Greenery Center For Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Canonsburg, Pennsylvania.
- Location
- 2200 Hill Church-houston Road, Canonsburg, Pennsylvania 15317
- CMS Provider Number
- 395695
- Inspections on file
- 26
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Greenery Center For Rehab And Nursing during CMS and state inspections, most recent first.
The facility failed to follow professional standards and physician orders for multiple diabetic residents by not consistently assessing and responding to abnormal capillary blood glucose (CBG) results. Several residents with diabetes and comorbid conditions such as CKD, CHF, CAD, COPD, dementia, ESRD, and heart failure had repeated CBG readings in both hypoglycemic and hyperglycemic ranges, including values below 70 mg/dl and above 400 mg/dl, without documented provider notification, rechecks, or clinical assessment. Some insulin and CBG monitoring orders lacked clear parameters for provider notification, and in at least one case a resident left on a leave of absence after a markedly elevated CBG without reevaluation. Although LPNs described appropriate protocols for managing low and high blood sugars during interviews, the documentation in the medical records did not show that these steps were consistently implemented or recorded, leading to an immediate jeopardy finding related to quality of care.
Surveyors found that for an extended period the facility did not employ a full-time qualified dietitian and also lacked a qualified director of food and nutrition services. An interim Dietary Manager, hired originally as a GN awaiting RN licensure, assumed the dietary manager role despite having an expired CDM credential. The RD functioned only as a consultant and was present on-site one day per week, and the NHA confirmed there was no full-time dietitian, no qualified dietary manager in place, and no job description for the RD position.
The facility failed to maintain sufficient dietary staffing to provide timely and adequate meal service, leading to repeated reports of late, cold meals and incomplete trays. Food Committee notes documented missing condiments, unannounced menu changes, posted menus not being followed, missing tray items, cold food, and running out of food before meal service ended. The interim dietary manager, who had allowed her CDM certification to lapse and had assumed the role after the prior CDM left abruptly, reported that there was not enough staff and that the RD was only on-site one day per week. Observations showed tray line assembly and meal delivery running significantly behind scheduled meal times, with only one cook, a cook in training, and one dietary aide on duty, and residents consistently reported that meals, especially those delivered to rooms, were late and cold and not reheated by staff.
The facility failed to maintain safe and appetizing food temperatures, as multiple residents reported that meals, particularly those delivered to rooms, were consistently cold and that staff would not reheat them. Surveyors observed open meal carts with trays left inside and additional trays on a hallway cooling rack, while staff admitted they did not know carts should remain closed between tray removals. Temperature checks showed that while food on the tray line was initially hot, a test tray delivered last had meat and side dishes well below required hot-holding temperatures, despite the food being palatable and visually appealing. The acting Dietary Manager confirmed the inadequate temperatures and limited use of insulated carts, and facility leadership acknowledged the failure to provide food at safe and appetizing temperatures.
The facility failed to use its QAPI program to guide changes in its restorative care services and nurse aide workload. Residents reported that the restorative program had been discontinued and that restorative duties were shifted to nurse aides, and they confirmed they were not receiving restorative care. Resident Council minutes documented prior concerns about the loss of the restorative program. The NHA acknowledged ongoing state enforcement for lack of nurse aide care and confirmed that multiple information sources, including residents, the Resident Council, the local Ombudsman, interviews, and staffing data, showed insufficient CNA staffing to meet basic care needs. The NHA further confirmed that the QAPI plan was not utilized to evaluate the impact of discontinuing the restorative program and adding duties to already short-staffed CNAs, and that the QAPI committee failed to ensure effective delivery of care and services.
The facility did not follow its Legionella water management policy by failing to complete and document required monthly water temperature testing and flushing over a three‑month period. Review of water temperature monitoring logs showed no evidence of the mandated testing, and the interim Maintenance Director confirmed that no documentation existed for those months. This represented a failure to implement the facility’s infection prevention and control program as written.
Multiple residents reported that staff frequently ignored call lights, delayed or refused assistance with toileting and transfers, and left individuals in soiled briefs or on bedpans for extended periods, causing discomfort and skin irritation. Residents described staff using cell phones and earbuds instead of attending to care needs, sitting in breakrooms while residents waited in the dining room late into the evening, and rushing care, including cleaning a resident with a pillowcase due to lack of washcloths. Several residents stated they felt dehumanized, invisible, and fearful of retaliation if they complained, and one noted that discussions with administration focused on profit rather than patient care. The administrator acknowledged that the facility failed to provide services in an atmosphere of dignity and respect for multiple residents.
The facility failed over several months to respond to repeated resident council concerns about inadequate staff response to care needs, including delayed call light response, lack of licensed nurse involvement, insufficient staffing on units when CNAs took breaks together, late meals, and residents not being assisted to or from bed or the dining room in a timely manner. Residents reported being neglected or left unattended while staff used cell phones or earbuds for personal activities, with some residents left in soiled briefs, not fed, or waiting hours for transfers. A group of residents documented these issues in a signed letter, and during a group interview most residents stated that administration had not resolved these concerns. Facility documentation of its response did not demonstrate that staff were educated or instructed to correct the timeliness of care or the length of staff breaks, and the administrator acknowledged the failure to respond promptly to the resident council’s grievances.
Surveyors found that the facility did not provide residents with required and accessible information on how to file grievances and how to contact the grievance official. On multiple nursing units and in the dining area, grievance boxes with forms were present but lacked posted details about the grievance official’s name and contact information, residents’ right to file grievances orally, in writing, or anonymously, and the expected time frame for grievance review. On one nursing unit, no grievance box was located at all. Although grievance information was posted on a hallway bulletin board, it was placed too high for a person seated in a wheelchair to easily see, limiting accessibility. The NHA confirmed the failure to provide this information on all nursing units.
The facility failed to implement and document restorative nursing programs intended to maintain residents' ADL abilities. Several residents with conditions such as stroke, Parkinson's disease, quadriplegia, dementia, diabetes, and a history of falls had care plans and PT discharge summaries specifying restorative interventions, including ambulation with a wheeled walker, passive stretching, and assisted range of motion exercises. The facility's restorative nursing policy required maintaining or improving functional status, and the PT Director indicated that restorative activities should be recorded on daily flow records. Review of these records over several months showed no documentation that the ordered restorative tasks were completed, and both a NA and the PT Director acknowledged that restorative nursing was not being carried out, which the administrator confirmed.
The facility did not follow its own weight-monitoring policy or MD orders for several residents with conditions such as COPD, HF, diabetes, and kidney disease. Although orders and care plans required weekly weights for four weeks and then monthly, weights were missing for extended periods, including after admission and readmission, with no refusals documented. In two cases, weights were only obtained at surveyor request, revealing significant weight changes over weeks to months without interim monitoring. The NHA acknowledged that ordered weight monitoring was not properly completed for multiple residents.
The facility failed to maintain sufficient nursing staff to meet residents’ assessed needs, resulting in repeated reports of long call light response times, delayed or missed toileting assistance, and inadequate hygiene. Multiple residents described waiting hours for help to use the bedpan or be put to bed, being left in soiled briefs or on bedpans for extended periods, and having to seek staff in hallways or involve family to get assistance. Some residents reported being left in urine and feces for many hours, experiencing skin irritation and rashes, and not receiving proper washing before creams were applied. Others reported not being gotten out of bed, being left in the dining room after meals, not being set up for meals in bed, and having poor oral care, unchanged linens, and unclean skin and nails. Resident Council minutes, confidential group interviews, and grievances consistently documented these staffing-related care failures over multiple months, and facility leadership acknowledged that nursing staff levels were insufficient to provide required nursing and related services.
Surveyors determined that the facility did not complete required annual performance evaluations or provide the mandated 12 hours of annual in‑service education for multiple nurse aides. During interviews, the HR Director acknowledged that annual performance reviews had not been done, and the Nursing Home Administrator confirmed that the affected nurse aides had not received the required in‑service hours within 12 months of their hire date anniversaries.
Facility leadership, including the NHA and DON, did not ensure that physicians or other advanced practice providers were notified when multiple residents’ capillary blood glucose (CBG) levels were outside the parameters ordered by their physicians. Despite job descriptions assigning the NHA overall operational responsibility and the DON overall clinical leadership and regulatory compliance responsibility, the facility failed to implement effective management to ensure timely provider notification of these changes in condition. During interviews, the NHA and DON acknowledged that administration had not effectively managed this process, resulting in an Immediate Jeopardy situation for numerous residents.
Surveyors determined that the facility did not document that several residents with conditions such as COPD, stroke, Parkinson’s disease, bipolar disorder, congestive heart failure, and diabetes were offered a COVID-19 vaccine or received required education on its benefits, risks, and potential side effects, despite a facility policy stating that residents would be educated and encouraged to stay up to date with COVID-19 vaccines. Review of consent/declination forms and immunization records showed no evidence that the vaccine was offered or declined, and the ICP confirmed the lack of documentation.
Surveyors found that multiple NAs did not receive the required minimum of 12 hours of annual in‑service education within 12 months of their hire date anniversary. Facility records showed that each of the reviewed NAs received only 2 to 4 hours of in‑service training during their respective 12‑month periods, despite the facility’s own assessment stating it follows all state and federal guidelines for staff education. No additional training documentation was produced, and the NHA confirmed that the required annual in‑service education had not been provided for these NAs.
A resident with sepsis, diabetes, and dependence on renal dialysis had physician orders for hemodialysis three times weekly and a care plan requiring monitoring of pre/post-dialysis weights and vital signs. Despite a facility dialysis management policy, nursing staff did not complete most pre-dialysis communication forms and had multiple dialysis communication sheets missing over several months. The RNAC and the NHA confirmed that required pre- and post-dialysis communication documentation between the facility and the dialysis center was not consistently completed or available.
Surveyors identified that the facility failed to remove multiple expired medications and medical supplies from a medication room, including blood collection tubes, culture bottles, topical agents, dressings, and needle sets, despite a policy requiring immediate removal of outdated items. On another unit, a treatment cart containing peroxide, rubbing alcohol, resident-specific ammonium lactate 12% lotion, triamcinolone acetonide cream, and various dressings was left unsecured in a supply room with the door propped open. An LPN and an RNAC confirmed the expired items and the expectation that the cart and room should be secured, and the NHA acknowledged these failures.
The facility failed to hold a required quarterly Quality Assessment and Assurance (QAA) committee meeting for one quarter, despite federal regulations and its own QAPI policy requiring at least quarterly meetings. Review of QAPI sign-in sheets and attendance records for the fourth quarter of the year showed no evidence that a QAA meeting occurred, and the Nursing Home Administrator confirmed that the committee did not meet with all required members during that quarter, including leadership and the infection preventionist.
The facility failed to accurately complete its Facility Assessment, leaving required tables for disease/condition categories, special treatments, and ADL assistance levels blank. The assessment also contained conflicting information, stating that residents requiring ventilator care are not admitted while listing ventilators as available equipment, and identifying amenities such as a gift shop and café/snack bar/bistro for resident use. Additionally, the staffing plan claimed compliance with all state and federal staffing education guidelines, but in-service records showed that no nurse aide met the 12-hour annual in-service requirement. The NHA confirmed the Facility Assessment was not accurately completed.
Surveyors found that the facility did not provide or document required written bed-hold policy notices at the time of hospital transfers for three residents. One resident with heart failure and prior stroke was sent to the ER after a decline in condition, another with COPD and severe cognitive impairment was transferred twice for leg evaluation and low HGB requiring transfusion, and a third with hypertension and prior stroke was transferred twice for acute neurologic events including unresponsiveness and seizures. In each case, the clinical record lacked evidence that the resident or representative received written information on the bed-hold duration, reserve bed payment policy, or return rights, and the NHA and DON confirmed this failure for three of six residents reviewed.
Surveyors found that the facility did not post complete and current Adult Protective Services (APS) contact information, including email, phone number, and mailing address, on the South, North, and West nursing units. Observations showed the required APS details were missing from the resident rights postings, and the Nursing Home Administrator confirmed that the postings on all three units lacked the full APS contact information as required by regulation.
