Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenfield Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and weakness had a care plan intervention for a wander guard with checks for placement and function every shift, but facility records over several months showed no documentation that these checks were performed and no corresponding physician order. Manufacturer guidelines requiring daily testing and documentation of the wander guard were not followed, and the resident’s MDS indicated no wander/elopement alarm in use despite the care plan. Only one wandering risk assessment was completed shortly after admission, with no further assessments as required by facility policy. An elopement investigation later documented that the wander guard alarm sounded and the resident was found outside, and the DON confirmed that elopement interventions and reassessments had not been monitored or documented as required.
Surveyors determined that the facility did not maintain complete and accurate shower documentation for a resident with Alzheimer’s disease, GERD, and weakness. Facility policy required documentation to be completed at the time of service and to be accurate, relevant, and complete, and the resident’s care plan called for showers twice weekly. Review of the point-of-care shower task for one month showed multiple scheduled shower days with no documentation that the showers were provided. The DON confirmed that the clinical record was incomplete and that showers were expected to be completed as scheduled and documented when done.
Failure to Provide Required Two-Person Hoyer Lift Transfer: A resident who was dependent for transfers was moved with a Hoyer lift by only one NA instead of the required two-person assist. The resident fell from the lift, sustained a scalp laceration, abrasions, bruising, a pelvic fracture, a wrist ligament tear, hypotension, and shock, and was hospitalized after the incident.
A resident who was dependent for transfers and required a Hoyer lift with a 2-person assist was transferred by only one NA, contrary to facility policy. The resident fell from the lift, sustained a scalp laceration, pelvic fracture, and wrist injury, and was sent to the ER with subsequent hospital notes describing critical illness, hypotension, shock, and other complications.
A facility failed to keep physician code status orders consistent with POLST documents for two residents and failed to document that four other residents and/or their representatives were given written advance directive information or assistance with formulating advance directives. One resident with COPD, bipolar disorder, and anxiety had a Full Code order but a DNR POLST, while another resident with HTN, weakness, and hyperlipidemia had a DNR order but a Full Code POLST; an RN confirmed the inconsistencies and the missing documentation.
Physician orders were not signed and dated at required visits for seven residents. The residents had diagnoses including COPD, DM, HTN, CKD, hyperlipidemia, chronic respiratory failure, OSA, stroke history, bipolar disorder, anxiety, and GERD. RN confirmed the orders were not reviewed and signed within the required 60-day timeframe after the initial period.
Physician visits were not completed at the required intervals for three residents. One resident with CKD, DM, and HTN, another with chronic respiratory failure, heart disease with HF, COPD, and malnutrition, and a third with GERD, HTN, and hyperlipidemia lacked evidence of required face-to-face MD visits in the clinical record. The RN confirmed the missing visit documentation and stated residents should be seen every 30 days for the first 90 days after admission and every 60 days thereafter.
Insufficient nursing staffing and delayed call bell response led to repeated resident complaints and a resident injury during a mechanical lift transfer. Several residents reported waiting more than 30 minutes for call bells to be answered, and one resident said a delayed response led to soiling an incontinence brief. Staffing records also showed direct resident care hours below the required minimum and NA shortages on a day when a resident fell out of a mechanical lift during a transfer.
Expired insulin vials were found in two medication carts during observation. Facility policy and manufacturer guidance required opened Humalog and Lantus vials to be discarded after 28 days, but an LPN confirmed that one open Lantus vial in the West North cart and three expired vials in the East North cart remained in use past the allowed timeframe.
Failure to maintain EBP was identified for residents with indwelling devices, chronic wounds, or infections on two units. Observations found no EBP signage or PPE available, and staff interviews confirmed that gowns and gloves were not maintained and were not used during high-contact care for these residents, despite facility policy requiring EBP for device care, wound care, and other high-contact activities.
Failure to Provide Showers per Resident Preference: Two residents did not receive baths/showers according to their stated preferences or facility schedule. One resident with CKD, DM, and HTN reported not having a shower in weeks despite being scheduled for showers, and the documentation showed missed or N/A entries. Another resident with GERD, HTN, and hyperlipidemia had no bath/shower schedule documented and reported only being washed up in the bathroom instead of receiving the showers desired.
Incomplete investigation of a resident fall from a Hoyer lift. A resident with a history of head injury, fractures, and shock was found on the floor after being dropped from a Hoyer lift, sustaining a scalp laceration, abrasions, bruising, and bleeding. Hospital records showed the resident remained critically ill with serious injuries, while the facility’s incident report and chart lacked a complete timely investigation, including witness statements, fall assessment, and documentation of physician and family notification.
The facility did not ensure proper disposal of garbage and refuse for one dumpster. The dumpster was observed open without a full lid, leaving garbage exposed, and the Dietary Manager confirmed the lid should be closed and tightly fitted when not in use to prevent insects and rodents from being attracted to the area.
Incomplete Fall Documentation After Hoyer Lift Incident: A resident with a hx of shock, closed head injury, and prior fall-related injuries was dropped from a Hoyer lift during a transfer and sent to the ER. The chart lacked nursing progress notes and other required post-fall documentation, including the resident assessment, fall assessment, and notification of the MD and family. Hospital records described a scalp laceration with bleeding, pelvic fracture, ligament tear, hypotension, shock, V-tach, and hypokalemia after the fall.
Failure to Implement Antibiotic Stewardship Program: The facility did not develop and implement its antibiotic stewardship program as part of the infection prevention and control program. The written policy called for antibiotic use protocols, monitoring of antibiotic starts, an antibiotic timeout within 48 to 72 hours, feedback reports, annual education, and documentation by the IP, but no evidence of the program was provided for review, and the NHA confirmed the failure.
The facility failed to follow its own policies requiring written bed-hold notices and communication of necessary clinical information during hospital transfers. Four residents with complex conditions, including COPD, epilepsy, stroke, encephalopathy, schizoaffective disorder, GERD, paraplegia, hypertension, and anxiety, were transferred to the hospital, but their records did not show that written bed-hold information was provided to them or their representatives, nor that required clinical details (such as practitioner contact, representative information, advance directives, care needs, special precautions, and care plan goals) were sent to the receiving providers. The NHA and DON confirmed these omissions in the residents’ records.
Surveyors found that the facility did not initiate required baseline care plans within 48 hours of admission or provide written summaries and order summaries to three newly admitted residents and/or their representatives. These residents had complex conditions including CKD, post-CVA hemiplegia, DM, COPD, morbid obesity, hyperlipidemia, OSA, severe protein-calorie malnutrition, dysphagia, gastroparesis, and diverticulitis. Review of clinical records showed no evidence of baseline care plans or written summaries covering physician orders, medications, dietary orders, or therapy services, and the NHA confirmed that such documentation and resident/representative copies were not in place, contrary to facility policy and state regulations.
Surveyors found that the facility did not transcribe or administer ordered Aspirin and Vitamin D3 from hospital discharge instructions for a resident with COPD, epilepsy, and prior stroke, and there was no documentation that the attending physician was notified of or changed these orders. The same resident had a PRN order for Clonazepam 0.5 mg for seizures, yet during documented seizure episodes, including prolonged seizure-like activity after a fall with complaints of headache, lightheadedness, and dizziness, the MAR and progress notes showed no evidence that the PRN Clonazepam was given as ordered.
The facility did not maintain complete and accurate documentation of showers for four residents with conditions such as diabetes, hypertension, hypothyroidism, and chronic respiratory failure. Required shower records and Point of Care documentation were missing for multiple scheduled dates, and the DON confirmed the deficiency during interview.
Physicians did not consistently review, sign, and date orders during required visits for five residents with conditions such as diabetes, COPD, and traumatic brain injury. Clinical records showed missing or overdue physician signatures and dates, and the NHA confirmed that these reviews were past due, contrary to facility policy and regulatory requirements.
The QAPI committee failed to correct a recurring deficiency involving physician orders not being consistently signed and dated during visits, despite previous plans and audits intended to address the issue. This resulted in repeated citations for noncompliance with regulations requiring physician review and signature of orders.
Two residents with complex medical histories experienced multiple falls, but the facility failed to document key information in their medical records, including details of the falls, assessments, treatments, notifications, and follow-up actions, as required by policy and regulations.
The facility did not meet the required minimum nurse aide staffing ratios across multiple shifts over a 21-day period. The day shift failed to meet the ratio of one NA per 10 residents on ten occasions, the evening shift did not meet the ratio of one NA per 11 residents on 17 occasions, and the overnight shift fell short of the ratio of one NA per 15 residents on five occasions. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to meet the required LPN staffing ratios across multiple shifts over a 21-day period. The deficiencies were identified through a review of staffing documents, revealing that the facility did not have the minimum number of LPNs on the day, evening, and overnight shifts on several occasions. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for 14 out of 21 days reviewed. Staffing documents showed that on several occasions, the nursing care hours per patient day (PPD) were below the required minimum, with the lowest being 2.84 PPD. This was confirmed by the Nursing Home Administrator.
A facility failed to ensure physicians signed and dated orders and progress notes during required visits for six residents. Facility policy requires timely physician documentation, but records showed significant lapses, confirmed by the DON. This deficiency violates specific state regulations regarding licensee responsibility, management, and medical records.
A resident's dignity and privacy were compromised when their bedside commode was not emptied in a timely manner, despite multiple staff entries into the room. The resident, with mobility issues, expressed discomfort about the situation, which was confirmed by the Nursing Home Administrator.
The facility did not ensure nurse aides completed the required 12-hour in-service training for the year, as records from January 2024 to January 2025 were incomplete. The Nursing Home Administrator confirmed the lack of evidence for the mandatory trainings, indicating non-compliance with federal regulations on nurse aide competence.
A facility failed to include a reconciliation of pre-discharge and post-discharge medications in a resident's discharge summary. The resident, with a history of osteoarthritis, pancytopenia, and aortic valve stenosis, was discharged home without the necessary documentation, as confirmed by the Regional Clinical Consultant.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call bells and inadequate care for residents. Residents reported waiting 30 minutes to over an hour for assistance, with staff often distracted by personal phone use. Observations confirmed these delays, with one resident left incontinent for 30 minutes and another found in a soaked bed. These issues highlight the facility's inability to meet residents' needs and ensure their well-being.
