Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenwood Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with RA and type 2 DM had a standing order for Humira injections every 14 days, but multiple scheduled doses over several months were not administered due to the drug being unavailable or expected to be supplied by family, with one scheduled dose lacking any documentation. MAR and eMAR entries showed repeated non-administration, and there was no evidence that the provider or the new resident representative were notified of the missed doses until a later nursing note, despite a change in representative and prior issues with the former representative supplying the medication.
The facility failed to follow its policy requiring prompt notification of a resident's representative about changes in condition and treatment. A resident with HTN and Type 2 DM developed a painful rash on the buttocks and was diagnosed with shingles, leading to a new order for oral Valacyclovir and initiation of contact precautions. Review of the clinical record showed no documentation that the resident's representative was informed of the new diagnosis, medication, or precautions, and the DON confirmed that the representative had not been notified.
Food storage, sanitation, and temperature monitoring failures were observed in the kitchen and on one nursing unit. Surveyors found expired sanitizer test strips, dirty and sticky equipment and surfaces, debris in coolers and freezers, unlabeled or out-of-date food items, and a broken ice cart with jagged edges covered by tape. During tray line, food temperatures were not readily available, and logs showed multiple missing meal temperatures with no further documentation provided.
Failure to provide ordered care and skin treatment: One resident with DM had repeated accucheck results above 400 mg/dL, but the DON could not provide documentation that the physician was notified as ordered. Another resident reported very dry, itchy skin on the arms, hands, and feet, and the record showed no documented skin assessments or treatment in place.
Failure to Offer and Document COVID-19 Vaccination Status: The facility failed to ensure several residents were up to date on COVID-19 vaccination, including one resident with no vaccine documentation and no refusal on record. The DON confirmed there was no evidence the residents were offered additional COVID-19 vaccines. The facility also lacked documentation of staff COVID-19 vaccination status and could not show that staff were offered the vaccine or information on how to obtain it.
A facility failed to keep resident personal and medical information confidential when a public lobby binder labeled for survey results contained full health survey and complaint survey documents. The binder included a deficiency letter and CMS-2567 with a resident’s full name and specific identifier, along with 15 other residents tied to the survey. The issue was reviewed with the DON.
The facility failed to maintain a clean, safe, and orderly medication and medical supply storage room on the 400 Nursing Unit. Surveyors observed dust and debris on the floor and under shelving, paper products discarded on the floor, and packaged medical items left on the floor, including a shower cap, toothbrush, expired nutritional drink, catheter protector cap, and rolled gauze. The issue was reviewed with the NHA and DON.
A resident with cataracts reported repeated cancellations of her cataract surgery and uncertainty about when it would occur. The record showed ophthalmology consults noting cataracts in both eyes and a later failed procedure because the resident ate breakfast, with no documentation that the surgery was rescheduled. The DON confirmed the facility knew the surgery was planned but did not obtain an NPO order before the procedure.
Failure to provide needed foot care for a resident. The resident reported not seeing podiatry in a very long time and said her toenails needed clipping, with the left foot worse than the right. Observation showed overgrown, jagged toenails on both feet, and the record showed the resident’s last podiatry visit was months earlier. The NHA and DON confirmed there was no evidence of any further podiatry services.
A resident with PTSD was admitted and later had PTSD added to his dx list and noted on the MDS and care plan, but the care plan did not identify any triggers. Psych notes also did not mention PTSD, and the DON confirmed the findings. The facility failed to identify and care plan triggers that may retraumatize the resident.
Failure to develop a person-centered dementia care plan. A resident admitted with a dementia diagnosis had an MDS indicating dementia, but the care plan did not include individualized, person-centered interventions related to cognitive loss. The DON confirmed the omission during interview.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found the facility’s medication error rate was 8% based on 25 medication opportunities and two errors. An LPN administered an expired house-stock multivitamin instead of the ordered Centrum Silver to one resident, and gave Biotin 1000 mcg to another resident despite an order for 10,000 mcg; the LPN later confirmed the lower dose had been given.
A resident reported concern about chipped and broken teeth, and staff observed multiple teeth that appeared chipped and broken. Record review showed the resident’s last dental exam identified five fractured, non-restorable teeth, and the dental consultant requested an oral surgeon referral for imaging and possible extractions. The NHA and DON confirmed there was no evidence that the referral had been attempted.
