheduled activities due to reduced staffing and increased paperwork. This deficiency affected residents who required cognitive and social stimulation as part of their care plans.
The facility did not honor drink preferences for six residents, who expressed a desire for soda with meals or snacks. Previously available, soda is now only accessible if purchased by residents or brought in by others. The Dietary Manager confirmed limited soda availability, and the NHA stated a preference for drinks with nutritional value, despite residents' requests.
The facility failed to ensure that residents received pneumococcal immunizations, as four residents were identified as not having received the vaccine, nor was there any documented evidence that it was offered. The facility's policy requires documentation of prior vaccinations at admission, but the MDS assessments revealed that these residents' vaccinations were not up to date and were not offered. Interviews confirmed the lack of documentation and offering of the vaccine, violating several Pennsylvania Code regulations.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. The resident, who was alert and oriented, was left with medications unattended, including Carvedilol, Xifaxan, and Lactulose. An LPN confirmed leaving the medications with the resident at his request, and the Nursing Home Administrator acknowledged that no assessment had been conducted to ensure the resident's safety in self-administering medications.
The facility failed to maintain a clean environment for two residents. One resident's wheelchair had a heavy accumulation of dust and debris, while another resident's room had a fan with dust accumulation. Staff interviews confirmed the conditions, and the Director of Environmental Services acknowledged the need for cleaning.
The facility failed to provide timely written notification to residents and their legal guardians regarding the reasons for hospitalization for two residents. One resident was transferred to the ER with a left femur fracture, and another during dialysis due to unresponsiveness and facial droop. The Nursing Home Administrator confirmed the lack of required written notices for these transfers.
A facility failed to complete a significant change MDS for a resident who was enrolled in hospice services for protein-calorie malnutrition. Despite the requirement to conduct a comprehensive assessment within 14 days of a significant change, no MDS was documented. The RNAC confirmed the oversight, highlighting a lapse in protocol adherence.
The facility did not update care plans for two residents, one involving antipsychotic medication use and another regarding infection control measures. The care plan for a resident on Zyprexa was not revised to include medication needs, and another resident's plan was not updated to reflect the discontinuation of Enhanced Barrier Precautions for ESBL.
The facility did not complete a discharge summary, including a recapitulation of the stay, for a resident discharged from the hospital to home. A nursing note confirmed the discharge, but there was no documented evidence of the summary, as verified by the Assistant DON.
Two residents in an LTC facility were not provided with necessary safety devices as per their care plans. A resident at risk for falls was found without a bolster overlay and reacher, while another was transported in a wheelchair without footrests. These deficiencies were confirmed by staff interviews.
A facility failed to obtain physician's orders specifying the size of an indwelling urinary catheter for a resident. The facility's policy required catheterization per provider's order, but the physician's orders only included catheter care instructions without specifying catheter or balloon size. The DON confirmed the omission, highlighting a deficiency in policy adherence.
A resident in an LTC facility received unnecessary drugs due to incorrect medication administration. The resident, who was cognitively intact and had diabetes, was prescribed azithromycin and prednisone for shortness of breath and congestion. However, the MAR indicated that the resident received an extra dose of azithromycin and additional doses of prednisone, contrary to the physician's orders. The DON confirmed the error in medication administration.
A resident with diabetes was administered insulin lispro despite physician orders to withhold it if blood sugar was below 100 mg/dL. The MAR indicated insulin was given on several occasions when the resident's blood sugar was below this threshold, which was confirmed by the DON.
A facility failed to properly store and label medications for a resident. During a tour, it was observed that medications were left unattended on a resident's overbed table. The resident, who was alert and oriented, had specific physician's orders for medications. An LPN confirmed leaving the medications because the resident wanted to take them himself. The Nursing Home Administrator acknowledged that medications should not have been left unsupervised.
A facility failed to obtain a physician's order for an invasive procedure to collect a urine specimen for a resident with dementia. The resident had an order for a urine culture and sensitivity test, but the urine sample was collected via straight catheterization without documented evidence of a physician's order. The DON confirmed the lack of documentation.
An LPN in an LTC facility failed to follow infection control practices by touching medication with bare hands after accidentally knocking over a medication cup. The facility's policy required avoiding direct contact with medications, but the LPN picked up the pills from the cart and administered them to a resident, acknowledging the error in a subsequent interview.
The facility failed to document the administration of controlled medications for two residents, leading to a deficiency in pharmaceutical services. A resident with chronic pain and lung disease had discrepancies in oxycodone documentation, while another cognitively impaired resident had missing records for morphine administration. The DON confirmed the lack of documentation, indicating non-compliance with medication policies.
The facility failed to dry dishes in a sanitary manner after manual dishwashing. Staff were observed using an industrial fan with visible dirt and dust accumulation to blow air on clean dishes. The unsanitary condition of the fan was confirmed by the Dietary Manager and Maintenance Director.
A resident experienced rough handling and mental abuse by an agency nurse aide, who refused to return the call light, leaving the resident without a means to call for assistance in a hot room with the door closed. The incident was confirmed as abuse per the facility's policy.
A facility failed to thoroughly investigate a potential abuse incident where an agency nurse aide was rough with a resident, refused to provide the call light, and left the resident without means to call for assistance. The incident was not documented or investigated according to the facility's policy.