Surveyors found that staff failed to protect resident confidentiality and privacy on two nursing units. On the North unit, resident-identifiable information about care and showers was taped to the nurse’s station desk where it was visible to anyone passing by, and on the South unit, similar resident-identifiable care information was left lying openly on the nurse’s station desk. Additionally, two nurse aides on the North unit were observed wearing earbuds while providing care to residents. The Assistant DON confirmed that required standards for confidentiality of personal information and privacy during care were not maintained.
Surveyors found multiple failures in food storage and handling in the main kitchen, including food stored directly under deep-freezer fans with ice buildup and items touching the ceiling, open and undated meats and opened butter stored under walk-in cooler fans, and an ice cream freezer with heavy ice buildup and product stuck in the ice. In dry storage, numerous boxes of food were kept on the floor, and open boxes of bacon bits and cereal were left unsealed. Staff hygiene practices were deficient, with a dietary aide serving on the tray line without a beard restraint and another in the kitchen without a hair restraint. The kitchen exit door did not close properly and had to be pulled shut, while garbage areas were located just outside this door. The Assistant DON acknowledged that the facility failed to properly store food products in the main kitchen, creating the potential for foodborne illness.
Surveyors found that resident rooms on multiple nursing units had peeled wallpaper with black mold, broken drywall, and uncovered floor heater units with exposed sharp metal, while floors on two units had broken tiles that could cause tripping. Facility grievances and a complaint also revealed ongoing shortages of clean wash cloths, bed pads, and towels throughout the day, and observations of linen carts showed very limited linens available despite a census of over 100 residents. The Maintenance Director and the Laundry/Housekeeper Supervisor both confirmed these environmental and linen supply deficiencies across all nursing units.
Surveyors found that two nursing units had hallways cluttered with wheelchairs, linen carts, soiled linen carts, medication carts, and lifts throughout the day, which blocked access to handrails used for ambulation and mobility assistance. The equipment also interfered with maintaining a homelike environment and prevented unobstructed egress and clear access for emergency staff to reach residents. The ADON acknowledged that resident care areas should be kept clean and orderly and confirmed the failure to maintain an environment free of accident hazards and obstacles to safe mobility.
The facility failed to maintain adequate floor stock of commonly used OTC medications, particularly MiraLAX and Prilosec (or generics), on all three nursing units despite a policy requiring such stock for use upon prescriber order. A complaint and grievance reported that common OTC medications were not available, and several nurses stated that MiraLAX and Prilosec were unavailable, that a resident with bowel issues purchased personal MiraLAX, and that staff were borrowing medications from each other. Observation of the medication room and carts showed minimal recent ordering of these medications and their absence from most med carts, and the DON confirmed the failure to meet residents’ pharmaceutical needs across all units.
The facility failed to consistently provide between-meal and bedtime snacks in accordance with residents’ needs and preferences on all three nursing units. Although facility policy required that between-meal snacks be available, staff interviews revealed that residents were unhappy because they were not receiving bedtime snacks. Resident Council and Food Committee minutes documented repeated reports that snacks were not being offered or delivered by NAs. Residents reported that while snacks were delivered to the units, NAs sometimes ate them and did not consistently offer or provide them. The ADON confirmed that snacks were not consistently provided as desired, constituting a deficiency under 28 Pa. Code 211.12(d)(3)(5) for nursing services.
The facility failed to maintain a fully functional resident call bell system on one nursing unit, including bathrooms and the shower room. Staff, including an LPN and nurse aides, reported that they must visually watch corridor call lights because the audible call light system does not work and the shower room call light alarms continuously. During observation, the shower room light was alarming, a resident’s call light above the door was illuminated with no audible alarm, and the central light panel showed the shower room light activated. The Maintenance Director confirmed that the call bell system was not being maintained in proper working order to allow residents to call for staff assistance.
The facility did not maintain sanitary conditions in the main kitchen, with ice build-up on freezers and food containers, improper food storage practices, incomplete temperature logs, and staff not following required hair restraint protocols. These issues were confirmed by management and observed during kitchen inspections.
Multiple residents reported missing scheduled showers and having difficulty rescheduling, with documentation confirming that some residents received significantly fewer showers than required. Residents cited reasons such as short staffing, lack of hot water, and prioritization of more dependent individuals. The facility's failure to provide necessary grooming and hygiene services was confirmed by the NHA and supported by resident council meeting minutes and clinical records.
The facility assigned an individual without the required certification or eligibility to direct the activities program, despite regulations mandating oversight by a qualified therapeutic recreation specialist or activities professional. This was confirmed by the NHA and documented in the employee's background.
Three residents requiring ostomy care did not have individualized physician orders or care plans specifying the type and size of appliances needed. One resident's urostomy care was being provided by a family member with supplies from home, and staff provided care only once. Another resident with an ileostomy and a third with a colostomy also lacked detailed care plans and orders for their ostomy care. LPNs reported gathering supplies as needed, but there was no evidence of care being provided according to professional standards.
A resident with a colostomy had a soiled ostomy bag removed, discarded, and then reapplied after being rinsed with mouthwash and wiped with bleach by an LPN who did not seek assistance or check for correct supplies. Additionally, an LPN failed to clean a glucometer before storage, and unbagged insulin pens were found stored together in two medication carts, increasing the risk of cross-contamination. The DON confirmed lapses in infection control practices.
Multiple residents reported consistently waiting thirty minutes or longer for their call lights to be answered, with some pressing their own call lights to help roommates receive assistance. Ongoing complaints about delayed call light response times were documented in resident council meeting minutes, and the NHA confirmed the facility did not meet timely response requirements.
A resident with a colostomy reported that an LPN, unable to find a replacement bag that fit, reused a soiled colostomy bag after cleaning it with mouthwash and bleach, instead of obtaining a new one. The resident's call bell had been ringing for about an hour before the LPN responded, and the LPN did not seek assistance or check the supply room for the correct supplies, despite multiple sizes being available. The facility failed to investigate this potential neglect as required by policy.
A resident with a colostomy reported that an LPN removed and discarded the colostomy bag, then reapplied the soiled bag after cleaning it with mouthwash and bleach when a replacement could not be found. The facility did not conduct or document an investigation into this neglect allegation, and the DON confirmed that no witness statements or reports were completed.
Two residents were admitted with complex medical needs, including a colostomy and continuous tube feeding via NG tube, but baseline care plans addressing these needs were not developed within the required timeframe. Facility policy requires a baseline plan of care to be reviewed shortly after admission, but this was not completed for these residents, as confirmed by the Nursing Home Administrator.
A resident with legal blindness, anemia, and spinal stenosis was admitted, but their care plan did not include goals or interventions for managing blindness. This omission was confirmed by record review and staff interview, showing the facility did not develop a comprehensive, person-centered care plan as required.
The facility did not update the care plans for two residents to reflect significant changes in their status and preferences, including a discharge from hospice services and a request for bed placement for comfort, as required by facility policy.
A resident with a history of stroke, dysphagia, and gastrostomy was observed receiving Jevity 1.5 for enteral feeding on two consecutive mornings, despite physician orders specifying Osmolite 1.5 unless unavailable. Facility staff did not follow the prescribed orders, as confirmed by the Nursing Home Administrator, even though Osmolite was in stock.
A resident with a colostomy did not receive care in accordance with facility policy when an agency LPN, unable to find a properly fitting replacement bag, retrieved a soiled colostomy bag from the garbage, cleaned it with bleach and mouthwash, and reapplied it to the resident. The LPN did not seek assistance from the RN supervisor or use available supplies, and the nurse aide on duty was not competent in ostomy care. This resulted in a failure to ensure nursing staff had the necessary competencies and skills to provide care as required by the resident's care plan.
A resident receiving enteral feedings was not assessed in a timely manner, and the facility failed to have the Registered Dietitian approve the planned menus for all four weeks of the menu cycle. The menus in use were not signed or approved, and staff confirmed that approved diet spreadsheets were not followed, nor were alternate menu selections of similar nutritional value offered.
A resident with an ileostomy did not have complete or accurate documentation of their ostomy care in the medical record, despite staff reporting that care was provided. The physician's order and care plan also lacked specific details regarding ileostomy care and appliance use, and the Nursing Home Administrator confirmed the documentation failure.
Two nurse aides did not receive required in-service education on effective communication, as confirmed by review of training records and interviews with the NHA and DON.
Two nurse aides did not receive required in-service education on the facility's QAPI program, as confirmed by a review of training records and interviews with the NHA and DON.
The facility did not provide required Behavioral Health training to a nurse aide and an LPN, as shown by missing documentation in their training records. This was confirmed by the NHA and DON, indicating noncompliance with staff development regulations.
A resident with severe cognitive impairment eloped from a facility due to inadequate supervision and monitoring. The resident's Wanderguard was removed prematurely, and the facility's 'Elopement Book' lacked complete information on at-risk residents. Additionally, the door alarm system was ineffective, allowing the resident to exit unsupervised.
The facility failed to notify physicians of high blood sugar levels for three residents, contrary to its policy. One resident not on sliding-scale insulin had CBG levels over 300 mg/dl without physician notification. Two other residents on sliding-scale insulin had CBG levels over 450 mg/dl without notification. Staff interviews revealed inconsistencies in understanding notification thresholds.
The facility failed to properly store and dispose of medications in two medication carts. Observations revealed unlocked carts and several opened, partially used, and undated medications, including insulin pens and ophthalmic solutions. The facility's policy requires proper labeling and disposal of outdated medications, which was not followed, as confirmed by the Nursing Home Administrator.
Failure to Assess and Notify Providers for Abnormal Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with diabetes received treatment and care in accordance with professional standards of practice and physician orders related to capillary blood glucose (CBG) monitoring and response. Surveyors found that the facility did not have policies for management of diabetes, hypoglycemia, or hyperglycemia available when requested, despite the facility assessment indicating it provides care for residents diagnosed with diabetes. The existing “Episodic and Narrative Documentation” policy only indicated that a narrative entry would be made for physician notification, without specific guidance for hypo- or hyperglycemic events. Manufacturer instructions for the glucometer defined “Low” as less than 20 mg/dl and “High” as greater than 600 mg/dl, and prescribing information for long-acting insulin (Basaglar) described its onset and duration of action, underscoring the need for appropriate monitoring and timely response to abnormal blood glucose values. For multiple residents with diabetes and other comorbidities such as chronic kidney disease, congestive heart failure, coronary artery disease, COPD, dementia, and end-stage renal disease, surveyors identified numerous CBG values that met or exceeded ordered parameters for provider notification or represented clinically significant hypo- or hyperglycemia, without documentation of physician notification, reassessment, or follow-up. Examples included residents with sliding-scale insulin orders specifying to notify the provider if blood glucose was under 70 mg/dl or over 400 mg/dl, yet blood sugars in the 400–500+ mg/dl range and lows in the 50–60 mg/dl range had no corresponding notes, rechecks, or documented provider contact. In some cases, residents had repeated elevated readings over several days, including meter readings of “HI” (over 600 mg/dl), with no documentation of notification or follow-up. Several insulin and blood sugar monitoring orders also lacked any parameters for provider notification, even as residents experienced significantly abnormal CBG values. Specific residents cited included individuals admitted with diagnoses of diabetes and chronic kidney disease, CAD, CHF, dementia, COPD, CKD, ESRD, and heart failure. Their records showed repeated elevated CBG values such as 401–591 mg/dl and lows as low as 55–57 mg/dl without documented assessment for signs and symptoms of hypo- or hyperglycemia, without rechecks, and without documented physician notification as required by orders. In one instance, a resident left the facility for a leave of absence after a CBG of 495 mg/dl without reevaluation. Interviews with LPN staff revealed that they could verbally describe appropriate steps for managing blood sugars under 70 mg/dl or over 400 mg/dl, including rechecking, giving snacks or glucose, monitoring, and notifying the physician and supervisor, and documenting in the MAR and progress notes. However, the clinical records reviewed did not reflect that these actions and notifications were consistently carried out or documented for the abnormal CBG values identified, leading surveyors to determine that the facility failed to notify physicians of elevated or decreased CBG levels and failed to assess residents for hyperglycemia and hypoglycemia, resulting in immediate jeopardy for 12 of 21 residents reviewed.