The facility failed to ensure the availability and use of dentures for two residents, leading to a deficiency in dental services. One resident's upper dentures went missing without investigation or replacement, while another resident's upper partial denture was lost shortly after admission, with no follow-up action taken by the facility.
Two residents at Greenfield Healthcare and Rehabilitation Center did not receive baths or showers according to their preferences, as required by regulations. One resident, with multiple chronic conditions, reported missing scheduled baths for several weeks, while another, with neurological impairments, had not received a shower since mid-January. Documentation confirmed these lapses, and the Regional Clinical Consultant acknowledged the failure to meet residents' bathing preferences.
A facility failed to notify a resident's representative of significant changes in the resident's condition, including a hospital transfer due to catheter issues and a new medication order. The resident had multiple diagnoses, including multiple sclerosis and Alzheimer's disease. The oversight was confirmed by the Regional Clinical Consultant.
A resident with a history of nicotine dependence and respiratory issues was found smoking in their bathroom, despite the facility's no-smoking policy. The facility failed to document a smoking assessment or consistently enforce the policy, as evidenced by multiple confiscations of cigarettes and lighters by the NHA. Staff interviews confirmed the presence of smoke, but there was no consistent supervision to prevent the resident from smoking.
The facility failed to provide proper respiratory care for two residents. One resident's CPAP machine was not maintained or connected to the oxygen concentrator, and there was no care plan or physician's order for its use. Another resident's oxygen concentrator filter was not cleaned as required, being covered in a thick layer of substance. Staff interviews confirmed these deficiencies, indicating a lack of proper equipment management and care.
A facility failed to maintain complete and accurate dialysis communication records for a resident with end-stage renal disease. The resident's dialysis book was missing several forms, and existing forms were outdated, as confirmed by the Nursing Home Administrator. The resident reported that facility staff did not regularly check the dialysis book, relying instead on dialysis center staff.
A resident with Parkinson's disease and other conditions experienced a delay in receiving pain medication due to a communication breakdown between the facility and the pharmacy. Despite having an order for Norco, the resident had to wait several hours for the medication, which was available in the emergency stock. The delay was confirmed by the resident and the Nursing Home Administrator.
A multi-dose vial of Flucelvax in the East Wing medication room was found opened without an open date, violating facility policy and CDC guidelines. The Assistant DON confirmed the issue, and it was noted that the vial should be discarded 28 days after opening, as per CDC and pharmacy guidance.
A resident with an indwelling catheter was observed multiple times with the catheter drainage bag lying uncovered on the floor, contrary to the facility's policy requiring it to be covered and off the floor. The resident, with multiple medical conditions, indicated staff were responsible for emptying the bag. Interviews with an LPN and the Nursing Home Administrator confirmed the improper handling, acknowledging the need for the bag to be covered and off the floor to prevent infection and maintain dignity.
The facility failed to post daily nursing staffing information as required by regulations. Observations over three days showed the absence of posted staffing data, which was confirmed by the Nursing Home Administrator. This deficiency violated the requirement to display nurse staffing data in a clear and accessible manner.
A facility failed to provide written postmortem procedures to all personnel, as evidenced by the absence of documentation in a resident's clinical record. The resident, with multiple diagnoses including metabolic encephalopathy and severe malnutrition, ceased to breathe, but the clinical record lacked postmortem procedure documentation. This was confirmed by a Regional Clinical Consultant.
The facility failed to include a recapitulation of stay in the medical records of two residents. One resident, admitted with multiple serious conditions, ceased to breathe without a summary of their stay documented. Another resident, with conditions like diabetic ulcers and end-stage renal disease, was transferred to a hospital without returning, yet their record also lacked a stay summary. The absence of these summaries was confirmed by the Regional Clinical Consultant.
The facility failed to document the disposition of medications for three residents, violating its own policy. One resident ceased to breathe, another was discharged home, and a third did not return from the hospital, yet their medication records lacked necessary details such as the name of the staff disposing of the medication, the resident's name, medication name, strength, prescription number, quantity, method of disposition, and the date of disposition.
The facility failed to meet the required nurse aide staffing ratios, with significant shortages observed over several days. No NAs were present during certain shifts, despite a resident census of 77 to 79. The Nursing Home Administrator confirmed the inability to meet the minimum staffing requirements.
The facility failed to meet the required LPN staffing levels across day, evening, and overnight shifts over a 21-day period. No LPNs were present on several shifts when multiple were required for a census of 77 to 79 residents. The Nursing Home Administrator confirmed the inability to meet the minimum LPN ratio requirements.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on several occasions. Staffing documents revealed significant shortfalls in care hours, with the lowest being 0.30 PPD. The Nursing Home Administrator confirmed the inability to provide complete staffing information, resulting in the failure to meet the required care hours.
The facility did not provide documentation for the annual 90-minute battery back-up lighting test, as required for emergency lighting. An interview with the maintenance supervisor confirmed the absence of evidence for the test.
The facility failed to maintain battery-operated smoke detectors, as they could not provide documentation for monthly testing and semi-annual battery replacement. The maintenance supervisor confirmed these deficiencies during the survey.
The facility did not perform annual testing and inspection of non-hospital grade electrical receptacles in resident sleeping rooms. Required tests, including visual inspection and polarity checks, were not conducted within the 12-month interval. The maintenance supervisor confirmed the lack of documentation for these tests.
The facility failed to maintain documentation for essential maintenance of the emergency generator, including weekly inspections, monthly load runs, and annual fuel samples. This deficiency was confirmed by the maintenance supervisor, indicating non-compliance with NFPA standards.
Failure to Assess and Monitor Elopement Risk and Wander Guard Use
Penalty
Summary
The deficiency involves the facility’s failure to assess and monitor a resident identified as at risk for elopement in accordance with its elopement and wandering policy and the manufacturer’s guidelines for a wander guard device. The facility’s policy required residents to be assessed for elopement risk upon admission and throughout their stay, and for charge nurses and unit managers to monitor interventions and document responses. Manufacturer guidelines for the wander guard required testing each signaling device before use and then daily, with results recorded in the resident’s record. The resident, admitted with diagnoses including Alzheimer’s disease, GERD, and weakness, had a care plan for elopement that included use of a wander guard with placement and function checks every shift. However, the treatment administration records for several consecutive months showed no documentation that the wander guard was checked for placement or function, and the physician orders contained no order for a wander guard during that period. An elopement investigation documented that on a specific date the wander guard alarm was sounding and the resident was found outside the facility. The resident’s MDS assessment indicated that a wander/elopement alarm was not used, despite the care plan intervention for a wander guard. The wandering risk assessment for the resident was completed only once shortly after admission, and the clinical record lacked evidence of any subsequent wander risk assessments throughout the stay, contrary to facility policy requiring ongoing assessment. In an interview, the DON confirmed that the clinical record did not show monitoring of elopement interventions, that wander risk assessments were not completed throughout the resident’s stay, and that the wander guard should have been checked every shift.
Incomplete Shower Documentation in Medical Record
Penalty
Summary
Surveyors found that the facility failed to maintain complete and accurate documentation of showers for one resident. Facility policy titled "Documentation in Medical Record" dated 1/16/26 stated that documentation shall be completed at the time of service and shall be accurate, relevant, and complete. The resident, admitted on 12/10/24 with diagnoses including Alzheimer’s disease, GERD, and weakness, had a shower task in the point-of-care system indicating showers were to be provided every Monday and Friday. Review of the resident’s shower task for April 2026 showed missing documentation that showers were provided on 4/3/26, 4/10/26, 4/13/26, 4/17/26, and 4/20/26. In an interview on 4/22/26 at 12:45 p.m., the DON confirmed that the clinical record lacked complete shower documentation and that showers should be completed as scheduled and documented when done. This deficiency was cited under 28 Pa. Code 211.5(f)(ix) Medical Records and 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Provide Required Two-Person Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure Resident R6 was free from neglect during a transfer with a Hoyer lift. Facility policy required two staff members for mechanical lift transfers, and the resident’s MDS and task order reviews identified the resident as dependent for transfers. On 9/29/25, the resident was found on the floor after being transferred by Nursing Assistant Employee E6 with only one person assisting, instead of the required two-person assist. The incident report documented that the resident stated he/she hit his/her head and was observed with a laceration to the back of the head, abrasions to the right arm, and bruising to the left hand, with bleeding from the head and arm wounds. The resident’s clinical record also noted that he/she was sent to the ER that day after the fall. Hospital documentation stated the resident remained critically ill after being dropped from a Hoyer lift approximately five feet and was being treated for scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension, and shock requiring vasopressors and fluid. Resident R6’s record showed diagnoses including shock, closed head injury, fall, left scapho-lunate dissociation, and closed fracture dislocation of the left pubis symphysis with diastasis. During interview, the resident stated he/she was lifted up and fell out of the lift, hit the floor hard, and received a terrible gash to the back of the head, and reported that only one NA assisted during the transfer. The NHA confirmed that the resident was dependent for transfers, required a Hoyer lift and two-person assist, and that the one-person transfer on 9/29/25 resulted in the fall and substantial harm.
Improper Hoyer Lift Transfer Resulted in Resident Injury
Penalty
Summary
The facility failed to ensure essential resident safety measures were followed during a transfer for Resident R6, who was documented as dependent for transfers and required a mechanical lift with a two-person assist. Facility policy stated that two staff members must be used when transferring residents with a mechanical lift, and the resident’s MDS and task order summaries identified the resident as dependent for transfers. On 9/29/25, the resident was found on the floor after a transfer incident involving a Hoyer lift used by only one nursing assistant. The incident report documented that staff entered the resident’s room and observed the resident on the floor, with the resident stating he/she hit his/her head. The assessment noted a laceration to the back of the head, abrasions to the right arm, bruising to the left hand, and bleeding from the head and arm wounds. The resident was sent to the emergency room later that day, and the clinical record did not contain additional progress notes related to the fall. Hospital documentation stated the resident remained critically ill after being dropped from a Hoyer lift approximately five feet. The hospital notes identified treatment for a scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension, shock requiring vasopressors and fluid, ventricular tachycardia, and hypokalemia. The Nursing Home Administrator confirmed that the resident was transferred by a single staff member despite requiring a Hoyer lift and two-person assist, and that this transfer resulted in the resident’s fall and substantial harm.