Failure to provide routine and specialty dental services for three residents. One resident had decayed, broken teeth and pain, with repeated dental notes showing extractions were still pending and no evidence of scheduling at a hospital-based oral surgery practice after an outside oral surgeon could not treat her. Two other residents had broken or missing teeth and limited documented dental care, with one resident reporting the dentist only looked at her teeth and never fixed them, and the DON confirming no evidence of routine 6-month dental services.
Infection Control Failure During Nail Care: An NA used the same nail clippers to trim the fingernails of two residents without cleaning the reusable equipment or washing and drying hands between residents. Facility policy for fingernail/toenail care requires cleaning reusable supplies and thorough hand hygiene, and one resident stated he had his own personal clippers in his room but staff used the nurses’ clippers.
The facility failed to meet food safety standards, with improper cooling of leftovers, expired and unlabeled food products, and a dishwasher operating below required temperatures. Additionally, the ice machine lacked a proper air gap, and communal condiments in the solarium pantry were not monitored for expiration. A dietary worker was also observed with uncovered facial hair.
The facility failed to maintain a clean, safe, and orderly environment, with issues such as marred drywall, cobwebs, dirt, and debris observed in several residents' rooms. The Director of Nursing acknowledged these concerns, and a follow-up confirmed that some issues remained unchanged.
The facility failed to employ a qualified activity professional, as the current Activity Director, promoted from a nurse aide position, did not meet regulatory qualifications. This was confirmed by both the Activity Director and the DON.
The facility failed to provide routine dental services for three residents, leading to a deficiency in care. A resident with dentures was not offered dental services, while another with natural teeth and a history of extractions did not receive cleanings despite being at risk for dental issues. A third resident with a chipped tooth had not received dental care since admission, and despite consenting to services, was not scheduled for the provider's visit. The DON confirmed these deficiencies.
A facility failed to provide a personal funds quarterly statement for a resident assessed as incapable of understanding her rights. Her sister, the responsible party, never received an accounting statement and was unaware of the account balance. The facility could not provide evidence of authorization signed by the responsible party for the personal fund, and the statement lacked the sister's name and address.
A facility failed to involve a cognitively intact resident in decisions regarding her advance directives. Initially, the resident's POLST indicated a full code status, signed by her sister, without evidence of the resident's involvement. Later, the status was changed to DNR, signed by her son, again without the resident's participation. The facility lacked documentation showing the resident's involvement in these decisions.
A resident with significant visual impairment reported losing money from his wallet on two occasions, but the facility failed to thoroughly investigate or notify appropriate agencies as required by their policy. Despite the resident's allegations, there was no evidence of a completed investigation or documentation in the resident's clinical record. The Director of Nursing confirmed the lack of investigation and notification, indicating a failure to protect the resident's belongings.
The facility failed to conduct an FBI background check for a newly hired LPN who had not been a Pennsylvania resident for the required two years. Despite signing a consent and provisional employment form, the employee's personnel record lacked evidence of the necessary background check, which was confirmed by interviews with HR and the DON.
The facility failed to provide necessary personal and oral hygiene assistance to three residents dependent on staff for ADL. One resident had long, discolored fingernails despite a care plan for regular trimming. Another had significant plaque buildup on her teeth, with no staff assistance despite dental recommendations. A third resident, with severe vision impairment, had overgrown nails, indicating a lack of staff support for personal hygiene.
A facility failed to provide an ongoing program of activities to meet the needs of residents in the memory care unit, as no activities were scheduled after 4:00 PM. Concerns were raised by a resident's responsible party, and interviews with the DON and Activity Director confirmed the deficiency.
The facility failed to follow physician orders for a resident requiring Geri sleeves and fall mats, and did not monitor another resident's cardiac pacemaker. Observations showed non-compliance with care plans, and there was no evidence of pacemaker monitoring or related physician orders.
The facility failed to implement effective fall prevention interventions for two residents, leading to repeated falls. One resident, with a history of falls, continued to fall despite reminders to use the call bell, resulting in injuries. Another resident experienced a fall without new interventions being implemented until after a subsequent fall. The DON confirmed the lack of timely interventions, indicating a deficiency in the facility's response to fall incidents.