Plan Of Correction
The physician was notified for Residents R2,R4,R16,R33,R37,R46,R47,R56,R70, R80, R97 and R116 that their Capillary Blood Glucose levels were either greater than 400 or less than 70. The facility NP saw these residents to assess any impact from a Capillary Blood Glucose result not reported to the physician. For residents with current orders for Capillary Blood Sugar testing, results greater than 400 or less than 70 will be recorded, documented, and the MD/designee will be notified to issue further treatment orders as needed. The DON/Designee began educating nursing staff, including contracted staff on the facility's new policy titled "Managing Hypo and Hyperglycemia." The DON/designee will educate new nursing staff to the facility before the start of their first shift. Licensed Nursing Staff will attend Directed In-Service with AAE Consulting Services Inc on May 5th, 2026 Titled F684 Quality of Care 483.25. Licensed staff who do not attend the training in person on this date will have to watch the training provided prior to the start of their next shift. The DON/Designee will review all current diabetic residents in the facility with orders for Capillary Blood Sugar testing results during the daily clinical Morning Meeting M-F to verify that residents' Capillary Blood Sugar results were recorded, documented, and the MD/designee was notified. Saturday and Sunday results will be reviewed by the Nursing Supervisor for the same compliance. The DON /Designee will complete audits for the compliance of the new policy Managing Hypo and Hyperglycemia for 10% of facility resident with orders for Blood Sugar testing for 4 weeks then monthly times 4 The facility NHA will query 5 random nurses 3 times a week for 4 weeks then weekly for 4 weeks and then monthly for 3 months to verify their knowledge of the protocols for Hypo/Hyperglycemic Management. Results of the audits will be reviewed during QAPI and frequency adjusted based on the results of the audits.
Removal Plan
- Report identified residents’ out-of-range finger stick blood sugar results to the Nurse Practitioner and have the NP evaluate the residents and update orders as indicated.
- Review and update Resident R16’s care plan to include a diabetes care plan.
- Conduct NP review/rounds on current residents who may be impacted by a diabetic emergency to verify appropriate orders are in place and update as indicated.
- Have the MDS nurse review current diabetic residents’ care plans to verify a diabetes care plan is in place and update as indicated.
- Create a facility policy titled “Managing Hypo and Hyperglycemia.”
- Provide education by DON/ADON to current nurses (including agency) on the hypo/hyperglycemia protocol; continue for staff not yet trained and all new hires; require completion prior to working a shift.
- Notify the Medical Director of the Immediate Jeopardy and that the NP is seeing all current diabetic residents.
- Hold an ad hoc QAPI meeting with the Medical Director to review and discuss the Immediate Jeopardy and the Immediate Plan of Correction.
- Implement daily review of all current diabetic residents’ FSBS results in weekday morning clinical meeting by DON/ADON and weekend review by nursing supervisor to verify FSBS is recorded/documented and MD/designee is notified; continue per the established audit schedule.
- Implement NHA competency checks by querying random nurses to verify knowledge of hypo/hyperglycemia management protocols per the established audit schedule.
- Review audit results in QAPI and adjust audit frequency based on results.
- Complete a root cause analysis identifying lack of a formalized hypo/hyperglycemia management policy as the cause.
Failure to Employ Qualified Dietary Leadership in Absence of Full-Time Dietitian
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time qualified dietitian or a qualified director of food and nutrition services for a 25-day period, as required by federal regulations. Surveyors reviewed the job description for the Dietary Manager position, which outlined responsibilities such as managing daily dietary operations, working closely with a registered dietitian to implement meal plans, maintaining food safety standards, supervising dietary staff, and overseeing food quality and inventory. During this time, the facility did not have a full-time dietitian on staff, and the registered dietitian functioned only as a consultant, present at the facility one day per week. Employee file review and staff interviews showed that the individual serving as interim Dietary Manager, identified as Employee E12, did not meet the qualification requirements for the role. E12 had been hired as a Graduate Nurse while awaiting RN licensure and later signed the Dietary Manager job description, but she reported that her Certified Dietary Manager (CDM) license had lapsed after a previous employer closed and she changed career paths. The Nursing Home Administrator confirmed that there was no full-time dietitian employed, that the RD was only a consultant without a facility job description, and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian during the identified period.
Plan Of Correction
The facility will employ a full-time qualified Dietary Manager. The interim Dietary Manager will be taking CDM renewal on 05/08/2026 The Administrator educated the governing body for the requirement for the Dietary Manager have a CDM certification The Administrator will audit compliance of the requirement that the Dietary Manager maintains a CDM certification.
Insufficient Dietary Staffing Resulting in Late and Cold Meals
Penalty
Summary
The facility failed to provide sufficient dietary staff to safely and effectively carry out food and nutrition services, resulting in late and cold meals and incomplete tray service. Facility meal schedules showed designated serving times for both the main dining room and cart service, but Food Committee meeting notes from two separate months documented ongoing concerns about condiments not being on carts, lack of notice about menu changes, posted menus not being followed, missing items from trays, meals being late, food being cold, and running out of food before meal service was complete. The interim Dietary Manager reported that the Certified Dietary Manager had left the facility without notice, she had stepped into the role temporarily despite having allowed her CDM certification to lapse, and that the facility only had a Registered Dietitian on-site one day per week. She specifically stated there was not enough staff for the kitchen to run efficiently. Multiple residents reported that their meals were consistently cold, that meals delivered to rooms were late and cold, and that staff refused to reheat food in a microwave. During a confidential group interview, all participating residents confirmed that meals were consistently late and cold. Surveyor observations showed that on one observed day, tray line assembly was still occurring after the scheduled lunch start time, dining room residents did not begin receiving meals until later than scheduled, and cart delivery of trays to resident rooms did not begin until well after dining room service started. The acting Dietary Manager acknowledged that lunch was running about 30 minutes behind due to insufficient staff to prepare the meal on time, and staffing for that meal period consisted of one cook, one cook in training, and one dietary aide. The Nursing Home Administrator confirmed that the facility failed to provide sufficient dietary staff to perform essential kitchen duties.
Plan Of Correction
The facility will provide sufficient dietary staff to perform essential kitchen duties. On the assessment of the kitchen function, it was found that the facility was using an older menu which did not match the food ordering guide. Creating the need for frequent menu changes. The menu and order guide have now been reconciled, which will decrease the need for menu changes. The Tray Line will be moved from the dining room into the kitchen to improve time management, meal preparation and accuracy of meal including condiments needed. Education will be provided by the Administrator/Designee on the need for accuracy and time management for meal production. The Administrator will audit the kitchen meal production and accuracy weekly for four weeks and monthly for two results will be presented to the QAPI committee for review and recommendations
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide food and drink at safe and appetizing temperatures, as required by policy and federal regulations. Facility policy specified that hot foods must be held at 140°F or above and cold foods at 45°F or below, and USDA guidance indicated poultry should reach 165°F and be held at 140°F or higher. Multiple residents reported that their meals were consistently cold, especially when delivered to their rooms, and that staff refused to reheat the food. Residents stated they chose to eat in the dining room to avoid cold food. In a confidential group interview, all participating residents reported that meals were consistently late and cold. Resident council minutes from two meetings also reflected concerns about meal temperatures. Surveyors observed breakfast service with metal kitchen carts left open between tray removals, with several trays remaining inside, and additional trays placed on a cooling rack in a hallway. Staff members acknowledged they were unaware that cart doors needed to be kept closed between removing trays. During a lunch observation, food on the tray line initially met or exceeded hot-holding temperatures for some items, but a test tray obtained when the last tray was delivered showed the sliced turkey at 48°F, mashed potatoes with gravy at 55.8°F, and diced carrots at 51°F. Although the food was described as palatable and visually attractive, it was not at an appealing or appetizing temperature. The acting Dietary Manager confirmed the low temperatures and reported that the facility had only one small insulated cart and two uninsulated metal carts for meal delivery. The Nursing Home Administrator confirmed the facility failed to provide residents with food at a safe and appetizing temperature.
Plan Of Correction
The facility will provide the residents with food and drink that is at safe and appetizing temperatures The tray line will be moved to the kitchen from the dining room to improve efficiency of meal production and improve meal temperatures. Equipment consisting of Thermal Pellet base/heating element and Thermal Dome will be purchased to add additional heated time to the food from the time the meal is planned until delivered to the resident. Ancillary staff as Activities Aide, Medical Records Clerk, Business office assistant will be utilized to assist with tray pass. The Nursing and Dietary staff will be educated by the Administrator/Designee on new process of tray line and meal delivery to the residents and that during meal delivery the cart door must remain closed when not in use. Audits will be completed by the Administrator/Designee on providing the residents with food and drink that is safe and appetizing temperatures. The last tray served will have food temperatures taken to provide safe and appetizing temperatures three times a week at different meal times and then weekly ongoing Results of these audits will be presented to the QAPI committee for review and recommendations
Failure to Use QAPI to Maintain Restorative Care and Adequate Nurse Aide Services
Penalty
Summary
The deficiency involves the facility’s failure to use its Quality Assurance Performance Improvement (QAPI) program to ensure effective delivery of care and services, specifically related to the restorative program and nurse aide staffing. The facility’s written Performance Improvement Program Plan states that it is the policy of the facility to continually improve the delivery of health care services by designing, measuring, assessing, improving, and redesigning processes of resident care, and that new or modified processes should meet criteria such as being clinically sound, meeting the needs of staff and individuals served, and incorporating results of performance improvement activities. Despite this written plan, the facility did not apply its QAPI processes when making changes to the restorative program and reallocating duties to nurse aides. During a confidential resident group interview, residents reported that the restorative program had been discontinued and that restorative duties had been placed on nurse aides. The residents in the group confirmed that they were not receiving restorative care. Review of Resident Council minutes from a prior meeting showed that residents had already expressed concerns that the restorative program had been discontinued, indicating that this issue had been raised through resident feedback mechanisms before the survey. In an interview, the Nursing Home Administrator (NHA) confirmed that the facility was in the state enforcement process for a lack of nurse aide care, with issues dating back several months, and that residents, the Resident Council, the local Ombudsman, resident interviews, and facility staffing data all indicated that nurse aide staffing was insufficient to meet basic resident care needs. When asked, the NHA confirmed that the facility had not used its QAPI process and plan to ensure effective delivery of the restorative program and acknowledged that, had the QAPI plan been utilized, it would have shown that assigning additional restorative duties to already short-staffed nurse aides was not a feasible replacement for the discontinued restorative program. The NHA further confirmed that the QAPI committee failed to ensure that the delivery of care and services was effectively provided to residents.
Plan Of Correction
A Quality Assurance and Performance Improvement (QAPI) will be held by the Administrator/Designee on May 11, 2026 Resident recently discharged from Therapy will be assessed by both the Therapy department and Nursing for the need for any restorative programming. A POC task for documentation will be created to ensure the program is completed by the CNA. When Staff in is insufficient to provide these services the Therapy Department staff will assist. The DON/Designee will Monitored the when the need for the therapy staff to assist occurs A Quality Assurance and Performance Improvement (QAPI) will be held by the administrator/Designee at least quarterly or more often if needed. Minutes of the QAPI committee will be presented to the Governing Body of the Greenery Center for Rehab and Nursing. The Management Team will be educated on the timing and requirement of the QAPI committee by the Administrator. The Governing Body of the Greenery Center for Rehab and Nursing will monitor for compliance of this regulation. The DON/Designee will audit the Restorative care documentation on the CNA task weekly times four and monthly times two. The DON/ Designee will monitor the need for therapy to assist ongoing
Failure to Follow Legionella Water Management and Monitoring Policy
Penalty
Summary
The facility failed to implement its infection prevention and control measures related to Legionella control for three consecutive months. The facility’s written "Legionella Policy and Water Management Plan" dated 1/5/26 required monthly water temperature testing and flushing to ensure water was being maintained and to guide specific actions for prevention of Legionella and investigation should a case occur. Review of the water temperature monitoring logs for February, March, and April 2026 showed no evidence that the required monthly testing was completed during those months. During an interview on 4/10/26, the interim Maintenance Director confirmed that the facility had no documentation of water testing in accordance with the Legionella policy for February, March, and April 2026. This lack of documented monitoring and testing meant the facility did not follow its established system for surveillance and control of potential Legionella in the water system as outlined in its infection prevention and control program and related policies.