Inconsistent Code Status Orders and Missing Advance Directive Documentation
Penalty
Summary
The facility failed to ensure physician orders and residents’ POLST documents were consistent and failed to ensure that residents and/or their representatives were provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding life-sustaining treatment for six of 20 residents reviewed. Facility policy stated that the facility would adhere to residents’ rights to formulate advance directives and follow policy regarding a resident’s right to request and formulate an Advance Directive/POLST. Resident R1, admitted with COPD, bipolar disorder, and generalized anxiety disorder, had a physician order for Full Code while the POLST indicated DNR. Resident R30, admitted with hypertension, weakness, and hyperlipidemia, had a physician order for DNR while the POLST indicated Full Code. Resident R5, with diagnoses including post-surgical digestive system care, C. difficile enterocolitis, convulsions, and atrial fibrillation; Resident R7, with hypertension, COPD, and cerebral infarction; Resident R50, with protein calorie malnutrition, iron deficiency, and major depressive disorder; and Resident R62, with GERD, hypertension, and hyperlipidemia, each had clinical records lacking evidence that they and/or their representatives were provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding life-sustaining treatment. During interview, an RN confirmed that R1 and R30’s physician orders and POLST were not consistent and that the records for R5, R7, R50, and R62 lacked evidence of their advance directive wishes.
Physician Orders Not Signed and Dated at Required Visits
Penalty
Summary
The facility failed to ensure that the physician signed and dated all orders during required visits for seven of 20 residents reviewed: R1, R7, R8, R10, R11, R30, and R62. Facility policy stated that the physician should see the resident within 30 days of admission, see the resident at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter, and sign and date all orders. Clinical record review showed that each of the seven residents had physician orders signed and dated on 10/30/25 and then not again until 1/26/26, which was beyond the required 60-day timeframe. The residents involved had diagnoses including COPD, bipolar disorder, anxiety disorder, hypertension, cerebral infarction, chronic kidney disease, diabetes, hyperlipidemia, chronic respiratory failure, obstructive sleep apnea, weakness, and GERD. During an interview on 1/26/26 at 2:35 p.m., RN E2 confirmed that physician orders for these residents were not reviewed and signed by the physician in the required 60 days and stated that physician orders should be reviewed and signed with every physician visit on admission, then every 30 days for the first 90 days, and then every 60 days.
Physician Visit Schedule Not Met for Three Residents
Penalty
Summary
The facility failed to ensure that physician visits were completed at the required intervals for three residents. Review of the facility policy stated that the physician should see a resident within 30 days of admission, then at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with each visit documented in a signed and dated progress note. Clinical record review showed that Resident R8, admitted with chronic kidney disease, diabetes, and hypertension, lacked evidence of physician visits every 60 days as required. During interview, R8 stated he/she had not seen the physician face to face since admission. Resident R11, admitted with chronic respiratory failure, hypertensive heart disease with heart failure, COPD, and protein calorie malnutrition, also lacked evidence of physician visits every 60 days as required. The record included a progress note related to medication refusal, but the resident stated he/she had not seen the physician and no physician had assessed him/her while at the facility. Resident R62, admitted with GERD, hypertension, and hyperlipidemia, lacked evidence of physician visits every 30 days during the first 90 days after admission. An RN confirmed that the records for R8, R11, and R62 lacked evidence of physician visits as required and stated that residents should be seen every 30 days for the first 90 days and every 60 days thereafter.
Insufficient Nursing Staffing and Delayed Call Bell Response
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet residents’ needs, as shown by repeated resident complaints about delayed call bell response and by staffing shortages documented on a day when a resident fell during a mechanical lift transfer. During a Resident Council meeting, residents stated that call bells were not answered in a timely manner, with several reporting waits of greater than 30 minutes. One resident reported that a call bell response took hours on 1/14/26, resulting in soiling an incontinence brief. Another resident reported needing staff to close the bathroom door after independently transferring to the toilet, but said staff took a very long time to respond, leaving the resident sitting on the toilet with the door open while the roommate could see. Resident Council minutes from November 2025 through January 2026 showed ongoing concerns that call bells were not being answered promptly, and a grievance log documented a complaint about call bell response time. Review of staffing records for 9/29/25 showed that direct resident care hours were 3.16 PPD, below the required 3.2 minimum, and day shift NA staffing was short with 6.59 NA worked when 7.0 were required for a census of 70 residents. On that same day, a two-person mechanical lift transfer involving a resident resulted in the resident falling out of the lift and being injured. The NHA confirmed that the facility did not have sufficient nursing staff and services to promote residents’ physical and mental well-being and meet resident needs, and confirmed that nursing hours for that day were below state mandated levels.
Expired Insulin Vials Found in Medication Carts
Penalty
Summary
The facility failed to ensure expired medications were discarded in a timely manner in two medication carts reviewed, the West North Cart and the East North Cart. Facility policy titled "Labeling of Medications and Biologicals" dated 11/01/25 stated that all opened or accessed multi-use vials should be discarded within 28 days unless the manufacturer specifies a shorter or longer date. Manufacturer guidelines for Humalog insulin and Lantus insulin both stated that opened vials and pre-filled pens should be discarded after 28 days. During observation on 1/24/26 at 4:15 p.m., the West North medication cart contained an open vial of Lantus with an open date of 12/26/25, which was expired, and this was witnessed and confirmed by LPN Employee E5. During observation on 1/24/26 at 4:29 p.m., the East North medication cart contained an opened Humalog vial with an open date of 12/18/25 and two open vials of Lantus, one opened on 12/21/25 and the other on 12/26/25, all of which were expired, and this was witnessed and confirmed by LPN Employee E4.
Failure to Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for residents on the East Unit and the [NAME] Unit. Facility policy stated that EBP are to be used to prevent transmission of multidrug-resistant organisms and that gowns and gloves should be available immediately near or outside resident rooms, with alcohol-based hand rub accessible in every resident room and trash cans positioned for PPE disposal. The policy also identified high-contact care activities such as dressing, bathing, transferring, hygiene, linen changes, toileting, device care, and wound care as situations where EBP may be needed. Observations on 1/23/26 and 1/24/26 found no educational signage or PPE maintained for EBP for residents with indwelling devices, wounds, or infections throughout the facility. During interviews on 1/25/26, an RN confirmed that no EBPs were maintained throughout the facility for residents with indwelling devices, chronic wounds, or infections, and staff did not use PPE during high-contact care for these residents. An LPN confirmed the same conditions on the East Unit and on the [NAME] Unit. The Nursing Home Administrator also confirmed the facility lacked signage and PPE readily available when providing care for residents with indwelling devices, chronic wounds, or infections who should have EBP maintained.
Failure to Provide Showers per Resident Preference
Penalty
Summary
The facility failed to provide baths/showers according to resident preference for two residents. Facility policy stated that residents would be provided showers as requested or according to the facility schedule, and that showers were to be documented in point of care if refused, given, or if a bed bath was given. For one resident, the clinical record showed a scheduled bath/shower routine on Tuesday and Friday daylight shift, but documentation for the review period included one date with no shower documented and multiple dates marked as N/A. During interview, the resident stated that he/she had not received a shower in weeks and would like a shower instead of being washed up in the bathroom. For the second resident, the clinical record did not contain evidence of a bath/shower schedule. During interview, the resident stated that he/she had not taken a shower in a long time, was washed up in the bathroom in the morning, and would like to get a shower every other day if not every day. The resident had diagnoses including GERD, HTN, and hyperlipidemia. During interview, the Nursing Home Administrator confirmed that the residents' records lacked evidence of showers or baths being given as the residents' preferences and confirmed that showers and baths should be given per resident request or schedule.
Incomplete investigation of a resident fall from a Hoyer lift
Penalty
Summary
The facility failed to complete a thorough investigation related to a fall involving a resident who had diagnoses including shock, closed head injury, fall, left scapho-lunate dissociation, and closed fracture dislocation of the left pubis symphysis with diastasis. Facility policy required assessment of the resident, completion of a post-fall assessment and incident report, notification of the physician and family, review and update of the care plan, documentation of all assessments and actions, and witness statements when injury occurred. The resident’s record showed an incident report describing that the resident was found on the floor, stated he/she hit his/her head, and had a laceration to the back of the head, abrasions to the right arm, and bruising to the left hand, with bleeding noted. The record also included a note that the resident was sent to the ER after the fall, but lacked further progress notes related to the fall. Hospital documentation indicated the resident had been dropped from a Hoyer lift approximately five feet and remained critically ill, with treatment for scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension, shock requiring vasopressors and fluids, ventricular tachycardia, and hypokalemia. The resident later stated that only one NA assisted during the transfer and that he/she was lifted up and fell out of the lift, hitting the floor hard and sustaining a gash to the back of the head. The NHA confirmed that the incident report and investigation were incomplete and lacked evidence of a timely complete investigation, including witness statements, nursing response to the fall from the Hoyer lift, response to the staff member using the Hoyer lift independently, fall assessment, and notification of the physician and family at the time of the fall.
Open Dumpster Left Garbage Exposed
Penalty
Summary
The facility did not ensure garbage and refuse were disposed of properly for one dumpster. On observation, the dumpster was open and did not have a full lid to secure the top, leaving garbage freely exposed. During interview, the Dietary Manager confirmed the dumpster top was open without a lid and stated the dumpster lids should always be closed and tightly fitted when not in use to prevent insects and rodents from being attracted to the area.