Failure to Maintain Resident Dignity Through Timely Call Bell Response
Penalty
Summary
The facility failed to maintain resident dignity by not responding promptly to call bells for two residents who were cognitively intact and dependent on staff for assistance with toileting, hygiene, and transfers. For one resident with multiple sclerosis, a quarterly MDS dated January 9, 2025, showed he was alert, oriented, and able to make his needs known, but required staff assistance for daily care. Interview with this resident on February 28, 2023, revealed he had to wait an extended period for staff to respond to his call bell. Review of his call bell logs for January and February 2026 showed multiple instances of prolonged response times, including waits of 19, 21, 27, 19, 60, 41, and 18 minutes on various January dates, and 16 and 46 minutes on February 1, 2026. These delays occurred despite a facility policy dated October 28, 2025, stating that staff alerted to an activated call light are responsible for responding promptly to promote a secure atmosphere for residents. Another resident, with an annual MDS dated January 6, 2026, was cognitively intact and required staff assistance for daily care needs due to hemiplegia and hemiparesis following a stroke, as well as diabetes. A grievance form dated December 15, 2025, documented that this resident reported being put to bed around 10:00 p.m. and not being checked on until about 4:00 a.m., during which time he attempted to call the nurses’ station with his cellphone but received no answer until staff eventually came and told him they were short staffed. Review of his call bell log from December 14–16, 2025, showed that his call bell was activated on December 14, 2025, at 9:19:49 p.m. and the response time was one hour and 47 seconds. In a February 3, 2026, interview, the resident stated that it took staff a long time to get him into bed after his request and that he sometimes called the front desk to get a faster response, but that night no one answered the phone. The Assistant DON acknowledged in a February 3, 2026, interview that the documented call bell wait times were excessive and not acceptable, and stated that she expects call bells to be answered within five minutes, noting that anyone can answer a call bell.
Failure to Provide Showers per Resident Preference and Care Plan
Penalty
Summary
Surveyors identified a failure to provide bathing care according to a resident’s preferences and care plan. Facility policy dated October 28, 2025, required that residents be bathed or showered according to their preferences to maintain hygiene and skin condition, and that the charge nurse speak with any resident who refused, attempt alternative arrangements, and document refusals in the medical record. Resident 5 had a quarterly MDS dated December 4, 2025, showing cognitive impairment, dementia, and a need for staff assistance with daily care needs including bathing. The resident’s care plan dated July 29, 2024, specified a preference for showers twice weekly on Wednesdays and Saturdays, with the option to refuse and receive a bed bath instead. Review of the bathing detail report for Resident 5 from December 1, 2025, through January 31, 2026, showed multiple missed showers on scheduled Wednesdays and Saturdays, including but not limited to December 6, 10, 13, 17, 20, 24, 27, 29, 2025, and January 3, 7, 10, 17, 21, 24, and 31, 2026. There was no documentation that showers were offered on these dates, that the resident refused, or that alternative bathing such as a bed bath was provided. In an interview on February 3, 2026, at 1:06 a.m., the Assistant DON confirmed there was no documented evidence that staff offered showers and that the resident should have received showers per her stated preferences and plan of care, resulting in noncompliance with 28 Pa. Code 211.12(d)(5) Nursing services.
Unsupervised and Unsecured Medications Left at Bedside
Penalty
Summary
Facility staff failed to ensure medications were properly stored and labeled, resulting in drugs being left unattended at the bedside for two residents. For one resident who was cognitively intact, required assistance with daily care, and had diagnoses including heart failure, anxiety, and depression, surveyors observed an unsupervised medicine cup containing twelve unlabeled pills on the overbed table while the resident was lying in bed. The resident reported that she was aware the pills were there and that nurses frequently left her pills sitting on the table. The LPN responsible acknowledged that he had left the medications in the room because he believed the resident would take them after eating breakfast and confirmed he did not remain in the room to observe medication administration, contrary to the facility’s medication administration policy that staff should not leave medications or chemicals unattended. For another cognitively intact resident who required assistance with daily care and had diagnoses including noninfective gastroenteritis and colitis, physician orders directed the use of triamcinolone 0.1% cream to the back and hips twice daily for dermatitis. During observation, surveyors found a box of triamcinolone 0.1% cream left on the bottom left side of the resident’s bed near the door, unsupervised by staff. The Assistant DON confirmed in both cases that medications and topical prescription products should not have been left unsupervised in the residents’ rooms, indicating noncompliance with the facility’s policy and state requirements for pharmacy and nursing services regarding proper labeling and secure storage of drugs and biologicals.
Failure to Follow Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to follow wound care recommendations for a resident with an unstageable pressure ulcer to the sacral area. The resident, who was cognitively intact and required assistance with daily care, was identified as being at risk for pressure ulcers. A wound consultation and physician's orders specified that Triad cream should be applied to the sacral wound every shift. However, review of the Treatment Administration Record showed that the cream was only applied daily over a four-day period, rather than every shift as ordered. This was confirmed by the Assistant Director of Nursing, who acknowledged that the treatment was not administered according to the physician's instructions.
Failure to Provide Ordered Assistive Eating Devices
Penalty
Summary
A deficiency occurred when staff failed to provide a resident with the assistive eating devices as ordered by the physician. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis following a cerebral infarction, required set-up assistance with eating and was specifically ordered to use a divided plate with dycem underneath and left angled black ridged non-weighted utensils for all meals. Occupational therapy and physician documentation confirmed the ongoing need for these adaptive devices, and a dietary slip was completed to communicate these requirements. During a lunch meal observation, the resident was found without the required divided plate and utensils. Both the resident and his sister confirmed that these items were necessary for him to eat independently, as he used the edge of the divided plate to assist with getting food onto his utensils. The Dietary Manager initially indicated that the adaptive equipment had been discontinued and the resident was not listed as needing them, but later confirmed that current dietary communication sheets still indicated the need for these devices. The resident did not receive the ordered adaptive equipment during the observed meal.
