Greenfield Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Erie, Pennsylvania.
- Location
- 1521 West 54th Street, Erie, Pennsylvania 16509
- CMS Provider Number
- 395262
- Inspections on file
- 33
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Greenfield Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
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.
The facility did not conduct the required semi-annual kitchen exhaust hood cleaning. A document review revealed missing documentation for the cleaning, and the maintenance supervisor confirmed the oversight.
The facility failed to properly label full and empty medical gas cylinders in the basement oxygen storage room, leading to a deficiency in storage standards. The maintenance supervisor confirmed the issue during an interview.
The facility did not meet NFPA 101 fire drill requirements, failing to document seven out of twelve required drills. Missing documentation included drills from various shifts across the first, second, third, and fourth quarters. The maintenance supervisor confirmed the absence of documentation during the survey.
The facility did not meet NFPA 101 standards for smoke barriers, failing to install and maintain them to form at least two smoke compartments on every sleeping floor with a capacity of 30 or more patient beds. Observations revealed incomplete smoke barriers throughout the building, confirmed by the maintenance supervisor.
The facility failed to maintain electrical safety in the basement laundry room, where an outlet within six feet of washing machines lacked a GFCI receptacle. This deficiency was confirmed by the maintenance supervisor during an interview.
The facility failed to thoroughly investigate injuries of unknown origin for three residents, resulting in incomplete documentation. The investigations lacked critical information such as witness accounts, physician response, and other pertinent details, as confirmed by the DON.
The facility failed to notify the responsible party and/or physician of injuries of unknown origin for two residents, despite policy requirements. One resident with a history of stroke and diabetes had a bruise on the forearm, and another with Parkinson's had a bruise on the hand. The DON confirmed the lack of notification.
The facility failed to maintain complete and accurate documentation for six residents regarding meal intake, medication administration records (MAR), and treatment administration records (TAR). Significant gaps in documentation were found for meal consumption percentages and completion of ordered treatments, compromising the quality of care provided.
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.
Failure to Conduct Semi-Annual Kitchen Exhaust Hood Cleaning
Penalty
Summary
The facility failed to ensure that kitchen exhaust hood cleanings were conducted at the required semi-annual intervals. During a document review on January 23, 2025, it was revealed that there was a lack of documentation indicating that the kitchen exhaust hood cleaning had been performed as required. An interview with the maintenance supervisor on the same day confirmed that the semi-annual kitchen hood cleaning had not been conducted within the required time frame.
Plan Of Correction
A semi-annual kitchen exhaust hood cleaning will be scheduled no later than February 14, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025 regarding kitchen semi-annual exhaust hood cleaning. An audit will be completed no less than quarterly by the Maintenance Director to ensure that the semi-annual kitchen exhaust hood cleaning 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.
Improper Labeling of Medical Gas Cylinders
Penalty
Summary
The facility failed to maintain proper medical gas cylinder storage in the basement oxygen storage room, affecting one of two building levels. During an observation on January 23, 2025, it was noted that the storage room contained both full and empty cylinders that were not properly labeled to identify their gas levels. This lack of proper labeling could lead to confusion and improper handling of the gas cylinders. An interview with the maintenance supervisor on the same day confirmed the deficiency in medical gas cylinder storage. The supervisor acknowledged the issue, indicating that the facility did not adhere to the required standards for labeling and segregating full and empty cylinders. This oversight in maintaining the storage standards for medical gas cylinders was identified as a deficiency by the surveyors.
Plan Of Correction
Full and empty cylinders signage were labeled to identify gas levels in the basement oxygen storage room January 24, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025 regarding the requirement for full and empty cylinders signage to identify gas levels in the basement oxygen storage room. An audit will be conducted by the Maintenance Director to ensure that signage is in the basement oxygen storage room to identify full and empty oxygen cylinders. The audit will be conducted 4 times a week for 4 weeks, 3 times a week for 3 weeks, 2 times a week for 2 weeks then weekly ongoing. The audit will be monitored by the Administrator. Results of the audits will be presented at the quarterly QAPI meeting and recommendations.
Failure to Document Required Fire Drills
Penalty
Summary
The facility failed to meet the National Fire Protection Association (NFPA) 101 fire drill requirements, as evidenced by the absence of documentation for seven out of twelve required fire drills. During a document review and interview conducted on January 23, 2025, it was revealed that the facility did not provide documentation for fire drills on the first shift of the first quarter, the first and second shifts of the second quarter, the third shift of the second quarter, the third shift of the third quarter, and the second and third shifts of the fourth quarter. The maintenance supervisor confirmed the lack of documentation during the survey.
Plan Of Correction
A quarterly fire drill was conducted February 3, 2025 on first shift. Second and third shift drills will be conducted no later than February 27, 2025. The Maintenance Director was educated on January 24, 2025 by the Administrator regarding the requirement that quarterly fire drills must be completed on each shift. A monthly audit will be conducted for 4 months by the Maintenance Director to ensure that quarterly fire drills are completed on each shift and will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting and recommendations will be implemented.