Incomplete Fall Documentation After Hoyer Lift Incident
Penalty
Summary
The facility failed to maintain accurate and complete documentation related to a resident’s fall. Resident R6 was admitted with diagnoses including shock, closed head injury, fall, left scapho-lunate dissociation, and closed fracture dislocation of the left pubis symphysis with diastasis. The resident’s record included a nutritional progress note stating the resident was sent to the ER after a fall, but the clinical record lacked further progress notes related to the fall on 9/29/25. Facility policy required assessment of the resident, completion of a post-fall assessment, incident report, physician and family notification, care plan review, documentation of all assessments and actions, and witness statements when injury occurred. Additional facility documentation showed a corrective action form for a nursing assistant who did not follow transfer orders and used a Hoyer lift alone instead of with two-person assist. Hospital records for the resident indicated the resident had been dropped from a Hoyer lift approximately five feet and was critically ill with a scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension, shock requiring vasopressors and fluids, ventricular tachycardia, and hypokalemia. During interview, the resident stated being lifted up and falling out of the lift, hitting the floor hard and sustaining a gash to the back of the head, and stated only one nursing assistant assisted during the transfer. The NHA confirmed the record lacked evidence of the nursing response, including assessment, fall assessment, and notification of the physician and family.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program as part of its infection prevention and control program. Review of the facility policy showed that the program was to include antibiotic use protocols, monitoring of antibiotic initiation, an antibiotic timeout within 48 to 72 hours of therapy, feedback on antibiotic use data, annual education, and documentation maintained by the Infection Preventionist. The policy also identified the Medical Director, DON, and Consultant Pharmacist as program leaders, with support from the Administrator and other governing officials. From 1/24/26 through 1/27/26, no evidence of the facility’s antibiotic stewardship program was provided for review. During an interview on 1/26/26 at 3:30 p.m., the Nursing Home Administrator confirmed that the facility failed to implement the antibiotic stewardship program as part of the facility’s overall infection prevention and control program.
Failure to Provide Bed-Hold Notices and Transfer Clinical Information
Penalty
Summary
The deficiency involves the facility’s failure to provide residents and/or their representatives with written notice of the facility’s bed-hold policy at the time of, or within 24 hours of, transfer to the hospital, as required by facility policy. The Bed-Hold Notice policy dated 1/7/26 states that written information regarding bed-hold practices, including how long a bed can be held during a leave of absence and the cost per day, must be provided well in advance and at the time of transfer, or within 24 hours in the case of an emergency transfer. The policy also requires documentation of multiple attempts to reach the resident representative if notification cannot be completed, and that a signed and dated copy of the bed-hold notice be kept in the resident’s record for all residents regardless of payment source. For four residents reviewed for hospitalization, the clinical records lacked evidence that this written bed-hold information was provided upon transfer or within the required timeframe. The facility also failed to ensure that necessary clinical information was communicated to the receiving health care provider when residents were transferred to the hospital, contrary to its Transfer and Discharge policy dated 1/7/26. That policy requires that, for any transfer to another provider, the receiving provider must be given contact information for the practitioner responsible for the resident’s care, resident representative information, advance directives, information necessary to meet the resident’s needs, special instructions or precautions for ongoing care, and care plan goals. For each of the four residents reviewed, the clinical records did not contain evidence that this required information was communicated to the hospital at the time of transfer. Resident R2, admitted with COPD, epilepsy, and a history of stroke, was transferred to the hospital on 12/8/25, but the record lacked documentation of necessary clinical information being sent and lacked evidence of bed-hold policy notice. Resident R5, with epilepsy, GERD, and paraplegia, was transferred on 12/26/25 with the same documentation gaps. Resident R6, admitted with encephalopathy, hypertension, and anxiety, was transferred on 11/24/25 without documented communication of necessary clinical information or provision of bed-hold notice. Resident R7, with schizoaffective disorder, epilepsy, and GERD, had transfers documented on 11/5/25, 11/17/25, and 12/29/25, and in each instance the record lacked evidence of required clinical information being communicated to the hospital and lacked evidence of bed-hold policy notice. During a telephone interview, the Nursing Home Administrator and DON confirmed that the records for all four residents did not contain this required documentation.
Failure to Initiate and Provide Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to initiate baseline care plans within 48 hours of admission and to provide written summaries of those plans, including order summaries, to three residents and/or their representatives. Facility policy dated 11/01/25 required development and implementation of a baseline care plan for each resident within 48 hours of admission, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations when applicable. The policy also required that a written summary of the baseline care plan be provided to the resident and/or representative in an understandable language, including initial goals, a summary of medications and dietary instructions, and any services and treatments to be administered by facility personnel. Clinical record review showed that one resident admitted with chronic kidney disease, hemiplegia/hemiparesis following cerebral infarction, diabetes mellitus, and COPD did not have evidence of an initiated baseline care plan or a provided written summary. A second resident admitted with morbid obesity, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea similarly lacked documentation of a baseline care plan and provision of the required written summary including physician orders, medications, dietary orders, and therapy services. A third resident admitted with severe protein-calorie malnutrition, dysphagia, gastroparesis, and diverticulitis also had no evidence of a baseline care plan or written summary being initiated or provided. During interview, the Nursing Home Administrator confirmed there was no evidence that baseline care plans or copies including physician orders, medications, dietary orders, and therapy services were initiated or provided for these three residents and/or their representatives, in violation of 28 Pa. Code 211.10(c) and 211.12(d)(1)(3)(5).
Failure to Implement Admission Medication Orders and Administer PRN Seizure Medication
Penalty
Summary
The facility failed to transcribe and implement hospital discharge medication orders at admission for one resident and failed to follow physician orders for seizure medication administration. Facility policy stated that written transfer orders signed and dated by the current attending physician on the date of admission should be implemented without further validation, and that any unsigned or differently dated orders, or those signed by another physician, must be verified with the attending physician and documented. The resident, admitted with COPD, epilepsy, and a history of stroke, had hospital discharge instructions dated 3/26/25 that included Aspirin 81 mg by mouth every morning and Cholecalciferol (Vitamin D3) 50 mcg by mouth daily. Between admission and 1/7/26, the facility’s physician orders and MARs showed no evidence that these medications were ordered or administered, and admission progress notes lacked documentation that the resident’s physician was notified or made any changes to the hospital discharge instructions. The same resident’s hospital discharge instructions also included Clonazepam 0.5 mg every 24 hours PRN for seizures, and the facility’s physician orders reflected this PRN seizure medication. On 12/8/25, progress notes documented that the nurse was called to the resident’s room after the resident was found on the floor, complained of headache, lightheadedness, and dizziness, and was assisted to bed and placed on a bedpan. When staff returned, the resident was observed having seizure-like activity with an approximate 13-minute seizure, followed by another seizure of about one minute. The clinical record progress notes and MAR lacked evidence that Clonazepam 0.5 mg PRN was administered during these seizure events, despite the existing physician order for PRN seizure management.
Incomplete Documentation of Resident Showers
Penalty
Summary
The facility failed to maintain complete and accurate documentation of showers for four residents, as required by facility policy and professional standards. Review of the facility's shower schedule and clinical records revealed missing shower documentation for all four residents on multiple scheduled dates. Specifically, shower sheets were absent for several dates for each resident, and there were no corresponding tasks identified in the Point of Care system where nursing assistants are expected to document showers. The residents involved had various medical conditions, including diabetes, hypertension, hypothyroidism, chronic respiratory failure with hypoxia, and obstructive sleep apnea. During an interview, the Director of Nursing confirmed that the clinical records for these residents did not contain complete documentation regarding showers and acknowledged that showers should be performed and documented according to the established schedule. The lack of documentation was found to be inconsistent with the facility's policy and regulatory requirements for maintaining medical records and nursing services.
Physician Orders Not Reviewed or Signed as Required
Penalty
Summary
The facility failed to ensure that physicians reviewed, signed, and dated all orders during each required visit for five residents. According to facility policy, physicians are required to see residents within 30 days of admission, every 30 days for the first 90 days, and at least every 60 days thereafter, signing and dating all orders at each visit. However, clinical record reviews for five residents with various diagnoses, including hyperlipidemia, bipolar disorder, traumatic brain injury, hypertension, COPD, and diabetes, showed missing or overdue physician signatures and dates on orders. For some residents, there was no evidence of the last time the physician reviewed, signed, and dated the orders, while for others, the last documented review was several months prior to the survey. During an interview, the Nursing Home Administrator confirmed that physician orders for these residents were past due for review and signature, acknowledging that the facility's practice did not align with its policy or regulatory requirements. The deficiency was cited under relevant state codes for licensee responsibility, management, and medical records.
Repeated Failure to Ensure Physician Orders Are Signed and Dated
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct a recurring deficiency related to physician orders. Despite having a policy in place for systematic analysis and sustained improvement, and a previous plan of correction that included quality assurance systems and audits, the facility did not ensure that physicians consistently signed and dated all orders during their visits. This deficiency was previously identified in a complaint survey and was cited again in the current survey, indicating that the QAPI committee did not effectively implement or monitor their corrective actions. During the current survey, it was found that the QAPI committee did not maintain compliance with regulations requiring physician orders to be reviewed, signed, and dated by the physician as mandated. The Nursing Home Administrator confirmed that the committee failed to ensure ongoing compliance with these requirements, resulting in a repeated citation under F711 and relevant state codes. No specific patient details or medical histories were provided in the report.