Failure to Serve Food and Drink at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food and drink at palatable and safe temperatures, as required by its own policy. According to the policy, hot foods should be plated at 135°F and cold foods at 41°F or below. During a lunch meal observation, a test tray revealed that hot items such as potato encrusted fish and sliced carrots were served at 121.1°F and 120.4°F, respectively, while cold items like creamy coleslaw, fruit cup, and milk were served at 67.7°F, 62.0°F, and 59.8°F, respectively. These temperatures were confirmed by tasting to be neither hot nor cold enough to be palatable. The Dietary Technician acknowledged that the foods were not served at the proper temperatures.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions as required by policy and professional standards. Review of the facility's policy indicated that refrigerated foods should be marked with the date for consumption or disposal, but observations in the main kitchen revealed multiple cartons and containers of prepared salads in the walk-in refrigerator that were not labeled or dated. Additionally, the deep cleaning calendar showed that required cleaning tasks, such as cleaning the outside of the dish machine and wiping walls, were not consistently documented as completed, with only two days signed off for the entire month. Further inspection found significant build-up of food debris and dust on kitchen equipment, including the convection oven, grease trap, ceiling vent, and ice machine filter, as well as dirty flooring around the stove and ice machine. The Dietary Technician confirmed that the food should have been labeled and that the areas identified were dirty and needed cleaning.
Failure to Ensure RN Assessment After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a registered nurse (RN) assessed a resident following a significant change in condition. According to the Pennsylvania Nursing Practice Act and the facility's own policies, an RN is required to assess residents after a change in condition, particularly when there is new or worsening pain. In this case, a resident who was cognitively intact and required assistance with daily care experienced severe, uncontrolled pain that was not relieved by scheduled Tylenol. The resident cried out in pain when moved, expressed distress, and verbalized a desire to die due to the pain. Documentation showed that an LPN noted the resident's pain and communicated with the physician regarding comfort care, stronger pain medication, or hospice, but there was no evidence that an RN assessed the resident during this episode. The Director of Nursing confirmed that there was no documented RN assessment at the time of the resident's pain episode, despite facility policy and state regulations requiring such an assessment. The lack of RN assessment and documentation following the resident's significant change in condition constituted a failure to meet professional standards of quality and the facility's own protocols for pain management and change in condition.
Failure to Provide Scheduled Showers and Document Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled according to her care plan and preferences. Facility policy required that residents be bathed or showered at least twice weekly, or as per their preference, and that refusals be reported to the charge nurse, who would then document the refusal and attempt to make alternative arrangements. For the resident in question, the care plan specified a preference for showers twice weekly on the day shift, with a prompt bed bath and skin checks if a shower was refused. A review of the resident's records, including the bathing detail report and weekly skin sheets over a six-week period, showed no documented evidence that the resident received showers as scheduled or that she refused them, which would have triggered a bed bath. The DON confirmed the lack of documentation and was unable to explain why some days were marked as 'did not occur.' The resident was cognitively impaired, required moderate assistance with bathing, was occasionally incontinent, and had diabetes, all of which were relevant to her care needs at the time of the deficiency.
Failure to Administer Ordered Pain Medication
Penalty
Summary
A cognitively impaired resident who required partial to moderate assistance and received routine pain medication was admitted with a physician's order for 500 mg of Naproxen to be administered twice daily with meals. Review of the resident's Medication Administration Record (MAR) for August 2025 showed that the Naproxen was not documented as given on several specified dates and times. The Director of Nursing confirmed that the resident did not receive the ordered Naproxen doses on those occasions, despite the medication being available as a stock item in the emergency box and as an over-the-counter medication.
Failure to Provide Timely Pain Management for Resident with Acute Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was experiencing acute pain. According to the facility's pain management policy, a pain evaluation should occur with any new onset of pain, and the physician should be notified of new or significantly increased pain. The resident, who was cognitively intact and required assistance with daily care, had a physician order for scheduled Tylenol. On one occasion, the resident was found to have a deep vein thrombosis (DVT) in the left lower extremity and was started on anticoagulant therapy. Despite this, nursing documentation indicated that the resident continued to experience significant pain that was not relieved by the scheduled Tylenol, including crying out in pain during care and expressing distress about her pain. A note was placed in the physician's communication book requesting comfort care, stronger pain medication, or hospice, but there was no documented evidence that the physician was contacted at that time for additional interventions or treatment to relieve the resident's pain. The Director of Nursing confirmed that the resident's acute pain was not controlled as it should have been. This lack of timely physician notification and intervention for uncontrolled pain constituted a failure to follow the facility's pain management policy and provide adequate nursing services.