Incomplete Smoke Barriers in Facility
Penalty
Summary
The facility failed to comply with the National Fire Protection Association (NFPA) 101 standards for smoke barriers, as required for existing buildings. Specifically, the facility did not install and maintain smoke barriers to form at least two smoke compartments on every sleeping floor with a capacity of 30 or more patient beds. The smoke compartments should not exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. During an observation on January 23, 2025, at 9:05 a.m., it was revealed that the facility had incomplete smoke barriers throughout the building. This finding was confirmed in an interview with the maintenance supervisor at the same time, who acknowledged the incomplete smoke barriers on both building levels.
Plan Of Correction
The completion of smoke barriers throughout the facility was completed February 2, 2025. The Maintenance Director was educated by the Administrator on January 24, 2025 regarding the requirement for the facility to have complete smoke barriers throughout the building. An audit will be completed monthly for 4 months by the Maintenance Director to ensure that the smoke barriers throughout the facility are complete and will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting and recommendations will be implemented.
Electrical System Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain the protection of electrical systems in wet locations, specifically in the basement laundry room. During an observation, it was noted that an electrical outlet was located within six feet of the washing machines, which is considered a wet location. This outlet was not equipped with a ground fault circuit interrupter (GFCI) receptacle, which is a requirement for safety in such environments. The maintenance supervisor confirmed the deficiency during an interview conducted at the time of the observation.
Plan Of Correction
Ground fault circuit interrupter receptacles were placed in the basement laundry rooms February 4, 2025. Education was provided to the Maintenance Director by the Administrator January 24, 2025 regarding the replacement of an interrupter receptacle to be placed within 6 feet of a water source. An audit will be conducted by the Maintenance Director to ensure that all receptacles that are located within 6 feet of a water source will be GFCI receptacles. The audit will be conducted by the Maintenance Director monthly for 4 months. 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.
Incomplete Investigation of Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for three residents, leading to a deficiency in their investigative processes. The facility's policy on accidents and incidents requires prompt initiation and documentation of investigations, including detailed information such as the date, time, nature of the injury, circumstances, witness accounts, physician notification, family notification, resident's condition, corrective actions, and follow-up. However, for Residents R2, R8, and R9, the investigations were incomplete, lacking critical information such as witness accounts, physician response, and other pertinent details. Resident R2, with a history of stroke and requiring extensive assistance, was found with a bruise on the forearm, but the investigation lacked comprehensive documentation. Resident R8, with traumatic brain injury and paraplegia, had a bruise on the wrist, yet the investigation was missing essential details. Similarly, Resident R9, with a history of stroke and Parkinson's Disease, had a bruise on the hand, but the investigation did not include necessary information. The Director of Nursing confirmed the deficiencies in the investigations, acknowledging the missing information.
Failure to Notify Responsible Parties of Injuries
Penalty
Summary
The facility failed to notify the responsible party and/or the physician of injuries of unknown origin for two residents. According to the facility's policy on accidents and incidents, designated staff are required to promptly initiate and document an investigation, including notifying the physician and family. However, for one resident, who had a history of stroke, diabetes, and ataxia, a bruise was observed on the left forearm, but there was no evidence that the responsible party or physician was informed. Similarly, another resident with a history of stroke, Parkinson's Disease, and heart disease was found with a bruise on the left hand, and while the family was notified, there was no documentation of physician notification. The Director of Nursing confirmed during an interview that there was no evidence of notification to the responsible party or physician for the bruises of unknown origin for these residents. This lack of communication is a violation of the facility's policy and state regulations, which require timely notification of such incidents to ensure appropriate medical oversight and family awareness.
Deficiency in Documentation of Meal Intake and Treatment Administration
Penalty
Summary
The facility failed to maintain complete and accurate documentation for six residents (R2, R3, R4, R7, R8, and R9) regarding meal intake, medication administration records (MAR), and treatment administration records (TAR). The review of clinical records revealed significant gaps in documentation for meal consumption percentages across breakfast, lunch, and supper over a 30-day period. For instance, Resident R2's record lacked documentation for 17 out of 30 breakfast meals, 18 out of 30 lunch meals, and 22 out of 30 supper meals. Similar patterns of missing documentation were observed for the other residents reviewed, indicating a systemic issue in record-keeping practices within the facility. Additionally, the TARs for these residents showed multiple instances where ordered treatments were not documented as completed, further highlighting the deficiency in maintaining accurate medical records as per the facility's policy dated 1/1/24, entitled Charting and Documentation, which mandates that all services provided to residents must be documented in their medical records. Resident R2, diagnosed with dementia, stroke, and high blood pressure, had numerous instances of missing meal intake documentation and incomplete TARs on specific dates. Resident R3, with diagnoses including emphysema, high blood pressure, and anxiety, also had significant gaps in meal intake documentation and incomplete TARs on several dates. Resident R4, suffering from congestive heart failure, high blood pressure, and depression, had missing meal intake documentation and an incomplete MAR on one occasion. Similar deficiencies were noted for Residents R7, R8, and R9, each with their respective medical conditions and missing documentation for meal intake and treatment administration. The Director of Nursing confirmed during an interview that the documentation for meal intake, MAR, and TAR for the six residents was incomplete for the past 30 days. This failure to maintain accurate and complete medical records is a violation of the facility's policy and state regulations, specifically 28 Pa. Code 211.5(f)(ii)(ix) and 28 Pa. Code 211.12(d)(1)(5). The lack of proper documentation compromises the quality of care provided to the residents and indicates a need for immediate corrective action to ensure compliance with professional standards and regulatory requirements.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