Failure to Maintain Complete and Accurate Medical Records Following Resident Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by both facility policy and state regulations. For one resident with Parkinson's disease, schizophrenia, anxiety, and generalized muscle weakness, there was no documentation in the clinical record regarding a fall that occurred during personal hygiene care, including the absence of vital signs, assessment of injuries, first aid or treatments administered, notifications to the family and physician, completion of a falls risk assessment, and the signature and title of the person recording the data. The only note present indicated that the family was informed the resident was at the hospital, but did not document the cause for the transfer. Another resident with a history of stroke, muscle weakness, abnormal gait, and previous falls experienced multiple falls, but the clinical record lacked documentation for each incident. Specifically, there was no record of the falls themselves, vital signs, assessments, treatments, notifications, or completion of falls risk assessments. Additionally, there was a lack of documentation regarding the cause of a skin tear and the presence of dressings for injuries, despite the resident disclosing a fall to a provider. The DON confirmed the absence of required documentation for both residents' falls.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios across multiple shifts over a 21-day period. Specifically, the day shift did not meet the required ratio of one NA per 10 residents on ten occasions, the evening shift failed to meet the ratio of one NA per 11 residents on 17 occasions, and the overnight shift did not meet the ratio of one NA per 15 residents on five occasions. These deficiencies were identified through a review of the facility's nursing staffing documents and confirmed by the Nursing Home Administrator during an interview. The staffing shortages were documented with specific census numbers and the number of NAs that worked versus the number required. For example, on 3/31/25, with a census of 88 residents, only 6.90 NAs worked during the day shift when 8.80 were required. Similarly, on 4/18/25, during the overnight shift, only 3.81 NAs worked when 5.60 were required for a census of 84 residents. These consistent staffing shortages indicate a failure to comply with the mandated staffing ratios, impacting the facility's ability to provide adequate care to its residents.
Plan Of Correction
The facility must maintain the minimum of one Nurse Aide for every 10 residents during the day shift, one Nurse Aide for every 11 residents during the evening, and one Nurse Aide per 15 residents overnight. To ensure that these regulatory requirements are met, the following action plan will be implemented: The scheduler was reeducated on 4/28/25 to ensure that they understand the regulatory staffing requirements for nursing assistants. The nursing assistant schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff will be contacted to cover any open shifts to ensure ratios are met. Bonuses will be offered as an incentive for employees to cover shifts. In addition, the facility utilizes a recruitment company to attract additional staff. An audit will be developed and completed by the Director of Nursing or Designee 3 times per week for 4 weeks, then 2 times a week for 3 weeks, then weekly ongoing, to ensure that nursing assistant ratios are met for all shifts. The audit will be monitored by the Administrator. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented.
LPN Staffing Shortages Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) across multiple shifts over a 21-day period. Specifically, the facility did not have the minimum number of LPNs on the day shift for one day, on the evening shift for six days, and on the overnight shift for thirteen days. The staffing shortages were identified through a review of the facility's nursing staffing documents and confirmed by the Nursing Home Administrator during an interview. The deficiencies were noted with specific census numbers and the corresponding number of LPNs required versus those that actually worked. For instance, on the day shift of April 15, 2025, with a census of 84 residents, only 3.31 LPNs worked when 3.36 were required. Similar discrepancies were observed on various dates for the evening and overnight shifts, with the facility consistently failing to meet the mandated LPN-to-resident ratios. These findings indicate a pattern of insufficient staffing that was acknowledged by the facility's administration.
Plan Of Correction
The facility must maintain the minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift, one Licensed Practical Nurse (LPN) per 30 residents for evening shift and one LPN for every 40 residents on the overnight shift. To ensure that these regulatory requirements are met, the following action plan will be implemented: The scheduler was reeducated 4/28/25 to ensure that they understand the regulatory staffing requirements for Licensed Practical Nurses. The LPN schedule will be reviewed by the scheduler and Director of Nursing to ensure that LPN ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff will be contacted to cover any open shifts to ensure ratios are met. The Director of Nursing and or the Scheduler are responsible for handling call offs on the off shifts and weekends. Bonuses will be offered as an incentive for employees to cover shifts. In addition, the facility utilizes a recruitment company to attract additional staff. An audit will be developed and completed by the Director of Nursing or Designee 3 times a week for 4 weeks, then 2 times a week for 3 weeks, then weekly ongoing, to ensure that LPN ratios are met for the day, evening and overnight shifts. The audit will be monitored by the Administrator or Designee. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for 14 out of 21 days reviewed. The deficiency was identified through a review of nursing staffing documents and confirmed by the Nursing Home Administrator during a telephone interview. On specific dates, the facility's nursing care hours per patient day (PPD) fell below the required minimum, with the lowest recorded at 2.84 PPD. This shortfall in nursing care hours was documented on multiple occasions, indicating a consistent failure to meet the mandated staffing levels over the reviewed period.
Plan Of Correction
The facility must maintain the minimum of 3.20 general nursing care hours for each 24-hour period. To ensure that this regulatory requirement is met, the following will be implemented: The scheduler was reeducated on 4/28/25 to ensure that they understand the regulatory requirement for general nursing care hours. The nursing schedule will be reviewed by the scheduler and Director of Nursing to ensure that general nursing care hours are met prior to posting of the schedule. In the event of call-offs by staff, all other staff will be contacted to cover any open shifts to ensure that general nursing care hours are met. Bonuses will be offered as an incentive for employees to cover shifts. In addition, the facility utilizes a recruitment company to attract additional staff. An audit will be developed and completed by the Director of Nursing or Designee 3 times per week for 4 weeks, then 2 times a week for 3 weeks, then weekly ongoing, to ensure that the minimum of 3.20 general nursing care hours for a 24-hour period is met. The audit will be monitored by the Administrator. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented.
Physician Documentation Lapses in LTC Facility
Penalty
Summary
The facility failed to ensure that physicians signed and dated all orders and wrote, dated, and signed progress notes during each required visit for six of seven residents reviewed. The facility policy mandates that physicians see residents within 30 days of initial admission, at least once every 30 days for the first 90 days, and at least every 60 days thereafter. However, the clinical records for Residents R1, R3, R4, R5, R6, and R7 lacked evidence of compliance with these requirements. For instance, Resident R4's last documented physician interaction was on 9/25/24, and Resident R5 had a draft progress note dated 8/21/24 that remained unsigned. The Director of Nursing confirmed during an interview that the physician progress notes and orders for these residents were overdue. The facility's policy clearly states the necessity for timely documentation by physicians, yet the records reviewed showed significant lapses. This deficiency was identified under the regulations 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(b)(1)(3), and 28 Pa. Code 211.5(f)(i), which pertain to the responsibility of the licensee, management, and medical records, respectively.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident, identified as Resident R2, by not ensuring the timely emptying of a bedside commode. Resident R2, who has diagnoses including anxiety, difficulty walking, and hypertension, had a physician's order and care plan intervention for a bedside commode to be available at all times. Observations on multiple occasions revealed that the commode was not emptied and contained a yellow and brown substance, with the lid on the floor, creating a strong foul odor in the room. Resident R2 expressed that the commode had not been emptied since the previous night and that several staff members had entered the room without addressing the issue. The resident was unable to empty the commode due to mobility issues and expressed discomfort about eating lunch in the presence of the unemptied commode. The Nursing Home Administrator confirmed the observations and acknowledged that the commode should be emptied after each use, indicating a failure to adhere to the facility's policy on promoting and maintaining resident dignity.
Incomplete Nurse Aide In-Service Training Documentation
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12-hour mandatory in-service training for the year. A review of the facility's employee in-service training records revealed incomplete documentation of the mandatory training for nurse aides from January 2024 through January 2025. During an interview, the Nursing Home Administrator confirmed the absence of evidence for the completion of the required in-service trainings. This deficiency indicates non-compliance with the federal regulation §483.95(g) concerning the continuing competence of nurse aides, including training in dementia management, resident abuse prevention, and care for cognitively impaired individuals.
Plan Of Correction
Review of Nurse Aides personnel files was conducted to ensure that they have 12 hour in servicing. All nurse aides that did not have evidence of completing the 12 hour in-service will receive 12 hour in-service training by the Director of Nursing/Designee and completed by 3/28/25. Audit will be conducted weekly to ensure nurse aides requiring the 12-hour training within the last year have received the training for 4 weeks, then monthly audit will be of 5 nurse aides per week by the administrator/designee. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Reconcile Medications in Discharge Summary
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for Resident CR82, which is a requirement under §483.21(c)(2). Specifically, the discharge summary did not include a reconciliation of all pre-discharge medications with the resident's post-discharge medications. This omission was identified during a review of the clinical record and confirmed by the Regional Clinical Consultant. The resident, who was admitted on 10/05/24, had a medical history that included osteoarthritis of the left knee, pancytopenia, a history of falling, and aortic valve stenosis. The resident was discharged to home on 10/31/24, but the necessary medication reconciliation was not documented in the discharge summary. The facility's policy, dated 11/01/24, mandates that a discharge summary be provided to the receiving care provider at the time of discharge. However, for Resident CR82, this policy was not adhered to, as evidenced by the lack of documentation in the clinical record. The deficiency was confirmed during an interview with the Regional Clinical Consultant, who acknowledged the absence of the required medication reconciliation in the discharge summary.
Plan Of Correction
For residents CR82, a discharge summary was completed. All residents of the facility for the last 30 days will be reviewed, and a discharge summary will be completed. Licensed staff will be educated on discharge summary and the reconciliation of medications at the time of discharge and disposition of medications by the Director of Nursing/Designee. An audit will be completed by the Director of Nursing/Designee for all residents who are being discharged from the facility prior to the resident being discharged to ensure that the resident's clinical record contains a discharge summary that includes a reconciliation of the resident's post-discharge medications. The audit will be weekly for 4 weeks, then monthly ongoing. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Insufficient Nursing Staff Leads to Delayed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely response to call bells and adequate care for residents, as evidenced by interviews and observations. During a Resident Council meeting, seven alert and oriented residents expressed concerns about delayed responses to call bells, with some residents waiting 30 minutes to over an hour for assistance. Residents reported staff being distracted by personal phone use, including using earbuds and talking on the phone while performing care. One resident mentioned being left wet for extended periods and not receiving assistance to get out of bed on weekends, leading to discomfort and prolonged periods in a wheelchair. Observations confirmed these concerns, with a call light in Room 233 remaining unanswered for 30 minutes, during which the Director of Nursing was notified. The resident in that room was found incontinent and at risk for skin breakdown. Additionally, during a dressing change, another resident was found lying in bed with a soaked adult undergarment and bed sheets, indicating prolonged exposure to urine. The LPN confirmed the resident had been in this state for an extended period. These findings highlight the facility's failure to maintain sufficient nursing staff to meet the residents' needs and ensure their well-being.