Failure to Update Care Plan After Falls and New Interventions
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect changes in care needs following multiple falls and the implementation of new safety interventions. The resident, who had a history of falls, left shoulder injury, left hip fracture, and conditions such as deconditioning, limited mobility, vertigo, orthostatic hypotension, and weakness, experienced several falls over a period of time. After each fall, the interdisciplinary team met and decided on new interventions, including the addition of bed and wheelchair alarms to help prevent further incidents. Despite these interventions being implemented, there was no documented evidence that the resident's care plan was revised to include the use of bed and wheelchair alarms. Observations confirmed the presence of these alarms in use, and staff interviews verified their application, but the care plan did not reflect these updates. This failure to update the care plan was confirmed by the Director of Nursing and was not in accordance with the facility's policy or regulatory requirements.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
Facility staff failed to protect a resident with dementia, who was dependent on staff for transfers and had no behavioral issues, from abuse and neglect. The incident involved a nurse aide removing the resident's call bell, making it inaccessible, and refusing to assist the resident out of bed over a weekend. Documentation and witness statements confirmed that the resident repeatedly requested to get out of bed and that her call bell was intentionally moved out of reach. The resident verbally reported not having access to her call bell, and staff observed the call bell draped over the nightstand. Multiple staff members, including two nurse aides and an RN, were aware of the situation. One nurse aide admitted to removing the call bell, while another was aware of the action and did not intervene. The RN was informed by the aides that the call bell was moved to prevent the resident from bothering them due to their workload. The incident was not reported in a timely manner as required by the facility's abuse policy, and the investigation determined that the resident was not allowed out of bed and was left without access to her call bell.
Failure to Follow Physician Orders for Medication and Pressure Ulcer Equipment
Penalty
Summary
A review of clinical records and staff interviews revealed that the facility failed to follow physician's orders for one resident. The resident, who was cognitively intact and required staff assistance for daily care, had diagnoses including paraplegia, wound infection, and a Stage 4 pressure ulcer. Physician's orders specified that the resident was to receive 4.5 grams of Piperacillin-tazobactam intravenously every eight hours. However, the Medication Administration Record showed no documented evidence that the resident received the antibiotic as ordered on three occasions within a specified day. Additionally, the resident requested bed rails and an air mattress for repositioning and pressure ulcer management. A wound consult by a CRNP recommended an air mattress for the resident's pressure ulcers. Despite these recommendations and requests, there was no documented evidence in the clinical record that the resident received an air mattress. The Director of Nursing confirmed that the resident did not receive the IV antibiotic as ordered and that there was no documentation of the air mattress being provided.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for three out of five residents reviewed. Facility policy required documentation of controlled substance administration in accordance with applicable law, including recording when medications are given on appropriate forms. For three residents, controlled drug records showed that doses of narcotic pain medications were signed out on specific dates and times. However, there was no corresponding documentation in the residents' clinical records or Medication Administration Records (MAR) to confirm that these medications were actually administered at those times. The residents involved were cognitively intact and had significant pain management needs, with diagnoses such as fractures, osteoarthritis, chronic pain syndrome, fibromyalgia, and polyneuropathy. Each had physician orders for opioid or narcotic pain medications, either scheduled or as needed. Despite these orders and the signing out of medications on controlled drug records, the lack of documentation in the MAR or clinical records was confirmed by the Director of Nursing, indicating a failure to ensure proper tracking and accountability for controlled substances as required by facility policy and state regulations.
Failure to Document Controlled Substance Administration in Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for five residents, specifically regarding the documentation of controlled substance administration. According to the facility's medication administration policy, staff are required to document the administration of controlled substances in accordance with applicable law, including recording each dose on the appropriate controlled medication record. However, for all five residents reviewed, there were multiple instances where narcotic pain medications such as Tramadol, oxycodone-acetaminophen, oxycodone, and hydrocodone-acetaminophen were administered as documented on the Medication Administration Record (MAR), but there was no corresponding documentation on the controlled medication record for those administrations. The residents involved were all cognitively intact and required assistance with care needs. Each had significant pain management needs and diagnoses such as multiple sclerosis, chronic pain, polyneuropathy, spinal stenosis, osteoarthritis, fibromyalgia, and fractures. Physician orders for these residents included scheduled and as-needed administration of opioid medications for pain control. Despite these orders and the administration of the medications as recorded on the MAR, the required documentation on the controlled medication record was missing for several dates and times for each resident. The Director of Nursing confirmed during an interview that there was no documented evidence on the controlled medication sheets for the administration of the specified medications to the five residents on the identified dates and times. This lack of documentation was found to be inconsistent with both facility policy and regulatory requirements for clinical records and nursing services.
Failure to Notify Provider of Ongoing Resident Behaviors During Medication Changes
Penalty
Summary
The facility failed to notify the physician or provider regarding ongoing behavioral issues for one resident who was severely cognitively impaired and required staff assistance for daily care. The resident exhibited repeated episodes of combative and aggressive behavior, including refusing care and medications, verbal aggression, yelling, wandering into other residents' rooms, making inappropriate sexual comments, and being physically combative with staff. Despite these ongoing behaviors, there was no documented evidence that the physician or Certified Registered Nurse Practitioner (CRNP) was notified on multiple occasions when these incidents occurred. The resident's care plan included a Gradual Dose Reduction (GDR) of antipsychotic medication unless clinically contraindicated. However, nursing notes indicated that the resident's behaviors persisted or increased during the period when the GDR was implemented and after the antipsychotic medication was discontinued. The lack of communication with the physician or CRNP regarding these ongoing and escalating behaviors meant that the provider was not informed in a timely manner to potentially prevent the GDR or address the resident's needs. The Director of Nursing confirmed that the provider was not notified about the ongoing behaviors or the inappropriateness of the GDR for this resident.