A facility failed to maintain and assess a resident's IV catheter as per the care plan. The policy required midline dressing changes 24 hours post-insertion and every five to seven days thereafter, with documentation of the procedure. However, there was no evidence of dressing changes, port flushing, or infection monitoring for the resident, as confirmed by the DON.
A facility failed to provide appropriate respiratory care for a resident, as the oxygen tubing was not changed according to physician orders, and the tubing was backdated without an actual change. Additionally, there was no humidification bottle attached, despite orders. The DON acknowledged these discrepancies, revealing that the resident was not supposed to have humidified oxygen ordered or administered.
A facility failed to assess potential entrapment risks from bed rails for a resident with a seizure disorder. The facility's policy required assessment of the sleeping environment, but documentation for zone 6 was missing. The resident's medical history of seizures was not included in the Side Rail and Entrapment assessments, contributing to the deficiency.
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Despite the determination to create care plans for dementia and cognitive loss during admission assessments, no such plans were developed or implemented. These deficiencies were confirmed during interviews with the DON and the Nursing Home Administrator.
A facility failed to implement enhanced barrier precautions for a resident with a chronic surgical wound, as required by CMS guidelines. The resident had an open surgical incision with possible infection, but no precautions were in place to alert staff or visitors. The issue was identified during a survey and discussed with facility leadership.
The facility failed to notify the State Ombudsman of hospital transfers for three residents, as required. One resident was transferred due to a change in condition, another for dehydration and hypotension, and a third for an elevated BNP level. The DON confirmed that notifications were not made unless a resident was permanently discharged.
The facility failed to follow physician orders for diagnostic testing and medication management, resulting in harm to two residents. One resident was not tested for influenza and COVID-19 as ordered, leading to a hospital admission with influenza A and pulmonary embolus. Another resident's medications were not adjusted per hospital discharge instructions, resulting in rehospitalization with severe conditions including digoxin toxicity and acute kidney injury.
A facility failed to provide scheduled bathing assistance for a resident with dementia and Parkinson's disease, who required extensive help. Despite a care plan indicating a preference for weekly showers, documentation showed missed bathing assistance on multiple occasions. These inconsistencies were confirmed in an interview with the Nursing Home Administrator and the DON.
A facility failed to adhere to a physician's order for a resident's vital signs to be taken every eight hours over three days. The resident's vital signs were only recorded once during this period. This deficiency was confirmed by the DON.
The facility failed to store food properly and maintain sanitary conditions in the main kitchen and dining areas. Issues included expired and unlabeled food items, dust and debris on various surfaces, improper cooling procedures, and soiled storage areas. These findings were reviewed with the Nursing Home Administrator and DON.
The facility failed to provide written bed hold notices to three residents or their representatives upon transfer to the hospital. The Director of Nursing confirmed the lack of documentation for these notices.
The facility failed to provide adequate bathing and transfer assistance for residents dependent on staff, as evidenced by missed bed baths, unkempt hygiene, and delayed transfers out of bed. The DON and Nursing Home Administrator acknowledged these deficiencies.
The facility failed to develop and implement individualized person-centered care plans for four residents diagnosed with dementia. Despite assessments confirming dementia, the necessary care plans were not created or implemented. These findings were confirmed by the DON.
The facility failed to implement an effective Water Management Program for preventing and controlling water-borne contaminants like Legionella. The provided documentation was outdated and incomplete, and the facility lacked a comprehensive plan to monitor and control these contaminants, putting residents at risk.
The facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for three nurse aides. The missing training included essential areas such as dementia training, abuse prevention training, and addressing areas of weakness or resident special care needs.
The facility failed to investigate a resident's injuries of unknown origin and did not complete a required background check for a newly hired employee. Resident 75 had multiple bruises, but no investigation was conducted. Additionally, Employee 1 was hired without a background check, as confirmed by the Director of Nursing.
The facility failed to ensure complete and accurate MDS assessments for a resident. The resident's MDS assessment incorrectly noted the use of a limb restraint, which was not observed during subsequent checks, and was confirmed as incorrect by the DON.