Plan Of Correction
All nursing staff are to be educated on resident rights, the cell phone policy, use of earbuds and answering call bells timely, by the Director of Nursing/Designee. Administrator will meet with the President/Vice President of Resident Council monthly to ask if they can attend Resident Council, to discuss if staff is answering call lights, completing incontinence care, and refraining from the use of cell phones and earbuds. Results of the discussion will be documented. An audit will be conducted to ensure staff are meeting residents' needs timely by the director of nursing/designee to include answering of call lights, incontinent care, and use of cell phones and earbuds by staff. The audit will be conducted by the DON/Designee by interviewing 3 residents per unit per shift 3 times a week for 4 weeks, weekly for 4 weeks and then 1 time per month ongoing. The audit will be monitored by the Administrator and results will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Ensure Denture Availability for Residents
Penalty
Summary
The facility failed to ensure the proper use and availability of dentures for two residents, leading to a deficiency in dental services. Resident R51, who has multiple sclerosis, Alzheimer's disease, and other conditions, was admitted with upper and lower dentures. Despite a dental evaluation confirming the dentures fit well, the resident later reported missing upper dentures, and the facility had not initiated any investigation or follow-up to replace them. Resident R187, admitted with cerebral infarction and other diagnoses, had an upper partial denture upon admission. The partial went missing shortly after admission, and despite efforts to locate it, including searching the resident's room and garbage, it was not found. The facility did not conduct an investigation or follow-up to replace the missing partial. Interviews with the Nursing Home Administrator confirmed the lack of action taken to address the missing dentures for both residents. The facility's failure to promptly refer residents for dental services or document efforts to ensure adequate nutrition while awaiting replacement dentures contributed to the deficiency.
Plan Of Correction
Resident #51 appointment was made by administrator/designee. Resident #187 is no longer a resident at the facility. All residents were reviewed to ensure that their dental needs are met by the Director of Nursing or designee, which included missing dentures and dental needs. Social Service and nursing staff were educated on the Care of dentures policy and making appointments in a timely manner by the Director of Nursing/designee. An audit will be conducted weekly for 4 weeks and then monthly ongoing to ensure that residents that required dental care to meet their needs, including residents that have missing or ill-fitting dentures, will be addressed as per policy by the Director of Nursing/Designee. Residents will be interviewed weekly by Social Services or designee to ensure dental concerns are being addressed weekly for 4 weeks, then monthly ongoing. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Provide Resident-Preferred Bathing Schedule
Penalty
Summary
Greenfield Healthcare and Rehabilitation Center was found to be non-compliant with the requirements for resident self-determination as outlined in 42 CFR Part 483, Subpart B. The facility failed to provide baths or showers according to the preferences of two residents, R2 and R68, as evidenced by interviews, clinical records, and observations. Resident R2, who has lupus, chronic obstructive pulmonary disease, heart disease, and rheumatoid arthritis, reported not receiving scheduled baths or showers for several weeks, despite being able to manage most of the bathing process independently. Documentation confirmed that Resident R2 missed scheduled baths/showers on multiple occasions. Similarly, Resident R68, who suffers from hemiplegia, hemiparesis, aphasia, muscle weakness, and unsteadiness, also reported not receiving scheduled showers since mid-January. The resident expressed uncertainty about when showers would be provided, as staff reportedly do not give showers on Sundays. Documentation corroborated that Resident R68 missed several scheduled showers. The Regional Clinical Consultant confirmed that the facility did not adhere to the residents' preferences for bathing frequency during the specified period.
Plan Of Correction
Residents #2 and #68 bath/shower preferences were reviewed. All residents' bath/shower preferences were reviewed by the Director of Nursing/designee. Nursing staff will be educated on resident preference and completing showers as per resident preference by the Director of Nursing/designee, and documentation of bath/shower. An audit will be conducted by the Director of Nursing/Designee on residents' bath records and 5 resident interviews to ensure that residents' preferences are being met, and documentation will be reviewed 3 times a week for 4 weeks, then 2 times a week for 4 weeks, then monthly ongoing. The audit will be monitored by the Administrator. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Notify Resident's Representative of Changes
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition in a timely manner. Specifically, the resident, who had multiple diagnoses including multiple sclerosis, Alzheimer's disease, neuromuscular dysfunction of the bladder, and muscle weakness, experienced a change in condition when their suprapubic catheter was leaking and not draining into the Foley bag, accompanied by abdominal pain. The physician was notified, and the resident was sent to the emergency room for evaluation. However, there was no evidence that the resident's representative was informed of this transfer to the hospital. Additionally, the facility did not notify the resident's representative of a new physician's order for Citalopram Hydrobromide, a medication used to treat depression and regulate mood and behavior. The lack of notification was confirmed during an interview with the Regional Clinical Consultant, who acknowledged that the resident's representative should have been informed of both the hospital transfer and the new medication order. This oversight was identified as a deficiency in the facility's compliance with the requirement to notify resident representatives of significant changes in the resident's condition.
Plan Of Correction
Resident # 51 responsible party was notified by the Director of Nursing or designee. Residents were reviewed for the last 30 days for change in condition, change in orders, and/or transfer to ensure resident and/or responsible party were notified by the Director of Nursing/designee. Licensed staff will be educated on timely notification of change in condition, change in orders, and transfer of resident to resident and/or resident representative and notifying appropriately by the Director of Nursing/designee. An audit will be conducted for those residents that have a change in orders or transfer to the hospital to ensure resident and/or resident representatives are notified timely of change in orders or transfer to hospital 5 times a week for 4 weeks, then weekly for 4 weeks, and then ongoing by the Director of Nursing/designee. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Enforce No-Smoking Policy for Resident
Penalty
Summary
The facility failed to ensure safe smoking practices for Resident R50, who has a history of nicotine dependence and other significant health issues, including respiratory failure and chronic obstructive pulmonary disease. Despite the facility's policy prohibiting smoking and the presence of a care plan addressing Resident R50's smoking habits, the resident was caught smoking in their bathroom. The clinical record lacked documentation of a smoking assessment, confiscation of cigarettes and lighters, a signed smoking policy agreement, and a signed admission agreement. Interviews with staff revealed that the Nursing Home Administrator had confiscated cigarettes and lighters from Resident R50 on multiple occasions, and staff had reported smelling smoke in the resident's bathroom. However, there was no evidence of consistent enforcement of the no-smoking policy or adequate supervision to prevent the resident from smoking. The Social Worker confirmed that the no-smoking policy is included in the Resident Handbook, but it appears to be enforced on a case-by-case basis, leading to inconsistencies in policy application.
Plan Of Correction
For residents R50 and all residents who will be admitted to the facility, a notice of non-smoking will be included in the admission packet and alternatives offered as the building is a non-smoking building. Admissions for the last 30 days were reviewed to ensure that they were notified of us being a nonsmoking facility by the administrator/designee. Staff will be educated on non-smoking policy and reporting of smoking material in resident rooms by the Director of Nursing/designee. No other residents have been reported to have smoking materials in their rooms at this time. An audit will be completed by social service/designee and will occur 3 times a week for 4 weeks, 2 times a week for 3 weeks, then weekly for 3 months to ensure that residents have signed the non-smoking policy and that residents with nicotine dependence do not have smoking materials in their possession. Social Service will ask to be able to speak at Resident Council, to provide additional education regarding the facility non-smoking policy. The audit will be monitored by the Administrator and the results of the audit will be presented at the monthly Quality Assurance meeting and recommendations will be implemented.
Deficiencies in Respiratory Equipment Care for Two Residents
Penalty
Summary
The facility failed to maintain proper respiratory care for two residents, leading to deficiencies in care. Resident R27, who was admitted with conditions including obstructive sleep apnea and respiratory failure, did not have a physician's order or care plan for the use of a CPAP machine, which was brought from home. Despite abnormal lab results and a fall that resulted in low oxygen saturation levels, the CPAP machine was not properly utilized or maintained. Observations revealed the CPAP mask and tubing were left on the floor, and the machine was not connected to the oxygen concentrator, indicating a lack of proper equipment management and care. Resident R50, who had diagnoses including chronic obstructive pulmonary disease and dependence on supplemental oxygen, had a physician's order to clean the oxygen concentrator filter and change tubing weekly. However, observations showed that the oxygen concentrator filter was covered in a thick layer of greyish white, fluffy substance, indicating that the equipment was not cleaned as required. This lack of maintenance could potentially compromise the resident's respiratory care. Interviews with staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, confirmed the deficiencies in equipment care and management for both residents. The Nursing Home Administrator also confirmed the absence of necessary documentation and care plans for Resident R27's CPAP machine, highlighting a systemic issue in ensuring proper respiratory care and equipment maintenance in the facility.
Plan Of Correction
Resident #27 orders were updated to contain CPAP and settings, and CPAP machine is functioning. Resident #27 care plan was revised. Resident #50 oxygen concentrator filter was cleaned at time of findings. All residents with CPAPs were reviewed to ensure that they have physician orders and care plans for CPAP machines by the Director of Nursing/Designee. All oxygen concentrators were checked to ensure filters were clean and in working order by the Director of Nursing/Designee. Licensed staff to be educated on CPAP machines and obtaining orders for CPAP machines, updating the care plan, and maintenance of respiratory equipment by the Director of Nursing/Designee. An audit will be conducted by the Director of Nursing/Designee to ensure that all residents with CPAPs were reviewed to ensure that they have physician orders and care plans for CPAP machines and all oxygen concentrators were checked to ensure filters were clean and in working order. The audit will occur 3 times a week for 4 weeks, 2 times a week for 3 weeks then weekly ongoing. The audit will be monitored by the Administrator and findings will be reported to the Quality Assurance Meeting for review and recommendations.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for one resident, identified as Resident R50. The Nursing Home Dialysis Transfer Agreement required the facility to ensure that all necessary information accompanies residents during transfers to the dialysis center and to maintain an interchange of information useful for the care of the residents. However, upon review, it was found that Resident R50's designated dialysis book was missing several Dialysis Communication Forms, and the existing forms were not current. This deficiency was confirmed during an interview with the Nursing Home Administrator. Resident R50, who was admitted to the facility with diagnoses including end-stage renal disease and dependence on dialysis, had a physician's order to attend dialysis sessions three times a week. Despite this, the facility did not ensure that the dialysis communication records were up-to-date and complete. During an interview, Resident R50 mentioned that the facility staff did not regularly check the dialysis book, and it depended on the staff at the dialysis center. This lack of proper documentation and communication could potentially impact the resident's care and treatment continuity.