Failure to Update Care Plan and Refer for Psychiatric Evaluation
Penalty
Summary
A resident with severe cognitive impairment was admitted from the hospital and exhibited ongoing behavioral issues, including combativeness, verbal aggression, refusal of care and medications, inappropriate sexual comments, and physical aggression towards staff. Despite these persistent behaviors, there was no documented evidence that the resident was referred for a psychiatric evaluation as indicated in the care plan. Additionally, the care plan was not updated to reflect new interventions to address the resident's escalating behaviors, even as the resident's antipsychotic medication was discontinued and later restarted by physician order. Clinical record reviews and staff interviews confirmed that the care plan was not reviewed or revised in response to the resident's changing condition and ongoing behavioral challenges. The Director of Nursing acknowledged that the care plan was not updated and that the psychiatric evaluation was not completed, resulting in a failure to meet regulatory requirements for timely and appropriate care planning and intervention.
Failure to Assess and Intervene for Escalating Resident Behaviors
Penalty
Summary
The facility failed to monitor, assess, and analyze a resident's escalating behavioral issues, including verbal and physical aggression as well as inappropriate sexual behaviors. The resident, who was severely cognitively impaired and required staff assistance for daily care, exhibited a pattern of combative and aggressive actions, such as refusing care and medications, yelling at staff, threatening to hit staff, wandering into other residents' rooms, and making inappropriate sexual comments. These behaviors were documented repeatedly in nursing notes over a two-month period. Despite the ongoing and increasing nature of these behaviors, there was no documented evidence that the facility assessed or analyzed the resident's behaviors or attempted new interventions to address them. Additionally, although the resident's antipsychotic medication was discontinued and later restarted, no psychiatric evaluation or treatment was scheduled. The Director of Nursing confirmed that the resident was in need of psychiatric evaluation, but none had been arranged as of the time of the survey.
Failure to Provide Showers per Resident Preferences and Care Plans
Penalty
Summary
The facility failed to provide showers to three residents according to their documented preferences and care plans. Facility policy required that residents be bathed or showered per their preferences, and if a resident refused, the charge nurse was to ascertain the reason, offer alternatives, and document the refusal in the medical record. For one resident with cognitive impairment and a history of stroke, the care plan indicated a preference for weekly showers, with bed baths as an alternative if refused. However, records showed inconsistent showering and no documentation of refusals or bed baths provided. Another resident, cognitively intact with incontinence, a deep tissue injury, and multiple diagnoses, preferred three showers weekly, but there was no evidence of showers given or refusals documented. A third resident with Alzheimer's dementia, requiring assistance with daily care, preferred twice-weekly showers, but records indicated missed showers and no documentation of refusals or alternative care. Review of bathing detail reports for all three residents over a nearly three-month period revealed that showers were not provided as per their preferences, and there was no documentation that showers were offered and refused, nor that bed baths were given as alternatives. An interview with the DON confirmed the lack of documentation and that the residents should have received showers according to their preferences. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Timely Implement Wound Care Recommendations
Penalty
Summary
A deficiency was identified when the facility failed to implement a wound care recommendation for a resident with an unstageable pressure injury on the right heel. The resident, who was cognitively intact and required substantial assistance with care, had significant medical conditions including peripheral vascular disease and diabetes. A wound care CRNP recommended a change in the wound care regimen, specifying the use of 0.125% Dakin's Solution, Santyl, calcium alginate, abdominal dressing, and kerlix. However, review of the resident's Medication Administration Record showed no evidence that this new treatment was initiated as recommended. The wound nurse, an LPN, was not present during the CRNP's visit and only became aware of the recommended change after returning to the facility. Upon review, the LPN found that the order had not been updated to reflect the new wound care protocol. The order was not changed until several days after the recommendation, resulting in a delay in implementing the prescribed wound care for the resident. The DON confirmed that the CRNP's recommendations were not followed in a timely manner.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to follow physician's orders for a resident diagnosed with chronic kidney disease. The resident, who was cognitively intact and independent with personal care needs, was prescribed 10 mg of metoclopramide to be taken before meals three times a day. On the morning of December 17, 2024, the resident was observed lying in bed with a medicine cup containing two white pills left unsupervised on the bedside table, and no breakfast was present. An interview with an LPN confirmed that these were the resident's morning medications, which should have been administered before breakfast. The Director of Nursing confirmed that the medication should not have been left unsupervised and should have been administered as ordered.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required timeframe for seven residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 48, 70, 98, 203, 204, 205, and 206 were completed between 15 to 21 days after admission, exceeding the mandated timeframe. This delay in completing the assessments was confirmed during an interview with the Nursing Home Administrator. Additionally, the facility did not complete an annual MDS assessment within the required timeframe for one resident. The RAI User's Manual specifies that an annual comprehensive MDS assessment should be completed no later than 14 days after the assessment reference date (ARD). For Resident 36, the annual MDS assessment was due on May 19, 2024, but was not completed until August 7, 2024, resulting in a delay of 94 days. This deficiency was also confirmed by the Nursing Home Administrator during the interview.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 calendar days after the ARD. However, the facility did not adhere to these guidelines for Residents 27, 45, 55, and 63. Resident 27's quarterly MDS assessment, with an ARD of May 4, 2024, was completed 96 days after the ARD, which was beyond the required timeframe. Similarly, the assessments for Residents 45, 55, and 63 were completed 16 days after their respective ARDs, exceeding the 14-day completion requirement. The Nursing Home Administrator confirmed these delays during an interview, acknowledging that the assessments were completed late.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, as determined through a review of clinical records and staff interviews. The deficiencies were identified in the coding of specific sections of the MDS assessments, which are crucial for evaluating residents' abilities and care needs. For instance, Resident 20's assessment inaccurately indicated that they did not receive anti-platelet or diuretic medications, despite physician orders and medication administration records showing otherwise. Additionally, the assessment failed to document a physician's note on the contraindication of a gradual dose reduction for an antipsychotic medication. Similar inaccuracies were found in the assessments of other residents. Resident 22's assessment incorrectly noted the administration of intravenous medication and failed to record the receipt of an antiplatelet medication. Resident 34's assessment also omitted the administration of an antiplatelet medication. Resident 38's assessment did not reflect the administration of a diuretic medication, and Resident 49's assessment failed to document the receipt of an anti-platelet medication. These errors were confirmed through a review of physician orders and medication administration records. Further discrepancies were noted in the assessments of Residents 87 and 92. Resident 87's assessment inaccurately stated that the influenza vaccine was not offered, despite documentation of the resident's refusal. Resident 92's assessment failed to indicate the receipt of hospice services, contrary to physician orders. These coding errors were confirmed by the Registered Nurse Assessment Coordinator, highlighting a pattern of inaccuracies in the facility's MDS assessments.