Plan Of Correction
The Facility has developed a Water Management Team which includes the Administrator, DON and Maintenance Director. Which has implemented control measures for Legionella testing within the facility following the "Legionella Policy and Water Management Plan" Both water temperature and water flushing logs were completed for the month of March and documented by the Maintenance Director. Water testing temperature logs and Water Flushing logs will be completed by the Maintenance Director as per the Legionella policy and Water Management Plan monthly. The Administrator has educated the Maintenance Director on the Legionella Policy and Water Management Plan. The Water Management Team have completed the Training from the CDC PreventLD. The Administrator will complete audits for completion of Legionella testing to include both the water temperature logs, and the water flushing logs monthly times four then quarterly times two. Results of this audit will be presented to the QAPI committee for review and further recommendations.
Failure to Provide Dignified, Responsive Care and Respect Resident Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide care in an atmosphere of dignity and respect and to protect residents’ rights to be free from neglect, interference, and dismissal of their needs. A facility document outlining resident rights states that residents must be treated with dignity and respect, be able to make their own schedules, and be free from abuse and neglect. A letter signed by nine residents reported that aides and other employees were frequently on their cell phones or wearing earbuds, talking, eating, watching videos, or listening to music instead of working. The letter described residents being left in the dining room until late in the evening while aides sat in breakrooms on their phones, residents not being fed, being left in dirty briefs for hours, waiting hours to be transferred from wheelchairs to beds, staff carrying hot plates in one hand and cell phones in the other while residents waited, and aides vaping in hallways and in the employee bathroom. During a resident group interview, 13 of 14 residents reported that staff ignored their care needs, turned off call lights without providing care, and that when concerns were brought to administration, they were told “We will look into it,” but residents stated this did not occur. Residents reported staff using phones while providing care, widespread delays in assistance getting in and out of bed, and feeling dismissed, dehumanized, and fearful of retaliation if they filed complaints. Individual residents described specific incidents: one resident reported waiting until late at night to be put to bed after being placed in a chair in the morning, despite ringing for help for a long time, and feeling completely ignored and “like a table.” Another resident reported being left on a bedpan through dinner after staff refused to assist, and another stated they were left sitting in urine and feces for about eight hours, developing a rash and being inadequately cleaned, with cream applied repeatedly without proper washing. Additional interviews reinforced these concerns. One resident reported having to call a family member to get staff to respond after being left in a room with the door shut, waiting an hour to an hour and a half for assistance. Another resident stated that staff would answer the call light, say they would return, and then never come back. A resident reported that during a meeting with the Administrator, the focus was on profit rather than patient care. Several residents described feeling that staff did not care about them, being rushed during care, being cleaned with a pillowcase due to lack of washcloths, and being left in soiled briefs long enough to cause skin irritation. One resident, who stated she was not incontinent, reported repeatedly waiting a long time for help to use the bedpan, not always receiving fresh water, and seeing staff walk by without entering her room, leading her to feel ignored and unworthy. The Nursing Home Administrator confirmed that the facility failed to provide services in an atmosphere of dignity and respect for multiple residents identified in the survey.
Plan Of Correction
Resident R9 is no longer in the facility. The social worker interviewed R21, R26, R63, R64, and R86. Any voiced concerns will be investigated without fear of retaliation. The social worker will document the follow-up of these investigations in the appropriate location The administrator requested that she attend the resident council meeting regularly. Will review with each current resident their preferred time to get out of bed and return to bed. This will be documented in the nurse aide documentation system and care planned. The social worker and the administrator will interview the current resident population to address any areas of concern or complaints. Resident interviews/satisfaction surveys/follow-up resident council interview will be completed to ascertain if the changes made have improved the life of the residents related to care. We will interview Five residents a week for four weeks and then monthly ongoing The staff have been educated on timely completion of ADL and incontinent care per care plan, The facility staff will be educated on the cell phone/earbud policy: they are not permitted in resident care areas. And that No Vaping is allowed in the facility. Signs indicating No Vaping have been posted at the front and back entrances. Facility Staff will be educated on the Call light policy and their requirement to assist answering call lights to their level of ability. Sensitivity training will be completed with the Nursing staff. Agency staff will also be required to view this training. Audits for the Cellphone/Earbud policy, Vaping, and call light response times will be completed by the DON/Designee four times weekly two audits per shift and monthly times three, with two audits per shift. occurring on varying units and times of the day.
Failure to Respond to Resident Council Concerns About Inadequate Staff Response
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident council concerns and grievances regarding inadequate staff response to care needs over a six‑month period. Resident council minutes from multiple meetings documented repeated complaints about delayed call light response times, lack of licensed nursing response, insufficient staff on units due to nurse aides taking breaks together, late meals, and residents not being assisted out of bed or to and from bed in a timely manner. Additional concerns included nurse aides being too busy to complete restorative care, staff not checking on residents, and residents not being assisted from the dining room after the evening meal. A facility‑provided letter signed by nine residents further described residents being neglected, dismissed, or left unattended by aides or employees who were frequently using cell phones or earbuds for personal activities instead of providing care. The resident letter also reported residents being left in the dining room until late in the evening while aides sat in breakrooms using their phones, residents not being fed, residents left in soiled briefs, and residents waiting hours to be transferred from wheelchairs to beds. It described aides carrying hot plates in one hand and cell phones in the other while residents waited, and aides vaping in hallways and in the employee bathroom. During a resident group interview, nearly all participating residents voiced ongoing concerns that facility administration had not resolved these issues related to inadequate staff response to care needs. The facility’s later documentation of its response to resident council concerns did not show that staff had been instructed or educated to address the timeliness of getting residents out of bed or the length of staff breaks, and by the end of the survey, evidence of such education or instructions was not provided. The Nursing Home Administrator confirmed that the facility failed to respond to resident council concerns and failed to do so in a timely manner for the entire review period.
Plan Of Correction
A Family Council meeting is scheduled for May 8th at 4:30 pm with the Management staff to discuss concerns regarding call light response, resident transfer status and bed mobility this is a new intervention to improve communication with families The follow-up of these conversations/concerns will be documented by the Social Worker in the appropriate location and in a timely manner. A Family Council meeting will be scheduled monthly The DON has created an assignment sheet that will clearly inform staff when, how long, and where their break time can be taken. Staff will be educated by the DON/Designee on the Call light policy and the new assignment sheet, which will show the scheduled break time of staff including how long the break will be. Education will be provided to the staff responsible for resident council and how to address concerns brought up in the meetings Audits will be completed by the DON/Designee on the call light policy, the new assignment sheet and timely response to council concerns weekly times four and monthly times two. Results of these audits will be reviewed by the QAPI committee for further recommendations.
Failure to Provide Accessible Grievance Information and Grievance Official Contact Details
Penalty
Summary
The deficiency involves the facility’s failure to provide required information to residents about how to file grievances and how to contact the designated grievance official. On the North nursing unit, surveyors observed a grievance box with forms available, but there was no information posted or provided regarding the grievance official’s name and contact information, residents’ right to file grievances orally, in writing, or anonymously, or the expected time frame for completion of the grievance review. The same issue was identified on the South nursing unit, where a grievance box with forms was present but lacked the required informational details. On the West nursing unit, surveyors were unable to locate a grievance box at all, indicating that residents on that unit did not have the same visible access to grievance forms as on other units. In the dining area, a grievance box with forms was present, but again, there was no accompanying information about the grievance official’s identity and contact information, the right to file grievances orally, in writing, or anonymously, or the expected time frame for review completion. These observations showed that residents did not have complete and accessible information about the grievance process in multiple common areas and units. Surveyors also observed a bulletin board in a hallway leading to the dialysis area, activities room, and conference room where information about the grievance official and filing grievances was posted. However, this information was placed far above the eyesight of a person seated in a wheelchair, limiting accessibility for residents who use wheelchairs. During an interview, the Nursing Home Administrator confirmed that the facility failed to provide information regarding how to file a grievance and information on the grievance official on all three nursing units, corroborating the surveyors’ findings.
Plan Of Correction
The information on the grievance box has been corrected to include the Grievance official's name and contact information, the right to file grievances orally, in writing, or anonymously and the expected time frame for completion of the grievance review. This information has been posted at eyesight level of a person seated in a wheelchair. A Grievance box has been added to the West Unit. The Administrator has educated the Social Worker who is the Grievance officer on the required posting with the required information. A new grievance form/process will be put into place to monitor the time frame for completing the grievance in the expected time frame. The Administrator/Designee will Audit for the placement and required information for the Grievance regulation and 10% of resident grievances for the timely completing weekly times four and monthly times four. Results of these audits will be presented to the QAPI committee for review and recommendations.
Failure to Implement and Document Restorative Nursing Programs for ADLs
Penalty
Summary
The facility failed to provide and document restorative nursing services necessary to maintain residents' abilities in activities of daily living (ADLs), as required by its own "Restorative Nursing Program" policy and federal regulations. The policy stated that the facility would safely and effectively improve or maintain a patient's functional status or prevent deterioration. The Physical Therapy Director reported that restorative activities were to be documented on the daily "Restorative Nursing Care Flow Record." However, review of these flow records from January through March 2026 for multiple residents showed no documentation that the ordered restorative tasks were completed. For one resident with a history of stroke and right-sided weakness, the care plan indicated a need for assistance with walking and transferring, and the restorative program specified walking 100 feet to dine with a wheeled walker and staff supervision, but there was no documentation of this being done. Another resident with Parkinson's disease required assistance with walking and was recommended to ambulate with staff and a wheeled walker; the restorative program also specified walking 100 feet to dine with supervision, yet no restorative care was documented. A third resident with quadriplegia and diabetes was dependent for all ADLs and had a therapy recommendation for lower extremity exercises and a restorative program for passive stretching of the right elbow, but again no restorative tasks were documented. A fourth resident with dementia, diabetes, and a history of falls, who walked with a wheeled walker and distant supervision, had a restorative program for assisted range of motion to all extremities, with no documentation of completion. A NA and the Physical Therapy Director both stated that restorative nursing was not being completed, and the Nursing Home Administrator confirmed that the facility failed to complete the restorative nursing program for these residents.
Plan Of Correction
Resident R24, R31, R78 and R93 will have a nurse/therapy evaluation to assess the restorative programs needed and POC task documentation will be created to ensure the program is completed by the CNA Resident recently discharged from Therapy will be assessed by both the Therapy department and Nursing for the need for any restorative programming. A POC task for documentation will be created to ensure the program is completed by the CNA. Staff education will be provided by the DON/Designee on the Restorative programs and the needed documentation for the programs. Education will occur on orientation and yearly. Audits will be completed by the DON/Designee on 10% of resident receiving restorative programs to ensure that the POC task documentation and the Nurse summary progress note are completed weekly times four onvarious shifts, then monthly timesthree months.Results of these audits will bepresented to the QAPI committee forreview and recommendations.
Failure to Monitor and Document Ordered Weights for Multiple Residents
Penalty
Summary
The facility failed to monitor and document resident weights according to physician orders and its own "Weight Protocol" policy, which required weights within 24 hours of admission, weekly for four weeks, and then monthly. One resident admitted in early February with COPD and a communication deficit had a care plan to monitor weights per facility policy and a physician order for weekly weights for four weeks then monthly; however, there was no recorded weight from 2/11 through discharge to the hospital on 2/14, and after readmission and a new order for weekly weights, no weights were documented after 3/3 for March and April, with no refusals noted. Another resident admitted in late March with heart failure and diabetes had a care plan to monitor weights per policy and a physician order for weekly weights for four weeks then monthly, but there were no documented weights after the admission date. A third resident admitted in early February with heart failure and diabetes had a care plan and physician order for weekly then monthly weights, yet only two weights were recorded in early March, and a subsequent weight obtained at surveyor request in April showed a 51‑pound change over 36 days, with no intervening weights documented. A fourth resident admitted in mid‑January with heart failure and kidney disease had a care plan and physician order for weekly then monthly weights, but no weights were recorded after 2/1 for February through April, until a weight was obtained at surveyor request in April showing an approximate 15‑pound change over two months. The Nursing Home Administrator confirmed that the facility failed to properly monitor weights as ordered for four of six reviewed residents.