Plan Of Correction
Resident #50 Dialysis Communication book will be sent with resident on dialysis days. All residents receiving dialysis will have a dialysis communication book go with them to dialysis. Licensed staff will be educated on dialysis communication book and review of documents in book by the Director of Nursing/Designee. Audit for all residents who are on dialysis will be conducted by the Director of Nursing/Designee weekly for 4 weeks to ensure that dialysis and the facility are communicating via communication book and the monthly ongoing findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Delay in Medication Administration for Resident
Penalty
Summary
The facility failed to ensure timely administration of medications for Resident R234, which adversely affected the resident's condition. The resident, who was admitted with diagnoses including Parkinson's disease, cardiac arrhythmias, bipolar disorder, and dysphagia, experienced pain and required medication. On the day of the incident, the resident's family requested pain medication, and the facility nurse discovered that only Tylenol was ordered as needed for pain relief. A new order for Norco was obtained from the Nurse Practitioner and sent to the pharmacy. Despite the new order, the facility nurse was unable to obtain the medication from the emergency medication kit due to the pharmacist's refusal to provide an authorization code. The pharmacist cited that the medication was already packed for delivery and could not be unpacked. This resulted in a delay of several hours before the resident received the first dose of Hydrocodone-Acetaminophen, which was administered late in the evening. Interviews with the resident and the Nursing Home Administrator confirmed the delay in medication administration. The resident expressed discomfort due to the delay, and the NHA acknowledged that the medication was available in the emergency stock and should have been administered earlier. The pharmacist's failure to communicate effectively with the physician for a one-time dose script contributed to the delay, impeding timely pain management for the resident.
Plan Of Correction
R234 received medication from the pharmacy that evening. Residents with medications that require a script were reviewed to ensure medication was on hand by the Director of Nursing/designee. Licensed staff were educated on the use of the emergency medication kit and the process to obtain authorization to pull a controlled substance, as well as who to contact if having difficulty, by the Director of Nursing/Designee. An audit will be conducted on new admissions and 8 other residents 3 times a week for 4 weeks to ensure controlled substances are provided timely by the pharmacy or a pull code was obtained timely by the director of nursing/designee, then weekly for 4 weeks, then monthly ongoing. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Improper Storage and Labeling of Multi-Dose Vaccine Vial
Penalty
Summary
The facility failed to adhere to proper medication storage protocols as evidenced by the observation of a multi-dose vial of Flucelvax in the East Wing medication room. The vial was found to be opened without an accompanying open date, which is a requirement according to the facility's policy on multi-dose vials. This policy mandates that opened vials must be labeled with the date they are opened and discarded according to manufacturer guidelines. The absence of an open date on the vial meant that staff were unable to determine when the vaccine should be discarded, potentially leading to the use of expired medication. During an interview, the Assistant Director of Nursing confirmed the lack of an open date on the vial and acknowledged the inability of staff to ascertain the discard date for the vaccine. Further review of CDC guidelines and information from the dispensing pharmacy indicated that the multi-dose vial should be discarded 28 days after opening. This oversight in labeling and storage practices represents a failure to comply with both federal and state regulations regarding the safe storage and management of medications in the facility.
Plan Of Correction
The Vial was discarded at the time of finding. All medication areas were checked at the time of survey. All licensed staff were educated by the Director of Nursing/designee on multidose vial policy. An audit will be conducted weekly to ensure vaccine vials are dated with date open for 4 weeks then monthly ongoing by the Director of Nursing/designee on all units including med room and carts. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Improper Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received essential care, as evidenced by multiple observations of the catheter drainage bag being improperly handled. The facility's policy on catheter care mandates that drainage bags should be covered and kept off the floor to maintain dignity and prevent infection. However, during observations on three separate occasions, the catheter drainage bag of a resident was found lying uncovered on the floor beside the bed. The resident indicated that the staff would be responsible for emptying the catheter bag, suggesting a lack of adherence to the facility's policy by the staff. The resident involved, identified as having multiple medical conditions including osteomyelitis, paraplegia, and protein-calorie malnutrition, was admitted to the facility in 2020. Interviews with a Licensed Practical Nurse and the Nursing Home Administrator confirmed the improper handling of the catheter drainage bag, acknowledging that it should be covered and maintained off the floor to prevent infection and ensure the resident's dignity. These findings highlight a deficiency in the facility's infection prevention and control practices as outlined in their policy.
Plan Of Correction
Resident #14 bag was removed from the floor at the time of findings. Residents were reviewed to ensure foley catheter bags were properly placed and covered. Nursing staff will be educated on catheter care policy and the need to ensure foley bag and tubing is not touching the floor by the Director of Nursing/Designee. Audit will be conducted 3 times a week for 4 weeks to ensure that foley bags are not on the ground and covered for all residents with foleys, then weekly for 4 weeks, then monthly ongoing by Director of Nursing/designee. Foley bags have built-in covers. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nursing staffing information. Observations on January 28, 29, and 30, 2025, revealed that the daily staffing information was not posted in the facility as required by §483.35(g). This deficiency was confirmed during an interview with the Nursing Home Administrator on January 30, 2025, at 1:10 p.m., who acknowledged that the staffing information was not posted. The facility did not meet the regulatory requirement to post nurse staffing data in a clear and readable format in a prominent place accessible to residents and visitors, as mandated by federal regulations and 28 Pa. Code 211.12 (c) Nursing services.
Plan Of Correction
Nursing staffing was posted at time of finding. Nursing staff were educated on posting of staffing for the day which included the required components by the Director of Nursing/designee. Nurse staffing will be posted by midnight registered nurse in the main common area and each unit. Audit will be conducted 5 times a week by the Director of Nursing/Designee to ensure that the nursing staffing is posted daily by the Director of Nursing/designee. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Lack of Postmortem Procedure Documentation
Penalty
Summary
The facility failed to ensure that written postmortem procedures were available to all personnel, as evidenced by the lack of documentation in the clinical record of Resident CR81. The resident, who was admitted on 10/29/22, had diagnoses including metabolic encephalopathy, bacteremia, urinary tract infection, and severe protein-calorie malnutrition. On 11/15/24, progress notes indicated that Resident CR81 had ceased to breathe, yet the clinical record lacked documentation of the postmortem procedures. This deficiency was confirmed during an interview with the Regional Clinical Consultant on 1/31/25.
Plan Of Correction
Licensed staff will have access to the facility postmortem procedures that are located at the nurse's station and will be educated on postmortem care by the Director of Nursing/Designee. An audit will be conducted by the Director of Nursing/Designee weekly for 4 weeks of all deceased residents who cease to breathe each week to ensure residents receive postmortem care process and appropriate documentation and observations will occur using clinical documentation review and observation and interview of 3 staff members regarding the knowledge of the facility postmortem care policy and then monthly for 4 months. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Missing Recapitulation of Stay in Resident Records
Penalty
Summary
The facility failed to include a recapitulation of stay in the medical records of two residents, CR81 and CR83, as required by regulations. Resident CR81 was admitted on 10/29/22 with diagnoses including metabolic encephalopathy, bactremia, urinary tract infection, and severe protein calorie malnutrition. Progress notes indicated that Resident CR81 ceased to breathe on 11/15/24, yet the clinical record lacked a summary of the resident's stay and course of treatment at the facility. Similarly, Resident CR83 was admitted on 4/10/24 with conditions such as diabetic ulcers, end-stage renal disease, Type 2 Diabetes, and peripheral vascular disease. A progress note dated 11/10/24 indicated that Resident CR83 was transported to an acute hospital for evaluation and did not return to the facility. However, the clinical record for Resident CR83 also lacked a recapitulation of the resident's stay. The Regional Clinical Consultant confirmed the absence of these summaries during an interview.
Plan Of Correction
Resident # 81 and # 83 recapitulation was completed. Residents discharged and or ceased to breathe within the last 15 days will be reviewed for recapitulation of stay and will be completed. The Intradisciplinary team will be educated on the recapitulation of stay that is to be completed for any discharged or ceased to breathe by the Administrator. An audit will be conducted on residents that all discharged or ceased to breathe weekly for 4 weeks then monthly by the Administrator to ensure a recapitulation of stay is completed. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Document Medication Disposition
Penalty
Summary
The facility failed to document the actual disposition of medications for three residents, leading to a deficiency in pharmacy services. The facility's policy on medication disposition requires detailed documentation, including the name of the staff disposing of the medication, the resident's name, medication name, strength, prescription number, quantity, method of disposition, and the date of disposition. However, this documentation was missing for three residents: one who ceased to breathe, another who was discharged to home, and a third who did not return from the hospital. Resident CR81, who had diagnoses including metabolic encephalopathy and severe protein calorie malnutrition, ceased to breathe, but the clinical record lacked documentation of medication disposition. Resident CR82, with conditions such as osteoarthritis and pancytopenia, was discharged to home without proper documentation of medication disposition. Resident CR83, who had diabetic ulcers and end-stage renal disease, was transferred to a hospital and did not return, yet the facility failed to document the disposition of their medications. These omissions were confirmed during an interview with the Regional Clinical Consultant.