Inadequate Activities for Memory Impaired Residents
Penalty
Summary
The facility failed to provide adequate ongoing activities designed to meet the needs of residents with wandering behaviors and/or dementia residing on the Memory Impaired Unit (MIU). Specifically, five residents were identified as not receiving the scheduled activities that were supposed to be provided according to their care plans and the MIU activity calendar. These residents were severely cognitively impaired, with some requiring a secure, locked unit for safety due to their conditions, such as dementia and behavioral disturbances. The care plans for these residents indicated the need for participation in individual and group activities to maintain cognitive and social stimulation. Observations during the survey revealed that the majority of the time, residents were either sitting or walking around the tables in the activity room, with only minimal activities being provided. Interviews with staff, including a registered nurse, a nurse aide, and the Activities Director, confirmed the lack of activities on the MIU. The Activities Director acknowledged that due to increased paperwork and reduced staffing, the residents had not been receiving the activities listed on the calendar. This deficiency was noted under 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Failure to Honor Resident Drink Preferences
Penalty
Summary
The facility failed to honor drink preferences for six residents, as determined through clinical record reviews, observations, and interviews with residents and staff. Residents expressed a desire to have soda as a drink choice with meals or snacks, a preference that was previously accommodated but is no longer available. Instead, residents were informed they could purchase soda from the activity room or snack wagon, or have someone bring it in for them. The Dietary Manager confirmed that only ginger ale is available for residents who are ill, and no other sodas are ordered regularly. The Activities Manager acknowledged that residents miss having soda and occasionally incorporates it into activities. The Nursing Home Administrator stated the facility prefers to provide drinks with nutritional value and is aware of the residents' continued requests for soda, but maintains that residents must purchase it themselves.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that each resident received pneumococcal immunizations, as evidenced by the review of clinical records and staff interviews. Specifically, four residents were identified as not having received the pneumococcal vaccine, nor was there any documented evidence that the vaccine was offered to them. The facility's vaccination policy, dated September 26, 2024, requires that residents and/or their responsible party be asked about prior vaccinations at admission, with documentation in the electronic health record. However, for Residents 20, 42, 49, and 55, the Minimum Data Set (MDS) assessments revealed that their pneumococcal vaccinations were not up to date and were not offered. Interviews with the Nursing Home Administrator confirmed the lack of documentation and offering of the pneumococcal vaccine to these residents at the time of their admissions or afterward. This deficiency is in violation of several Pennsylvania Code regulations, including the responsibility of the licensee, management, and nursing services. The absence of documented evidence and the failure to offer the vaccine highlight a significant lapse in the facility's adherence to its own vaccination policy and regulatory requirements.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess whether a resident was safe to self-administer medications, as required by their policy. The policy, dated September 26, 2024, mandates that the interdisciplinary team must evaluate each resident's ability to self-administer medications based on their functionality and health condition. However, for Resident 107, who was alert and oriented upon admission, no such assessment was conducted. Despite having physician's orders for Carvedilol, Xifaxan, and Lactulose, the resident was left with these medications unattended. An LPN confirmed that she left the medications with the resident because he preferred to take them himself without her presence. The Nursing Home Administrator also confirmed that no assessment had been performed to determine the resident's capability to self-administer medications safely.
Failure to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by the condition of a resident's wheelchair and another resident's room. One resident, who was severely cognitively impaired and required assistance with most daily care needs, was observed with a wheelchair that had a heavy accumulation of removable dust and debris on the wheels and metal supports, as well as a large amount of crumbs and dirt beside the seat cushion. Staff interviews confirmed the condition of the wheelchair and indicated that environmental services were responsible for cleaning it. The Director of Environmental Services acknowledged that the wheelchair should have been cleaned and mentioned a recently implemented process for cleaning facility wheelchairs. Another resident's room was observed to have a fan with an accumulation of dust on the fan guard over several days. The Director of Environmental Services confirmed the dust accumulation and stated that staff should notify them if a resident's equipment needs cleaning sooner. These observations and interviews highlight the facility's failure to ensure a clean and homelike environment, as required by their policy and resident rights regulations.