Plan Of Correction
Residents R15 has discharged from the facility, Residents R18, R29 and R33 will have their weights reviewed by the Dietitian for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care changes. Resident weights will be completed on admission, weekly times 4 and then monthly until a physician order changes this policy. Weights will be reviewed by the Dietitian and DON/Designee. The Dietitian will review for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care changes. Education will be provided by the DON/designee to the nursing staff that resident weight needed to be completed upon admission, then weekly times four and monthly by the 7 th of the month per the weight policy. DON/Designee will complete audits for weights recorded at 90% of resident admissions, weekly weights, and monthly weights and ensure the Dietitian has reviewed the weights for any changes related to weight increase or decline. Any changes will be reported to the Physician/NP for further orders or plan of care adjustments. Results of these audits will be reviewed at the QAPI committee meeting for further recommendations
Insufficient Nursing Staff Leading to Delayed Care, Poor Hygiene, and Unmet Toileting Needs
Penalty
Summary
The deficiency involves the facility’s failure to maintain sufficient nursing staff with appropriate competencies and in adequate numbers on a 24-hour basis to meet residents’ assessed needs and care plans, as required by its facility assessment and federal regulations. The facility assessment dated 4/14/25 stated that staffing would follow state-required ratios to meet per patient day needs for ADLs, mobility and fall prevention, bowel and bladder care, and prompt response to bathroom assistance to maintain continence and dignity. However, multiple resident interviews, observations, Resident Council minutes, confidential group interviews, and grievance reviews showed that residents frequently experienced delayed or missed care, including long call light response times, inadequate toileting assistance, and insufficient hygiene and ADL support. Several residents reported prolonged waits for assistance and unmet toileting needs. One resident who stated she was not incontinent reported that staff did not help her onto the bedpan despite repeated requests, causing painful bladder holding and long call light waits, and she also reported not always receiving fresh water. Another resident reported having to leave her room to find staff to assist her roommate. Multiple residents described call light response times as very long, sometimes four to five hours, and one resident confirmed being left in a soiled brief for a long time, resulting in skin irritation. Observations included a resident with greasy-appearing skin and an unclean face who reported rushed care and late meals. Resident Council minutes over several months documented ongoing concerns about call light response, staff not being present on the floor, residents not being gotten out of bed, residents left in the dining room after meals, and call lights being shut off without care being provided. During a confidential resident group interview, numerous residents reported that staff turned off call lights without providing care, that residents needing assistance in and out of bed were not reliably helped, and that they experienced extremely long waits to be put to bed or assisted off bedpans. Specific accounts included being left in a chair from late morning until late at night with swollen, painful legs; being left on a bedpan through dinner after staff failed to return; sitting in urine and feces for up to eight hours with only cream applied over unwashed skin; and having to call family to contact staff because call lights were not answered. Grievances further documented concerns about lack of oral care, poor hygiene, unchanged bed linens, soiled pads with urine and feces, residents not being set up for meals in bed, being told to use briefs instead of a urinal, missed showers, and not being assisted to bed until midnight. The Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable well-being of multiple residents over several months.
Plan Of Correction
The facility will provide for sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical mental and psychosocial well-being. Staffing levels will be developed to meet the needs of the resident's care examples are ADL care, Incontinent care Transferring ,meal time, nail care, linen changes based on the facility assessment results. The facility will do this by Working with Veeshift/Eshift Staffing agency and Dropstat a scheduling oversite company to look at staff schedule to optimization the staff required to provide resident Care. The HR Director will develop a hiring plan based on the needs presented by the company Dropstat.Monthly staff meetings will be held by the HR Director to understand the needs of the staff and promote staff retention.Education will be provided To the nursing staff regarding What to do when unable to complete a care task. That they need to follow the change of command and let the nurse know they can not complete the task the nurse will then complete the task or notify their supervisor. Documentation will be completed by the staff or manager that completes the task. The Administrator/Designee will audit daily nursing staff to ensure the required number of staff are present to provide for sufficient nursing staff to meet the residents' needs. the DON/Designee will audit 90% of residents who have care concerns weekly times four and monthly time two Results of these audits will be presented to the QAPI committee for review and recommendations
Failure to Complete Annual Nurse Aide Performance Reviews and In‑Service Education
Penalty
Summary
The facility failed to complete required annual performance reviews and provide mandated annual in‑service education for nurse aides. Surveyors reviewed facility documents and interviewed the Human Resources Director, who confirmed that annual performance evaluations had not been completed for five of five nurse aides (Employees E2, E3, E4, E5, and E6). In a separate interview, the Nursing Home Administrator confirmed that these same nurse aides had not received the required 12 hours of annual in‑service education within 12 months of their hire date anniversary, as required by federal and state regulations. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the facility’s failure to conduct timely performance reviews and provide the corresponding in‑service education for the identified nurse aides.
Plan Of Correction
Employees E2, E3, E4, E5, and E6 from facility documents given to the survey team will have their annual performance evaluation completed by their Department Manager/DON. The DON/Designee will complete annual evaluations for Nurse Aide on an annual basis. The Administrator will provide education to the facility DON/Designee on the importance of completing Annual Evaluations on the employee in the facility. These evaluations will include Core Values and Objectives, of Quality of Work, Attendance and Punctuality, Communication Skills, Judgement and Decision-making skills Cooperation and Teamwork and Knowledge of position. Audits will be completed by the HR Director/Designee on 10% of Nurse Aide employees each month that the Employee Annual Evaluation has been completed. The results of these audits will be reviewed by the QAPI committee for further recommendations
Failure to Ensure Provider Notification of Abnormal Blood Glucose Levels
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility to ensure provider notification of residents’ changes in condition, specifically related to capillary blood glucose (CBG) levels. Review of the NHA’s job description showed that the NHA is responsible for overall leadership, management, and operation of the facility, including ensuring high-quality care and regulatory compliance. Review of the DON’s job description showed that the DON is responsible for overall clinical leadership and management of nursing services, including ensuring resident-centered care and compliance with Pennsylvania Department of Health and CMS regulations. Surveyors determined that the facility failed to ensure that physicians or other advanced practice providers were notified when residents’ CBG levels were outside the parameters set in the physicians’ orders. This failure affected 12 of 21 residents reviewed (R2, R4, R16, R33, R37, R46, R47, R56, R70, R80, R97, and R116). During an interview, the NHA and current DON confirmed that facility administration did not effectively manage the facility to ensure provider notification of changes in condition. This failure resulted in an Immediate Jeopardy situation for those residents, and was cited under 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).
Plan Of Correction
Nursing Home Administrator (NHA) and the Director of Nursing (DON) will effectively manage the facility to ensure provider notification of resident changes in condition by ongoing auditing and staff education on the requirement to notify the physician of abnormal blood sugar results to prevent a negative outcome to occurs Weekly reports by both the Administrator and the DON will be presented to the Greenery Center for Rehab and Nursing governing body to ensure the delivery of high-quality short-term rehabilitation and long-term care services while maintaining compliance with all federal, state (Pennsylvania), and local regulations. The Nursing Supervisor will be educated by the DON/Designee on the importance of notifying a physician of abnormal blood sugar results This education will be ongoing for licensed nursing staff. The DON/Designee will complete weekly ongoing audit of 90% abnormal blood sugar results and physician notification to prevent any negative outcome from occurring.
Failure to Document Offering and Education of COVID-19 Vaccination for Multiple Residents
Penalty
Summary
Surveyors found that the facility failed to document that certain residents were offered a COVID-19 vaccine and received required education on its benefits, risks, and potential side effects, as required by 42 CFR 483.80(d)(3). The facility’s policy titled “Covid Protocols Post PHE,” dated 1/5/26, stated that vaccines are administered in accordance with CDC recommendations, that all residents are encouraged to remain up to date with recommended COVID-19 vaccine doses, and that staff and residents will be educated on the risks and benefits of the COVID-19 vaccination and will be offered the vaccination. However, for four of five residents reviewed for immunizations, the clinical records and consent/declination forms did not contain evidence that the COVID-19 vaccine was offered or that education was provided. Resident records showed that one resident admitted with COPD, one with a history of stroke, one with Parkinson’s disease and bipolar disorder, and one with congestive heart failure and diabetes each had a “Resident Influenza/Pneumococcal/Covid-19 Consent Declination” form completed in October 2025 that lacked documentation that the COVID-19 vaccine was offered. Additionally, the “Immunizations” sections of their clinical records, reviewed on 4/10/26 at 11:00 a.m., did not include information that COVID-19 vaccines were offered or declined. During an interview at the same time, the Infection Control Preventionist confirmed that the facility failed to document that these residents were offered a COVID-19 vaccine and that they or their representatives were provided education regarding the benefits and potential side effects of the immunization.
Plan Of Correction
The facility will document that each resident was offered a Covid 19 immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations. Resident R 20 is no longer in the facility. Resident R24, R31, R98 will be offered the Covid 19 immunization, and the resident or resident's representative will be provided education regarding the benefits and potential side effects of immunizations. On Admission and annually residents will be offered a Covid 19 immunization, and the resident or resident's representative was provided with education regarding the benefits and potential side effects of immunizations. Education will be provided to the licensed Nursing Staff that resident on admission and annually need to be offered the COVID-19 Immunization provided education regarding the benefits and potential side effects of immunizations.Audits will be completed by the DON/Designee on 10% of facility admission for being offered and educated on side effects of the COVID-19 weekly times four and monthly times twoResults of these audits will be reviewed at the QAPI committee meeting for further recommendations.
Failure to Provide Required Annual In‑Service Training for Nurse Aides
Penalty
Summary
The facility failed to provide the federally required minimum of 12 hours of annual in‑service training for nurse aides within 12 months of their hire date anniversary. Review of the facility’s most recent Facility Assessment, dated 4/15/25, showed that the facility stated it follows all state and federal guidelines for staffing education. However, review of the facility’s "Nursing Assistant In-Service Hours" document showed that five nurse aides did not receive at least 12 hours of in‑service education in their respective 12‑month periods. Specifically, one nurse aide hired on 3/7/86 received 2.00 hours of in‑service education between 3/7/25 and 3/7/26, and another aide hired on 3/6/20 received 2.00 hours between 3/6/25 and 3/6/26. A nurse aide hired on 9/30/91 received 4.00 hours between 9/30/24 and 9/30/25, an aide hired on 12/21/00 received 4.00 hours between 12/21/24 and 12/21/25, and an aide hired on 1/22/24 received 4.00 hours between 1/22/25 and 1/22/26. No additional documentation of in‑service hours was provided to the survey team by the end of the survey. In an interview on 4/10/26, the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours of annual in‑service education within 12 months of the hire date anniversary for these five nurse aides.
Plan Of Correction
Twelve hours of servicing will be provided for the Nurse Aide who's files were reviewed by the survey team. Beginning next month, the DON or their designee will conduct monthly in-service training for Nurse Aides, totaling 12 required class hours. The HR Director will be educated by the Administrator on the need to provide 12 hours of Inservice education to Nurse Aides yearly. The HR director will audit 10% of nurse aides to ensure they complete the monthly class required to acquire 12 hours of in-servicing. Results of these audits will be presented to the QAPI committee for review and recommendations.
Failure to Maintain Required Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to maintain ongoing communication with an outpatient dialysis center for a resident who was dependent on renal dialysis. The resident was admitted with diagnoses including sepsis, dependence on renal dialysis, and diabetes, and had a physician’s order to receive hemodialysis three days per week. The facility’s dialysis care plan included interventions to monitor pre- and post-dialysis weights, encourage attendance at scheduled dialysis appointments, and monitor vital signs with physician notification of significant abnormalities. The facility had a “Dialysis Management” policy stating it had designed and implemented processes to ensure the comfort, safety, and appropriate management of hemodialysis residents. Review of dialysis communication forms from January through April showed that 12 of 16 pre-dialysis communication forms were not completed by facility nursing staff on specified dialysis dates, and 16 additional dialysis communication sheets for other dialysis days were possibly missing and not available at the facility. The RN Assessment Coordinator confirmed that the facility failed to ensure the dialysis communication forms were completed pre- and post-treatment between the facility and the dialysis center and confirmed the missing sheets were not available. The Nursing Home Administrator also confirmed that the facility failed to ensure dialysis communication sheets were completed prior to dialysis treatment.