Plan Of Correction
Resident CR 81, CR 82, CR 83, we were unable to complete a disposition of medications. Residents that were discharged for the last 30 days were for disposition of medications but unable to complete a disposition of medications. Residents discharged, transferred, or ceased to breathe will have a disposition of medication completed. Licensed staff were educated on the disposition of medication policy by the Director of Nursing/designee. Audit will be conducted for those residents who were discharged, transferred, or ceased to breathe weekly for 4 weeks to ensure that disposition of medication on all residents are completed by the Director of Nursing/Designee then monthly for 2 months. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift. This deficiency was observed over several days, with complete absence of NAs on certain shifts, notably from July 28 to July 31, 2024, where no NAs were present during the day and evening shifts despite a census ranging from 77 to 79 residents. The review of staffing documents revealed consistent shortages across multiple time periods, including late December 2024 and late January 2025. The Nursing Home Administrator confirmed the facility's inability to provide the required staffing information and acknowledged the failure to meet the minimum NA ratio requirements. This deficiency was identified through a review of staffing documents and staff interviews, highlighting a significant lapse in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
The facility must maintain the minimum of one nursing assistant for every 10 residents during the day shift, a minimum of one nursing assistant for every 11 residents for the evening shift, and a minimum of one nursing assistant for every 15 residents for the overnight shift. To ensure that this regulatory requirement is met, the following action plan will be implemented: Education was provided to the scheduler on February 4, 2025, and will be provided to the Director of Nursing by the Administrator to ensure that they understand the regulatory staffing requirements for nursing assistants, as they are the two staff members who cover call-off scheduling on the off shifts and weekends. The nursing assistant schedule will be reviewed by the scheduler and Director of Nursing to ensure that nursing assistant ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that nursing assistant ratios are met for all shifts. The audit will be monitored by the Administrator. Results of the audit will be presented at the Quality Assurance monthly meeting, and recommendations will be implemented. All supporting documents will be kept in the Human Resource office so that they are available for review upon request.
LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across multiple shifts over a 21-day review period. Specifically, the facility did not provide the minimum required number of LPNs per resident on the day, evening, and overnight shifts. On the day shift, there were no LPNs present when 3.08 to 3.16 were required for a census ranging from 77 to 79 residents. Similarly, the evening shift also had no LPNs present when 2.57 to 2.63 were required for the same census range. The overnight shift was also understaffed, with only 1.07 LPNs working when 1.90 to 1.98 were required, and on several nights, no LPNs were present at all. The Nursing Home Administrator confirmed during an interview that the facility was unable to provide the required staffing information and acknowledged the failure to meet the minimum LPN ratio requirements. This deficiency was identified through a review of the facility's nursing staffing documents and staff interviews, highlighting a significant gap in meeting regulatory staffing standards for LPNs during the specified periods.
Plan Of Correction
The facility must maintain the minimum of one LPN for every 25 residents during the day shift, a minimum of one LPN for every 30 residents for the evening shift, and a minimum of one LPN for every 40 residents for the overnight shift. To ensure that this regulatory requirement is met, the following action plan will be implemented: Education was provided to the scheduler on February 4, 2025, and will be presented to the Director of Nursing by the Administrator to ensure that they understand the regulatory staffing requirements for Licensed Practical Nurses. The LPN schedule will be reviewed by the scheduler and Director of Nursing to ensure that LPN ratios are met prior to posting of the schedule. In the event of call-offs by staff, all other staff/agency will be contacted to cover any open shifts to ensure ratios are met. The Assistant Director of Nursing and/or the Scheduler are responsible for handling call-offs on the off shifts and weekends. An audit will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that LPN ratios are met for the day, evening, and overnight shifts. The audit will be monitored by the Administrator or Designee. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented. All supporting documents will be kept in the Human Resource office so that they are available for review upon request.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period for six specific days. The deficiency was identified through a review of nursing staffing documents and confirmed during a staff interview. On the dates in question, the facility's direct resident care hours per patient per day (PPD) were significantly below the required minimum, with the lowest being 0.30 PPD. The Nursing Home Administrator acknowledged the inability to provide all necessary staffing information to accurately calculate PPD for all days, confirming the shortfall in meeting the required care hours.
Plan Of Correction
The facility must maintain a minimum of 3.2 general nursing care hours for each 24-hour period. To ensure that this regulatory requirement is met, the following will be implemented: Education will be provided to the scheduler and Licensed Staff by the Director of Nursing/Designee on February 26, 2025, to ensure that they understand the regulatory requirement for general nursing care hours. Education was also provided to the Director of Nursing by the Administrator. The nursing schedule will be reviewed by the scheduler and Director of Nursing weekly to ensure that general nursing care hours are met prior to posting of the schedule. In the event of call-offs by staff, all other staff as well as those from our sister facilities will be contacted by the scheduler, Director of Nursing, or Licensed staff to cover any open shifts to ensure that general nursing care hours are met. Shift bonuses will also be offered as an incentive for shift pickups. The facility also utilizes a recruitment company to acquire qualified staff. An audit of the daily nursing schedules will be developed and completed by the Director of Nursing or Designee daily for 4 weeks, then 3 times a week for 3 weeks, then 2 times a week for 2 weeks, then weekly ongoing, to ensure that a minimum of 3.20 general nursing care hours for each 24-hour period are met. The audit will be monitored by the Administrator. Results of the audit will be presented at the Quality Assurance monthly meeting and recommendations will be implemented. All supporting documents will be kept in the Human Resource office so that they are available for review upon request.
Failure to Document Emergency Lighting Test
Penalty
Summary
The facility failed to provide documentation of functional tests for battery-powered emergency lighting, which is a requirement for emergency lighting of at least 1-1/2-hour duration as per NFPA 101. During a document review on January 23, 2025, it was revealed that the facility lacked documentation for the annual 90-minute battery back-up lighting test. An interview with the maintenance supervisor confirmed that the facility could not provide evidence that the required annual test had been conducted.
Plan Of Correction
An annual 90-minute battery back-up lighting test was completed January 30, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025 regarding the annual 90-minute battery back-up lighting test. An audit will be completed annually by the Maintenance Director to ensure that the annual 90-minute battery back-up lighting test is completed and will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting and recommendations will be implemented.
Failure to Maintain Battery-Operated Smoke Detectors
Penalty
Summary
The facility failed to maintain smoke detectors for all battery-operated smoke detectors within the facility. During a document review and interview conducted on January 23, 2025, it was revealed that the facility could not provide documentation for the required monthly testing and semi-annual battery replacement of these smoke detectors. The maintenance supervisor confirmed these deficiencies at the time of the survey.
Plan Of Correction
Monthly testing and battery replacements were completed for the facility battery-operated smoke detectors on January 30, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025, regarding the monthly testing and semi-annual battery replacement of the facility battery-operated smoke detectors. An audit will be conducted monthly for 4 months by the Maintenance Director to ensure that the monthly testing and semi-annual battery replacement for the facility battery-operated smoke detectors are completed. The audit will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting and recommendations will be implemented.
Failure to Test Non-Hospital Grade Electrical Receptacles Annually
Penalty
Summary
The facility failed to conduct annual testing and inspection of non-hospital grade electrical receptacles in resident sleeping rooms throughout the entire facility. During a document review on January 23, 2025, it was revealed that these receptacles were not tested at intervals not exceeding 12 months, as required. The testing should have included patient care rooms, a visual inspection of physical integrity, correct polarity of the hot and neutral connections, and ensuring the retention force of the grounding blade was not less than 115g (4 oz). An interview with the maintenance supervisor confirmed the absence of documentation for these tests.
Plan Of Correction
Electrical receptacles in resident care rooms were tested February 4, 2025, for visual inspection of physical integrity, correct polarity of the hot and neutral connections, and retention force of the grounding blade which shall be not less than 115g (4oz.). Education was provided to the Maintenance Director by the Administrator on January 24, 2025, regarding the requirement for electrical receptacles in resident care rooms to be tested for visual inspection of physical integrity, correct polarity of the hot and neutral connections, and retention force of the grounding blade which shall be not less than 115g (4oz.). An audit will be conducted by the Maintenance Director to ensure that all receptacles in resident care rooms were tested for non-hospital grade receptacles at intervals not exceeding 12 months. The audit will be conducted monthly for 4 months and will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting, and recommendations will be implemented.
Failure to Maintain Emergency Generator Documentation
Penalty
Summary
The facility failed to maintain the emergency generator as required, affecting the entire facility. During a document review, it was found that the facility did not provide documentation for several critical tests. These included the weekly visual inspection and battery voltage/electrolyte levels, the monthly 30-minute load run and transfer switch operation, and the annual fuel sample. This lack of documentation indicates that the facility did not perform or record these essential maintenance activities, which are crucial for ensuring the reliability of the emergency power system. An interview with the maintenance supervisor confirmed that the documentation for these tests was unavailable at the time of the survey. This deficiency suggests a lapse in the facility's adherence to the National Fire Protection Association (NFPA) standards, specifically NFPA 101, NFPA 110, and NFPA 111, which outline the requirements for maintaining and testing emergency power systems. The absence of these records raises concerns about the facility's ability to provide a reliable power source in emergencies, potentially impacting the safety and well-being of residents.
Plan Of Correction
Weekly visual inspection and battery voltage/electrolyte levels and a monthly 30-minute load run and transfer switch operation was completed February 5, 2025. The annual fuel sample was taken January 30, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025 regarding the requirement for weekly visual inspection and battery voltage/electrolyte levels and a monthly 30-minute load run and transfer switch operation of the emergency generator, as well as an annual fuel sample. An audit will be conducted by the Maintenance Director to ensure that weekly visual inspection and battery voltage/electrolyte levels and a monthly 30-minute load run and transfer switch operation of the emergency generator, as well as an annual fuel sample is completed. A weekly audit will be conducted for visual inspection and battery voltage/electrolyte levels and a monthly audit will be conducted for 4 months for a 30-minute load run and transfer switch operation of the emergency generator. An annual audit will be conducted to ensure that a fuel sample is completed. These audits will be monitored by the Administrator. Results of the audits will be presented at the quarterly QAPI meeting and recommendations will be implemented.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 162 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Erie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Millcreek Manor | 0.3 mi | ★★★★★ | 5 | 0 |
| Lecom At Presque Isle, Inc | 1.3 mi | ★★★★★ | 17 | 0 |
| Forestview | 1.3 mi | ★★★★★ | 3 | 0 |
| Walnut Creek Nursing And Rehab | 1.6 mi | ★★★★★ | 14 | 0 |
| Lecom At Elmwood Gardens, Llc | 1.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.