Failure to Notify Residents and Guardians of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the residents and their legal guardians regarding the reasons for hospitalization for two residents. Resident 22, who was cognitively impaired and required assistance with daily care, was transferred to the emergency room after being found on the floor with severe pain in her left hip. She was later admitted to the hospital with a left femur fracture. There was no documented evidence that a written notice of her transfer was provided to her responsible party. Similarly, Resident 32, who was undergoing dialysis, became unresponsive and exhibited a left facial droop, prompting a transfer to the emergency room. She was subsequently admitted to the hospital with diagnoses including anemia, syncope, and end-stage renal disease. Again, there was no documented evidence that a written notice of her transfer was provided to her responsible party. The Nursing Home Administrator confirmed that the facility did not provide the required written notices for these transfers.
Failure to Complete Significant Change MDS for Hospice Enrollment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a significant change in condition. According to the Resident Assessment Instrument (RAI) User's Manual, a comprehensive assessment must be conducted within 14 days after a significant change in a resident's physical or mental condition is determined. This includes when a resident enrolls in a hospice program. The resident in question was cognitively impaired, required assistance with daily care needs, and had a diagnosis of atherosclerosis. The resident was admitted to hospice services for protein-calorie malnutrition, and the care plan indicated hospice services began on August 14, 2024. Despite the resident's enrollment in hospice services, there was no documented evidence that a significant change MDS was completed. A nurse's note indicated that the resident's family requested a transfer to a different hospice provider, but the necessary MDS assessment was not conducted. An interview with the Registered Nurse Assessment Coordinator confirmed that the significant change MDS should have been completed when the resident was enrolled in hospice services, indicating a lapse in following the required assessment protocol.
Failure to Update Care Plans for Medication and Infection Control
Penalty
Summary
The facility failed to review and revise care plans to reflect changes in residents' care needs for two residents. For one resident, the care plan was not updated to include the care and treatment needs for antipsychotic medication use, despite the resident being administered Zyprexa nightly. This oversight was confirmed by the Director of Nursing, who acknowledged that the care plan should have been revised to include this information. Another resident's care plan was not updated to reflect the discontinuation of Enhanced Barrier Precautions (EBP) for ESBL in the urine. Observations revealed that there were no signs indicating the resident was on contact precautions, and the Director of Nursing confirmed that the resident no longer required EBP, indicating the care plan should have been revised accordingly.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for a discharged resident. A nursing note indicated that the resident was discharged from the hospital directly to home. However, as of a later date, there was no documented evidence of a completed discharge summary for this resident. An interview with the Assistant Director of Nursing confirmed the absence of this documentation.
Failure to Implement Safety Devices for Residents
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place for two residents. Resident 22, who was cognitively impaired and at risk for falling, was observed without a bolster overlay on her air mattress and without a reacher within reach, despite these interventions being part of her care plan. This was confirmed by both a Licensed Practical Nurse and the Director of Nursing during interviews. Resident 74, also cognitively impaired and at risk for falls due to dementia, was observed being transported in a wheelchair without footrests, causing her to elevate her feet off the floor. This was confirmed by the Nurse Aide transporting her and the Assistant Director of Nursing. These observations indicate a failure to adhere to the care plans designed to prevent accidents for these residents.
Failure to Obtain Complete Physician's Orders for Urinary Catheter
Penalty
Summary
The facility failed to obtain physician's orders for the size of indwelling urinary catheters for one of the residents reviewed. The facility's policy, dated September 26, 2024, required staff to catheterize residents per the provider's order. An admission Minimum Data Set (MDS) assessment for the resident, dated October 8, 2024, indicated that the resident had an indwelling urinary catheter and required staff assistance for care. A care plan dated October 28, 2024, also indicated the use of an indwelling urinary catheter per orders. However, the physician's orders dated October 2, 2024, only included instructions for catheter care and monitoring of catheter output each shift, without specifying the catheter or balloon size. An interview with the Director of Nursing on October 31, 2024, confirmed that the physician's order for the resident did not contain the necessary catheter or balloon size, which was a requirement. This oversight was identified as a deficiency in the facility's adherence to its own policies and regulatory standards.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as evidenced by the incorrect administration of medications. A quarterly Minimum Data Set (MDS) assessment for the resident, who was cognitively intact and required assistance for daily care needs, revealed a diagnosis of diabetes. On a specific date, the resident was seen by a Certified Registered Nurse Practitioner for shortness of breath and congestion, leading to orders for azithromycin and prednisone. However, the Medication Administration Record (MAR) showed that the resident received an extra dose of azithromycin and additional doses of prednisone beyond the physician's orders. The Director of Nursing confirmed that the staff did not follow the physician's orders correctly, resulting in the administration of one extra dose of azithromycin and two extra doses of prednisone. This discrepancy in medication administration was identified during a review of clinical records and staff interviews, highlighting a failure in adhering to prescribed medication regimens for the resident.