Plan Of Correction
Resident R1 receiving Dialysis will be reviewed with the Dialysis Nurse to ensure complete communication has occurred to provide for accurate Plan of Care for the residents. Resident receiving Dialysis will be reviewed with the Dialysis Nurse to determine that complete communication has occurred and that the accurate Plan of Care is in place for the resident. The Medical records staff will be educated to not upload any Dialysis communication that is not complete. Medical Records staff will communicate with the DON/Designee if this occurs. Nursing Staff will be educated on the need for accurate completion of the Dialysis Communication Form by the DON /Designee Audit of 10% of residents receiving Dialysis will have the Dialysis Communication form audited for completion and placement in the Resident Medical Record by the DON/Designee. These will be completed weekly times four and monthly times three. Results on these audits will be submitted to the QAPI committee for review and further recommendations.
Expired Medications and Unsecured Treatment Cart
Penalty
Summary
Surveyors found that the facility did not comply with its own medication storage policy and federal requirements for labeling and storage of drugs and biologicals. In the North Unit medication room, an observation revealed multiple expired items that had not been removed from inventory, including blood collection tubes with expiration dates ranging from the previous year to earlier in the current year, anaerobic and aerobic blood culture bottles past their expiration dates, glycerin swab sticks, hydrocortisone packets, hydrocolloid and foam dressings, Huber needle sets, and a silicone contact layer. The facility’s policy dated 1/5/26 required that outdated, contaminated, or deteriorated medications and those in compromised containers be immediately removed from inventory. An LPN confirmed during interview that the identified items were expired. On a separate unit, surveyors observed a treatment cart that was unsecured inside a supply room with the door propped open. The cart contained two bottles of peroxide, one bottle of rubbing alcohol, multiple bottles of resident-specific ammonium lactate 12% lotion, several tubes of triamcinolone acetonide cream, and various bandages and gauze. The RN Assessment Coordinator confirmed that the treatment cart should be secured when unattended and that the supply room door should not be propped open. The Nursing Home Administrator later confirmed that the facility failed to ensure out-of-date medications were discarded in one medication room and failed to properly secure the treatment cart inside a propped-open supply room door.
Plan Of Correction
The DON/designee completed an OTC medication room audit on 3 units (North, South, West) for expired medications; all expired medications found were destroyed. The DON/designee will educate nursing staff on storing over-the-counter (OTC) medication according to manufactures guidelines for labeling and expiration dates, and ensure that treatment carts and the treatment room are locked. This education will also be part of the Nursing New Hire process during orientation. Audits will be completed by the DON/designee on the storage of OTC medication according to manufacturer guidelines for labeling and expiration dates, and ensuring treatment carts and treatment rooms are locked. These audits will be done four times weekly and three times monthly. The QAPI committee will review the results of these audits for further recommendations.
Failure to Hold Required Quarterly QAA Committee Meeting
Penalty
Summary
The deficiency involves the facility’s failure to conduct required Quality Assessment and Assurance (QAA) meetings at least quarterly with all mandated committee members. Federal regulations require that the QAA committee include, at a minimum, the DON, the Medical Director or designee, at least three other staff members including an individual in a leadership role such as the administrator, and the infection preventionist (IP), and that this committee meet at least quarterly to coordinate and evaluate activities under the QAPI program. The facility’s own “Quality Assurance and Performance Improvement (QAPI)” policy, dated 1/5/26, states that the QAPI program is an ongoing comprehensive program addressing all systems of care and that meetings are to occur at least quarterly, monthly, or more often if needed. Surveyors reviewed QAPI sign-in sheets and attendance records for Quarter Four of 2025 and did not find evidence that a QAA meeting was held during that quarter as required. During an interview on 4/10/26 at 10:40 a.m., the Nursing Home Administrator confirmed that the facility failed to conduct QAA meetings at least quarterly with all required committee members for one of the four quarterly meetings, specifically Quarter Four of 2025. No resident-specific information, medical histories, or clinical conditions were described in relation to this deficiency.
Plan Of Correction
A Quality Assurance and Performance Improvement (QAPI) will be held by the Administrator/Designee on May 11, 2026. A Quality Assurance and Performance Improvement (QAPI) will be held by the administrator/Designee at least quarterly or more often if needed. Minutes of the QAPI committee will be presented to the Governing Body of the Greenery Center for Rehab and Nursing. The Management Team will be educated on the timing and requirement of the QAPI committee by the Administrator. The Governing Body of the Greenery Center for Rehab and Nursing will monitor for compliance of this regulation.
Inaccurate and Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to accurately complete its Facility Assessment as required by regulation. Review of the Facility Assessment Tool dated 4/15/25 showed that the section titled "Disease and Conditions" contained tables intended to document categories of care and the average number of residents receiving special treatments, but these tables were left blank. In the same section, a table to document residents’ levels of assistance with Activities of Daily Living (ADLs) was also left blank. The "Disease and Conditions" section further stated that the facility denies admissions for residents requiring ventilator care, while elsewhere in the assessment conflicting information was documented. In the section titled "Physical Environment and Building/Plant Needs," the facility listed ventilators as a type of physical equipment available for resident care, which conflicted with the statement that residents needing ventilator care are not admitted. This section also listed a gift shop and a café/snack bar/bistro as available for resident use. In the "Staffing Plan" section, the facility documented that it follows all state and federal guidelines for staffing education; however, review of in-service education records showed that no nurse aide met the 12-hour annual in-service requirement. During an interview, the Nursing Home Administrator confirmed that the Facility Assessment had not been accurately completed.
Plan Of Correction
The facility will accurately complete the Facility Assessment to include Review of the Disease and Conditions, Activities of Daily Living that residents require. Physical Environment and Building/Plant. Staffing Plan and in-service education for facility staff. This assessment will be reviewed quarterly and as necessary. Results of this assessment will be presented to the Governing Board of the Greenery Center for Rehab and Nursing quarterly and when changes are made. The Administrator will be educated by the Regional Nurse Consult on completing the required sections of the facility assessment. The Governing Board of the Greenery Center for Rehab and Nursing will monitor this assessment for further compliance with this regulation. Results will be presented at the QAPI committee meeting for review and further recommendations.
Failure to Provide Required Bed-Hold Policy Notices at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to the hospital or for therapeutic leave, as required by 42 CFR §483.15(d). Federal regulation specifies that facilities must issue two notices related to bed-hold policies: one that may be provided in advance (such as in the admission packet) and a second written notice that must be given to the resident and, if applicable, the resident’s representative at the time of transfer, or within 24 hours in cases of emergency transfer. The notice must explain the duration of any bed-hold, the reserve bed payment policy, and information about the resident’s right to return to the next available bed. For three of six residents reviewed for hospitalization, the clinical records did not contain documentation that this second written bed-hold notice was provided at the time of transfer. One resident, identified as R8, was admitted with diagnoses including heart failure and a history of stroke, and had moderate cognitive impairment per the MDS. A progress note documented that the resident’s wife requested transfer to the ER due to the resident’s decline, including poor oral intake, vomiting with attempts to eat or drink, and worsening lab results, leading to a 911 call and transfer. Review of this resident’s clinical record did not show any notation that written bed-hold information was provided to the resident or the resident’s representative upon this transfer. Another resident, identified as R15, had COPD and a communication deficit, with severe cognitive impairment noted on the MDS. A progress note described the resident leaving via EMS to a local hospital for evaluation and treatment of the right leg, with the wife and brother-in-law present and reportedly satisfied with the plan of care. A later note documented that the resident’s hemoglobin was 5.5 and that the resident was sent to the hospital for a transfusion, with family made aware of the results and transfer. For both of these hospital transfers, the clinical record lacked documentation that written bed-hold notification was provided to the resident or representative. A third resident, identified as R30, had diagnoses including high blood pressure and a history of stroke, with severe cognitive impairment documented on the MDS. One progress note described a nurse finding the resident slumped over on the commode, unresponsive compared to baseline, drooling, and not following commands, after which the nurse practitioner was notified and the resident was sent to the hospital via squad for evaluation. Another note documented that the resident was seizing, had received medication without effective results, and that 911 was called; EMTs administered medication via an internal jugular line, stopped the seizure, and transported the resident to the hospital, while attempts to reach the son were unsuccessful and the provider was notified. For both of these transfers, the clinical record did not contain notation that written bed-hold notification was provided. In an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to ensure that residents and/or their representatives received written notice of the facility bed-hold policy at the time of transfer for three of six residents reviewed.
Plan Of Correction
The facility will ensure that the residents and/or their representatives receive written notice of the facility bed-hold policy at the time of transfer. Resident R 15 has been discharged from the facility. The BOM educated resident R8 and R30 to the facility bed hold policy Before a resident is transferred to a hospital or the resident goes on therapeutic leave, the nursing facility will provide written information to the resident or resident representative that specifies the bed hold policy. Residents on admission will receive a copy of the facility bed hold policy which will be signed by the resident and uploaded into the medical record. When a resident is transferred to a hospital or is on therapeutic leave the BOM will notify the resident/representative by phone the next day to explain the facility's bed hold policy and confirm whether the resident wants to maintain a bed in the facilityThe DON/Designee will educate the nursing supervisors on the requirement to send a copy of the bed hold policy with the resident on transfer to hospital or on a therapeutic leave Audits will be completed to ensure the bed hold notice was provided and completed promptly for 90% of residents transferring to a hospital or on a therapeutic leave.These Audits will occur weekly times four then monthly times three. Results will be reviewed at the QAPI committee meeting for further recommendations
Incomplete Posting of Adult Protective Services Contact Information on All Nursing Units
Penalty
Summary
The facility failed to meet federal and state requirements for posting complete and current contact information for Adult Protective Services (APS) on all three nursing units (South, North, and West). During an observation on 4/9/26 at approximately 1:00 p.m., surveyors noted that the required postings on each of these units did not include APS email address, phone number, and mailing address, as required under 42 CFR 483.10(g)(5). In a subsequent interview on 4/10/26 at approximately 3:00 p.m., the Nursing Home Administrator confirmed that the facility had not posted complete and current APS contact information on the three nursing units, resulting in noncompliance with federal resident rights posting requirements and related Pennsylvania regulations. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency pertains to facility-wide posting of resident rights and contact information for state agencies and advocacy groups, specifically APS.
Plan Of Correction
Complete and current contact information for Adult Protective Services has been posted in a form and manner, accessible and understandable to residents and representatives on three of the three nursing units (South, North, West). The Social Worker has been educated by the Administrator on the regulation to maintain these required posting. The Administrator/Designee will complete random audits to ensure the placement of the required posting is maintained. Results of this audit will be presented to the QAPI committee for review and further recommendations.
Failure to Protect Resident Confidentiality and Privacy During Care
Penalty
Summary
Surveyors determined that the facility failed to maintain the confidentiality of residents’ personally identifiable information and failed to provide privacy during care on multiple nursing units. On the North nursing unit, at 8:57 a.m., resident-identifiable information related to care and showers was observed taped to the nurse’s station desk in a manner visible to any passerby. On the South nursing unit, at 9:02 a.m., resident-identifiable information regarding care was observed lying openly on the nurse’s station desk, also visible to anyone passing by. In addition, on the North nursing unit at 8:52 a.m., two nurse aides (Employees E4 and E5) were observed wearing earbuds while providing care to residents. During an interview later that day at 1:31 p.m., the Assistant DON (Employee E1) confirmed that the facility failed to maintain confidentiality of residents’ personal identifiable information as required and failed to maintain privacy during the provision of care. These findings were cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 201.29(c.3) Resident Rights, 211.5(b) Medical records, and 211.12(d)(1)(3) Nursing services.
Improper Food Storage and Employee Hygiene in Main Kitchen
Penalty
Summary
Surveyors identified that the facility failed to store and handle food in the main kitchen according to facility policy, the Pennsylvania Food Code, and federal regulations. Policy required thermometers in hot and cold storage, food stored off the floor, and use of clean uniforms and hairnets or caps in all food service areas. The Pennsylvania Food Code required hair and beard restraints and storage of food at least six inches off the floor. Federal regulation S483.60(i)(2) required proper storage of frozen foods to allow air circulation and maintenance of frozen temperatures, and labeling, dating, and monitoring of refrigerated foods. During a kitchen tour, surveyors observed food stored directly under the fans in the deep freezer with ice accumulation on pipes and food touching the ceiling, which did not allow proper air circulation. In the walk-in cooler, a cart contained open, undated meats, and opened packages of butter were stored under the cooler fans. The ice cream freezer had ice buildup with ice cream stuck in the ice. Additional observations showed multiple violations of food storage and employee hygiene requirements. In the dry storage area, 13 boxes of dry foods were stored in boxes on the floor, and a box of bacon bits and a box of cereal were unsealed, exposing them to possible contamination. A dietary aide working on the dining room tray line was serving food without a beard restraint, and another dietary aide was in the kitchen near the freezer without a hair restraint and stated he had forgotten to put one on. The kitchen exit door would not close on its own and had to be pulled shut, while the facility garbage areas were located outside this door, creating a potential entry point for animals or bugs. During interviews, the Nursing Home Administrator reported the Dietary Manager was unavailable, and the Assistant DON confirmed that the facility failed to properly store food products in the main kitchen, creating the potential for foodborne illness.
Environmental Disrepair and Inadequate Linen Supply on All Nursing Units
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment on all nursing units. On observation of the North, South, and another named nursing unit, one unoccupied resident room had peeled wallpaper with black mold on the walls under the window. Another resident room had broken drywall behind one bed and a broken, unused floor heater panel with exposed sharp metal pieces. A third resident room had a floor heater unit with no cover, also leaving exposed sharp metal pieces. Floors on both the North and South units had broken floor tiles that had the potential to cause tripping accidents. The Maintenance Director confirmed these environmental deficiencies on all three nursing units. In addition, review of facility grievances and a complaint showed concerns that there were not enough clean and available wash cloths, bed pads, and towels throughout the day. During observations of linen carts facility-wide, surveyors noted only approximately six sheets (top and bottom), seven towels, and two or three wash cloths on each cart, despite a census of 106 residents. The Laundry/Housekeeper Supervisor confirmed awareness of complaints about running out of wash cloths, towels, and bed pads and acknowledged that the facility failed to provide a safe, clean, comfortable, and homelike environment on all three nursing units.
Obstructed Hallways and Handrails Create Accident Hazards
Penalty
Summary
Surveyors observed throughout the survey day that the North and South nursing unit hallways contained multiple pieces of equipment, including wheelchairs, linen carts, soiled double linen carts, medication carts, and lifts. These items were present in the corridors from the morning through late afternoon and obstructed continued access to the handrails intended for resident ambulation and mobility assistance. The equipment placement also interfered with creating a homelike environment and did not allow unobstructed egress through the halls or clear access for potential emergency staff to reach residents. In an interview, the Assistant Director of Nursing stated that resident care areas should be maintained in a clean and orderly manner and confirmed that the facility failed to maintain an environment free of potential accident hazards and obstacles for safe mobility and use of mobility assistance devices on two of three nursing units. No specific residents or their medical conditions were identified in the report as being directly involved in this deficiency.
Failure to Maintain Adequate OTC Medication Stock for Resident Needs
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident on all three nursing units by not maintaining adequate floor stock of commonly used over-the-counter (OTC) medications, specifically MiraLAX and Prilosec (or their generic equivalents), despite a policy stating that such OTC medications would be available upon receipt of a prescriber’s order. A complaint and grievance from January 2026 documented that common OTC medications were not available. Three of five interviewed nurses reported that MiraLAX and Prilosec were not available, that one resident had to purchase his own MiraLAX due to bowel issues, and that nurses were borrowing medications from each other to meet residents’ needs. Observation of the medication room and review of recent medication orders showed only one bottle of MiraLAX and three bottles of Prilosec ordered in the last seven orders over three months, and inspection of three of five medication carts found no MiraLAX on any cart and no Prilosec or generic equivalent on two of the three carts. The Director of Nursing confirmed that the facility failed to provide pharmaceutical services to meet residents’ needs on the North, South, and [NAME] nursing units.
Failure to Consistently Provide Resident Snacks as Required
Penalty
Summary
The facility failed to consistently provide snacks in accordance with residents’ needs, preferences, and requests on all three nursing units (North, South, and [NAME]). The facility’s Greenery Snack Policy dated 1/5/26 stated that between-meal snacks shall be available for residents. However, two nurse aides reported that residents were unhappy because they were not receiving bedtime snacks and that the facility was aware of this issue. Resident Council meeting minutes from 1/6/26, 2/4/26, and 3/3/26 documented residents’ statements that snacks were not being offered or delivered by nurse aides. Food Committee meeting minutes from 1/5/26, 2/3/26, and 3/2/26 also recorded that snacks were not being delivered to residents. During resident interviews, residents stated that snacks were delivered to the units but that NAs ate them and/or did not offer them consistently or provide them to residents. The Assistant DON confirmed that the facility failed to consistently provide snacks as desired for all three nursing units, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services. No specific resident medical histories or clinical conditions related to the deficiency were described in the report.
Failure to Maintain Functional Call Bell System on West Nursing Unit
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system on the West nursing unit, including resident bathrooms and bathing areas. Staff interviews with an LPN and two nurse aides revealed that they must visually monitor call lights outside resident rooms because the call light sound system is not working, and the shower room call light is constantly alarming. During observation, the surveyor noted the shower room light was alarming, a resident’s call light above his door was illuminated without any audible alarm, and the central light panel showed the shower room light illuminated. The Maintenance Director confirmed that the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system on the affected nursing units. No additional resident medical history or specific clinical conditions were documented in the report beyond the observation that a resident had an illuminated call light above his door at the time of the surveyor’s observation.
Failure to Maintain Sanitary Food Service Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as evidenced by multiple observations and staff interviews. Ice build-up was present on all shelves of the ice cream freezer, causing ice accumulation on ice cream containers. The deep freezer and refrigerator freezer units had boxes of food touching the ceilings, and there was condensation and ice build-up under the fan and on the pipes of the fan in the refrigerator/freezer, resulting in ice formation on multiple boxes of frozen goods and on top of containers of various food items stored underneath. Additionally, temperature logs for the dish machine, freezers, and refrigerators were incomplete for April and May, with no documentation provided for previous months. Further observations revealed that a Human Resources employee entered the kitchen without a hair restraint, and a dietary aide was serving food from the steam table without facial hair covered. The facility's policy required the use of hairnets or caps in food service areas and facial hair to be covered, as well as proper temperature maintenance and food storage practices. These deficiencies were confirmed by the dietary manager and the nursing home administrator during interviews.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal hygiene for seven of twelve residents, as evidenced by missed or insufficient assistance with showers and other personal care activities. Facility policy requires support for activities of daily living (ADLs), including bathing, grooming, and hygiene, but multiple residents reported consistently missing scheduled showers and having difficulty rescheduling. Residents cited reasons given by staff such as short staffing, lack of hot water, prioritization of more dependent residents, and recent power outages. These concerns were repeatedly raised in resident council meetings, with documented complaints about missed showers and lack of assistance with personal care. Clinical record reviews revealed that one resident with a history of stroke, aphasia, and hemiplegia, who required substantial assistance with showers, received only one shower in a month with no refusals documented. Another resident with heart failure and mild cognitive impairment missed eight out of fourteen scheduled showers, and reported that missed showers were not rescheduled. The Nursing Home Administrator confirmed the failure to provide necessary services to maintain grooming and personal hygiene. These findings were supported by resident interviews, documentation reviews, and meeting minutes.
Unqualified Professional Directed Activities Program
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional as required by federal regulations. Review of the Activities Director's job description indicated the need for a qualified therapeutic recreation specialist or activities professional to oversee the program. However, documentation showed that the individual assigned to this role held a Bachelor of Arts in Parks and Recreation Management but lacked the necessary certification, work history, or eligibility to be considered a qualified therapeutic recreation specialist or activities professional. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not have a qualified professional directing the activities program during the specified period.
Failure to Provide Ostomy Care per Professional Standards
Penalty
Summary
The facility failed to provide ostomy care and services consistent with professional standards of practice for three out of four residents reviewed. For one resident with a urostomy, the clinical record lacked physician orders specifying urostomy care, the frequency of care, or the supplies needed. The care plan also did not include interventions for urostomy care, such as the specific type and size of appliance to be used. The resident reported that her daughter was providing the ostomy care using supplies brought from home, and that staff had only provided care once, which was not satisfactory to her. Another resident with an ileostomy had documentation indicating the presence of the ileostomy and that care was provided, but there were no physician orders for ileostomy care, nor was there a care plan detailing the specific type and size of appliance required. For a third resident with a colostomy, while physician orders and the care plan included general instructions for colostomy care and monitoring, they did not specify the type and size of appliance needed for proper care and maintenance. Interviews with LPNs revealed that nurses are responsible for ostomy care and typically gather supplies from the resident's room or central supply, but there was no indication that care was being provided according to individualized physician orders or care plans specifying appliance details. The Nursing Home Administrator confirmed that the facility did not provide ostomy care and services consistent with professional standards for these residents.
Failure to Maintain Infection Control in Ostomy Care and Medication Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances. For one resident with a colostomy, an LPN removed a soiled colostomy bag, discarded it, and then, unable to find a suitable replacement, retrieved the soiled bag from the garbage, rinsed it with mouthwash, wiped it with bleach, and reapplied it to the resident. The LPN did not seek assistance or check the supply room for the correct supplies, despite multiple sizes of ostomy supplies being available in stock. The resident reported feeling nervous about the incident, although no pain or discomfort was noted. Additionally, during medication administration, an LPN placed a used glucometer on top of the medication cart and then stored it in the cart drawer without cleaning it. Observations of two medication carts revealed that multiple insulin pens were stored unbagged together, posing a risk for cross-contamination. Staff interviews confirmed that proper infection control procedures were not consistently followed, and the Director of Nursing acknowledged the failure to prevent cross-contamination and ensure proper infection control practices.
Failure to Timely Respond to Call Bells
Penalty
Summary
The facility failed to ensure that call bells were answered in a timely manner for five of eight residents, as required by facility policy. According to resident group interviews, multiple residents reported consistently waiting thirty minutes or longer for their call lights to be answered, and some residents indicated they would press their own call lights to help their roommates receive assistance. Review of resident council meeting minutes over several months documented ongoing complaints about delayed call light response times and staff not answering call lights. The Nursing Home Administrator confirmed that the facility did not meet the requirement for timely call bell response for these residents.
Failure to Investigate and Prevent Neglect in Ostomy Care
Penalty
Summary
A deficiency occurred when a resident with a colostomy, who was cognitively intact and had diagnoses including diverticulitis and muscle weakness, reported that an LPN removed their colostomy bag and, upon being unable to find a replacement that fit, retrieved the soiled bag from the garbage, cleaned it with mouthwash and bleach, and reapplied it. The resident stated this did not cause pain or discomfort but made them feel nervous. The facility's policy required prompt and thorough investigation of any reports of abuse or neglect, and specified procedures for ostomy care, including the use of clean supplies and proper documentation. The LPN involved admitted to not seeking assistance or checking the supply room for the correct ostomy bag size, instead reusing the soiled bag after cleaning it with mouthwash and bleach. The LPN also stated that the resident's call bell had been ringing for about an hour before the situation was addressed, and that she did not gather supplies before entering the room. Other LPNs interviewed confirmed that standard practice is to gather new supplies before performing ostomy care and that nurses, not aides, are responsible for this care. During an observation, it was confirmed that multiple sizes of ostomy supplies were available in stock at the facility. The Director of Nursing acknowledged that the facility failed to ensure the resident was free from neglect in this instance. The incident was not promptly and thoroughly investigated as required by facility policy, and the actions taken by the LPN did not align with established procedures for ostomy care.