Significant Medication Errors Due to Insulin Misadministration
Penalty
Summary
The facility failed to administer medication as ordered by the physician, resulting in significant medication errors for one resident. Resident 34, who was cognitively intact and required assistance for daily care needs, had a physician's order to receive 10 units of insulin lispro twice a day, to be withheld if blood sugar levels were below 100 mg/dL. However, the Medication Administration Record (MAR) showed that insulin lispro was administered on multiple occasions when the resident's blood sugar was below the specified threshold: 95 mg/dL on October 7, 82 mg/dL on October 9, 74 mg/dL on October 29, and 70 mg/dL on October 30. The Director of Nursing confirmed these errors, acknowledging that insulin was given when it should not have been.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that medications were properly stored and labeled for one resident. The facility's medication administration policy, dated September 26, 2024, stated that staff should not leave medications or chemicals unattended. However, during a tour of the facility, it was observed that a plastic cup containing two white pills and another cup containing 30 mL of a green liquid were left on a resident's overbed table without any staff present. The resident, who was alert and oriented, had been admitted to the facility on October 9, 2024, and had physician's orders for Carvedilol, Xifaxan, and lactulose. An LPN confirmed that she left the medications with the resident because he preferred to take them himself and did not want to do so in her presence. The Nursing Home Administrator confirmed that medications should not have been left unsupervised and unlabeled at the bedside.
Failure to Obtain Physician's Order for Invasive Procedure
Penalty
Summary
The facility failed to obtain a physician's order for an invasive procedure to collect a urine specimen for a laboratory test for one resident. The resident, who had dementia and was always incontinent of urine, had a physician's order dated October 7, 2024, for staff to obtain a urine culture and sensitivity test after completing antibiotics. On October 10, 2024, a urine sample was collected via straight catheterization, but there was no documented evidence of a physician's order for this procedure. The Director of Nursing confirmed the lack of documentation for the physician's order for the straight catheterization.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for one resident. The facility's policy, dated September 26, 2024, required staff to avoid touching medication with bare hands. However, during an observation on October 31, 2024, an LPN was seen preparing medications for a resident when she accidentally knocked over a medication cup, causing two pills to fall onto the medication cart. The LPN then picked up the pills with her bare hands and placed them into a plastic medication cup before administering them to the resident. The LPN later confirmed in an interview that she should not have touched the pills with her bare hands.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents, leading to a deficiency in pharmaceutical services. For Resident 11, who was cognitively intact and had diagnoses including chronic pain syndrome and chronic obstructive pulmonary disease, there were discrepancies in the documentation of oxycodone administration. Although the controlled drug record indicated that doses were signed out on specific dates, there was no evidence in the resident's clinical record or Medication Administration Record (MAR) that these doses were administered. Similarly, for Resident 13, who was cognitively impaired and required assistance with care needs, there was a lack of documentation for the administration of morphine. The controlled drug record showed that a dose was signed out, but the clinical record and MAR did not reflect that the medication was given. The Director of Nursing confirmed the absence of documentation for both residents, indicating a failure to adhere to the facility's medication administration policy and applicable laws.
Unsanitary Drying of Dishes
Penalty
Summary
The facility failed to ensure that dishes used for residents' meals were dried in a sanitary manner after manual dishwashing. During observations in the main kitchen area, staff were seen removing dishes from the sanitization solution and placing them on a rack to dry while an industrial fan was blowing on them. This fan had an accumulation of dirt and dust on both the air intake side and the grate at the front where the air blew out. Dust was also visible on the interior walls of the fan. Interviews with the certified Dietary Manager and the Maintenance Director confirmed the unsanitary condition of the fan and acknowledged that it should not have been used to blow air on clean dishes.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by the incident involving Resident 1. According to the report, Resident 1, who was able to understand and communicate, experienced rough handling by Agency Nurse Aide 3 during evening care. Following this, Nurse Aide 3 did not place the bed remote and call light within Resident 1's reach. When Resident 1 requested these items, Nurse Aide 3 engaged in a game-like manner, offering and retracting the call light, which upset the resident. After Resident 1 swore in frustration, Nurse Aide 3 refused to return the call light and instead dropped it in the trash can, leaving the resident without a means to call for assistance and closing the door behind her. This left Resident 1 in a hot room without the ability to call for help, which he found concerning and distressing. Interviews with Resident 1 and Registered Nurse 1 confirmed the details of the incident, with Resident 1 expressing that he felt mistreated and wanted Nurse Aide 3 terminated. The Nursing Home Administrator confirmed that the incident was considered abuse per the facility's policy. The facility's policy, dated August 29, 2023, clearly stated that abuse, including mental abuse such as humiliation and threats of punishment, would not be tolerated and that all incidents would be investigated. However, the actions of Nurse Aide 3 directly contradicted this policy, resulting in a failure to protect Resident 1 from abuse.
Failure to Investigate Potential Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate a potential abuse incident involving a resident. The resident reported that an agency nurse aide was rough during evening care and subsequently refused to provide the call light unless the resident agreed not to use it until a specified time. The nurse aide then engaged in a game-like manner, offering and retracting the call light, which upset the resident. Eventually, the nurse aide placed the call light in the trash can and left the room, closing the door and leaving the resident without a means to call for assistance in a hot room. The resident expressed dissatisfaction with the treatment and requested the termination of the nurse aide. The Assistant Director of Nursing was informed of the incident the following morning and spoke with the resident, who did not initially consider the incident as abuse because another nurse aide had retrieved the call light. The facility contacted the agency to prevent the nurse aide from returning. However, there was no documented evidence of the interaction between the Assistant Director of Nursing and the resident, nor were statements obtained from the involved nurse aides or the resident's roommate. Interviews with the Director of Nursing and other staff confirmed the lack of thorough investigation and documentation. The Nursing Home Administrator acknowledged that the incident was not investigated according to the facility's policy, which mandates a thorough investigation of all alleged abuse incidents. The failure to document and investigate the incident properly led to the deficiency noted in the report.
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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