Failure to Investigate Allegation of Neglect Related to Colostomy Care
Penalty
Summary
The facility failed to fully investigate an allegation of neglect involving a resident with a colostomy. The resident, who was cognitively intact and had diagnoses including diverticulitis, colostomy, and muscle weakness, reported that an LPN removed his colostomy bag, discarded it, and when unable to find a replacement, retrieved the soiled bag from the garbage, cleaned it with bleach and mouthwash, and reapplied it. The resident stated this did not cause pain or discomfort but made him feel nervous. The LPN confirmed she did not seek assistance or look for the correct supplies and used mouthwash and bleach to clean the soiled bag before reapplying it. Despite the resident's grievance, the facility did not document an investigation into the neglect concern in the progress notes or submit a report indicating an investigation was completed. The Director of Nursing confirmed that the incident was not recognized as neglect, no investigation was conducted, and no witness statements were obtained from the resident, other residents, or staff members. This failure to investigate was not in accordance with the facility's policy, which requires prompt and thorough investigation of all abuse and neglect allegations.
Failure to Develop Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to develop baseline care plans for two residents within the required timeframe following their admission. One resident was admitted with a colostomy, but the clinical record did not show that a baseline care plan addressing colostomy care was created. Another resident was admitted with dementia and high blood pressure and had a physician order for continuous enteral feeding via a nasogastric tube, yet the clinical record did not indicate that a baseline care plan for tube feeding was developed. The facility's policy requires a baseline plan of care to be reviewed with the resident or their representative within 72 hours of admission, but this was not completed for these residents. The Nursing Home Administrator confirmed the failure to develop the required baseline care plans within 24 hours as mandated.
Failure to Address Legal Blindness in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's identified needs. Specifically, for one resident with diagnoses including legal blindness, anemia, and spinal stenosis, the care plan did not include goals or interventions related to the resident's legal blindness. This omission was confirmed through review of the resident's clinical record and care plan, as well as during an interview with the Nursing Home Administrator, who acknowledged that the care plan did not reflect the resident's blindness diagnosis. The facility's policy requires a person-centered care plan to be developed within seven days of admission, but this was not completed for the resident in question.
Failure to Update Care Plans to Reflect Residents' Current Needs
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents to reflect their current needs as required by policy. For one resident with diagnoses including Alzheimer's dementia, diabetes, and weakness, the care plan did not reflect the resident's discharge from hospice services, despite a physician order indicating the change in status. For another resident with dementia, bipolar disorder, and a history of repeated falls, the care plan did not document the resident's bed being placed against the wall per the request of the resident and family for comfort, as observed during a room inspection. These deficiencies were confirmed through clinical record review, staff interviews, and direct observation. The facility's policy requires that care plans be developed and updated to reflect individualized needs and changes in resident status, but in these cases, the care plans were not revised to account for significant changes in the residents' conditions and preferences.
Failure to Follow Physician Orders for Enteral Feeding
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders for a resident receiving enteral feedings. The resident, who had a history of stroke affecting her dominant side, cognitive communication deficit, dysphagia, and required gastrostomy feedings, was admitted with orders to receive Osmolite 1.5 at 100cc/hr for 12 hours nightly, with Jevity 1.5 to be used only if Osmolite was unavailable. Clinical record review confirmed these orders, and facility policy required staff to verify and follow physician orders for enteral feedings. During observations on two consecutive mornings, the resident was found to be receiving Jevity 1.5, despite Osmolite being available in the facility. This was confirmed in an interview with the Nursing Home Administrator, who acknowledged that the facility did not follow the physician's order. The deficiency was cited under relevant Pennsylvania Codes for management, resident care policies, and nursing services.
Failure to Ensure Competent Ostomy Care by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide care in accordance with the resident's care plan and individual needs, specifically in the case of one resident with a colostomy. The resident, who had a history of colostomy status, diverticulitis with perforation, and chronic pain, required regular colostomy care as outlined in both physician orders and the care plan. The facility's policy for ostomy care included specific steps to maintain cleanliness, skin integrity, and infection prevention, as well as proper documentation and use of appropriate supplies. On one occasion, an agency LPN removed the resident's colostomy bag, discarded it, and was unable to find a replacement that fit from the supplies available in the resident's room. Instead of seeking assistance or obtaining the correct supplies from the supply room, the LPN retrieved the soiled bag from the garbage, cleaned the outside with bleach and the inside with mouthwash, and reapplied it to the resident's stoma. The LPN did not consult the RN supervisor on duty and relied on previous experience as a nurse aide for this method, which was not in accordance with facility policy or standard practice. The nurse aide on duty also indicated a lack of competency in emptying a colostomy bag and did not assist with the care. Interviews with other LPNs confirmed that proper procedure involves gathering new supplies before entering the room and that nurses, not nurse aides, are responsible for ostomy care. The Director of Nursing acknowledged that the LPN did not follow standards of practice for colostomy care. The incident demonstrated a failure to ensure that staff were competent and followed established procedures for ostomy care, as required by facility policy and resident care plans.
Failure to Timely Assess Enteral Feeding and Approve Menus
Penalty
Summary
The facility failed to assess a resident receiving enteral feedings in a timely manner and did not ensure that the planned menu for all four weeks of the menu cycle was approved by the Registered Dietitian. Review of the Registered Dietitian's job description indicated responsibilities for implementing, coordinating, and evaluating medical nutrition therapy, as well as developing dietary assessments and plans of care for residents. However, facility documentation revealed that the corporate Registered Dietitian had not signed or approved the menus currently in use. Additionally, it was confirmed through staff interview that the facility did not follow the approved diet spreadsheets and did not offer residents an alternate menu selection of similar nutritional value.
Failure to Document Ileostomy Care in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate documentation for one of seven residents, specifically regarding the care of a resident with an ileostomy. The facility's policy required documentation in the nurse's progress notes to reflect changes in status, events, or notifications, as well as a narrative entry for episodes such as admission and response to treatment. The resident's admission record noted the presence of an ileostomy and that care was provided, but the physician's order did not include ileostomy care, and the plan of care lacked details about the specific type and size of appliance to be used. Although an LPN reported providing care for the resident's ostomy several times, there was no documentation in the clinical progress notes indicating that ileostomy care had been provided on any date or shift during the specified period. The Nursing Home Administrator confirmed the failure to accurately and appropriately chart the resident's care as required.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required training on effective communication to two of ten direct care staff members, specifically two nurse aides. Review of facility policy, personnel in-service training records, and staff interviews revealed that these two employees did not have documented in-service education on effective communication from their respective hire dates through the date of the survey. This deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of training for these staff members.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to two of ten reviewed staff members. Specifically, Nurse Aide Employee E12, hired on 6/1/22, and Nurse Aide Employee E13, hired on 11/11/22, did not have documented QAPI in-service education from their respective hire dates through 5/6/25. This was confirmed through a review of facility documents, training records, and interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of QAPI training for these staff members. The deficiency was cited under 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(c) Staff development.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required Behavioral Health training to two staff members, specifically a nurse aide and an LPN, as evidenced by a review of facility documents and training records. The nurse aide, hired on 6/1/22, and the LPN, hired on 11/11/22, did not have documented in-service education on Behavioral Health from their respective hire dates through 5/6/25. This deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of Behavioral Health training for these staff members. The findings reference noncompliance with state regulations regarding staff development and management responsibilities.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
Greenery Center for Rehab and Nursing was found to be non-compliant with federal and state regulations due to a failure in providing adequate supervision to residents at risk of elopement. The facility's policy on 'Wandering and Elopements' was not effectively implemented, leading to an incident where a resident with severe cognitive impairment and a history of wandering exited the facility unsupervised. This resident, who had been admitted with diagnoses including dementia and anxiety disorder, was identified as high risk for elopement but was not adequately monitored, resulting in her being found outside the facility in cold weather conditions. The deficiency was further compounded by the removal of the resident's Wanderguard, an electronic monitoring bracelet, shortly after it was initially placed. The decision to remove the Wanderguard was made by the Director of Nursing, who instructed the LPN to do so based on the resident not exhibiting exit-seeking behaviors at that time. However, documentation did not reflect any ongoing monitoring interventions, and the resident subsequently eloped from the facility. The incident highlighted a lack of consistent supervision and monitoring, particularly during times when the front desk was unstaffed. Additionally, the facility failed to maintain an accurate and complete 'Elopement Book' at the front desk, which should have contained information and photographs of all residents at risk for elopement. Several residents identified as at risk did not have their information properly documented, and the facility's door alarm system was found to be ineffective, as the doors could be pushed open despite the alarm sounding. These lapses in protocol and supervision contributed to the immediate jeopardy situation identified by the surveyors.
Plan Of Correction
Resident R1 has discharged from the facility on 1/22/2025. Residents with current orders for a wander guard will have been reevaluated/assessed and their care plans have been updated to reflect the most up to date information regarding their risk for elopement. The DON or Designee began education with nursing staff, including contracted staff, on the facility elopement management policy, where to locate the elopement binder and how to identify exit seeking behaviors. The DON or Designee will educate new nursing staff to the facility prior to the start of their first shift. The NHA or Designee began immediately educating dietary, housekeeping, management, laundry, and other staff on the elopement policy and where to locate the elopement binders. The NHA and or designee will educate new facility staff prior to the start of their first shift. Automated Entry Systems did an assessment of the doors on 1/28/2025 and are working to find a compatible part to lock the doors to prevent residents at risk of elopement from getting out of the front doors. The maintenance director is working with Life Safety as well to ensure the plan for the doors adheres to Life Safety Code. The DON or Designee will audit elopement assessments upon admission to review and develop appropriate interventions with the interdisciplinary team in the clinical morning meeting. The DON or designee will audit two residents weekly to identify those at risk for elopement for four weeks. Staff will attend Directed In-Services with AAE Consulting Services, Inc on 2/13/2025. Staff that do not attend the training in person on this date will have to watch the training provided prior to the start of their next shift. Until the facility can determine that the doors adhere to Life Safety Code, a staff member will remain to be assigned to monitor the doors 24/7 until the doors are adjusted for safety of residents. The NHA was notified the MD of the IJ on 1/28/2025. Findings will be submitted to QAPI for review and further action if needed.
Removal Plan
- Elopement reassessments of all residents currently identified as elopement risk.
- Complete whole house education with all staff on elopement policy/procedure, the elopement binder, and appropriate supervision.
- The door vendor was onsite to evaluate doors for repairs.
- All residents upon admission will be evaluated for elopement risk and interventions. The DON will audit two residents weekly for appropriate interventions.
Failure to Notify Physicians of High Blood Sugar Levels
Penalty
Summary
The facility failed to notify physicians of increased capillary blood glucose (CBG) levels for three residents, leading to a deficiency in care. The facility's policy required physician notification for glucose levels greater than 300 mg/dl in diabetic patients not using sliding-scale insulin, and greater than 450 mg/dl for those using sliding-scale insulin. Resident R2, who was not on sliding-scale insulin, had CBG levels exceeding 300 mg/dl on multiple occasions, yet there was no record of physician notification. Similarly, Residents R3 and R4, both on sliding-scale insulin, had CBG levels exceeding 450 mg/dl without physician notification, despite orders to call the doctor for such levels. Interviews with nursing staff revealed inconsistencies in understanding the facility's policy for notifying physicians of abnormal blood sugar levels. LPN Employee E1 believed the notification threshold was 200 mg/dl, while RN Employee E2 and LPN Employee E3 cited 400 mg/dl as the threshold. The Nursing Home Administrator confirmed the failure to notify physicians as required. This deficiency was identified under several Pennsylvania Code regulations, including management, resident rights, resident care policies, and nursing services.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure that medications were properly stored and disposed of in two of three medication carts, specifically the North One and North Three medication carts. During an observation, it was noted that the North One medication cart was unlocked with a drawer visibly open, and contained several opened and partially used medications, including Pataday eye drops, artificial tears, and Lumigan ophthalmic solution, some of which were undated. Similarly, the North Three medication cart contained opened and partially used medications such as Lantus and Novolog insulin pens, a Lantus vial, and Tobradex and Latanoprost ophthalmic solutions, many of which were undated or lacked proper labeling. The facility's policy on medication storage, dated 8/9/24, requires that medications be stored securely and properly, with outdated or deteriorated medications removed and disposed of according to procedures. The policy also mandates that nurses place a date opened sticker on medications and enter the date opened and new expiration date if applicable. However, the observations revealed non-compliance with these procedures, as several medications were found without proper labeling or dating, indicating a failure to adhere to the facility's medication storage policy. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to dispose of out-of-date medications in the specified medication carts.
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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