A facility failed to develop and implement a comprehensive care plan for a resident experiencing significant emotional distress related to past traumatic events, including the loss of her infant son and multiple miscarriages. The care plan did not address her mental health needs or include measures to monitor her for worsening symptoms of depression or suicidal ideation.
The facility failed to involve a resident's responsible party in care plan development by not inviting them to scheduled meetings. The responsible party attended only one meeting, which they had to request themselves. The DON confirmed the lack of invitations for other meetings.
The facility failed to maintain a resident's range of motion after discharge from physical therapy, leading to a decline in the resident's bilateral lower extremities. The director of rehabilitation was not informed of the decline, and the facility lacks a restorative nursing program.
A resident, dependent on staff for bed mobility and hygiene, fell out of bed and sustained injuries when a nurse aide provided care alone, contrary to the physician's order requiring two staff members. The incident occurred when the aide turned away to plug in a call bell, leaving the resident momentarily unattended.
The facility failed to assess and implement individualized interventions to promote bowel and bladder continence for a resident. Despite documentation indicating incontinence, the facility did not further assess the resident or implement appropriate interventions, and the DON confirmed the lack of a policy on evaluating incontinence.
A resident experienced significant weight loss after admission, and the facility failed to implement the dietician's recommendation for double protein portions due to a lactose allergy. The assistant director of nursing confirmed the lack of documentation addressing the severe weight loss.
Failure to Administer Ordered Humira and Notify Provider/Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered medication in accordance with professional standards of practice and physician orders for a resident with rheumatoid arthritis (RA) and type 2 diabetes mellitus. The resident had a physician’s order, dated December 1, 2025, for Humira 40 mg/0.4 ml to be injected every 14 days for RA. Review of the MARs for February, March, and April 2026 showed multiple scheduled Humira doses were not administered. On several dates, the eMAR documented that the medication was not given because it was on route from the pharmacy, not available, or none available. On one scheduled date, there was no documentation at all and the MAR was left blank with no corresponding eMAR note. On a later date, the eMAR documented that the medication was not available at the facility, that the RN supervisor was notified, and that the pharmacy reported the medication should be supplied by the family. Record review showed no evidence that the provider or the resident’s representative were notified that the resident did not receive Humira on any of the missed administration dates, except for the later date when the nurse documented speaking with the representative and leaving a message with the rheumatology provider. The DON reported that the resident’s representative had changed around early December 2025, that the prior representative had been unreceptive and uncooperative with providing Humira, and that she could find no documented evidence that anyone contacted the new representative about providing the medication prior to the April nursing note. The DON also stated she could find no documentation that the resident’s provider was made aware of the missed Humira doses on the identified dates.
Failure to Notify Resident Representative of New Diagnosis and Treatment Orders
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition and new treatment orders as required by its policy. The facility policy titled "Change in a Resident's Condition or Status," revised May 2017, states that the facility shall promptly notify the resident, the attending physician, and the resident's representative of changes in the resident's medical or mental condition and/or status. For one resident reviewed, the clinical record showed no evidence that the representative was informed of a new diagnosis, new medication order, or the initiation of contact precautions. The affected resident had diagnoses including hypertension and Type 2 Diabetes Mellitus. A physician note documented that the resident presented with a painful rash on the right buttocks and was diagnosed with shingles, with a new order for Valacyclovir 1 gram by mouth three times a day for seven days and initiation of contact precautions. Review of the clinical record revealed no documentation that the resident's representative was notified of the shingles diagnosis, the new Valacyclovir order, or the contact precautions. In an interview, the Director of Nursing confirmed that the representative was not made aware of these changes and acknowledged that the facility should reach out to representatives with any changes in condition or new treatment orders.
Food Storage, Sanitation, and Temperature Monitoring Failures
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the main kitchen and on one nursing unit. During the initial tour of the main kitchen, expired sanitizer test strips were found with the dishwasher documentation, and multiple surfaces and pieces of equipment had visible dust, dried stains, sticky residue, or liquid accumulation, including a cooler used during tray line, a commercial coffee maker, ceiling vents, a wall-mounted fruit and vegetable wash container, and chemical test strips near a cleaning bucket. A rodent glue trap behind the coffee machine was wet, and dried drip stains were observed on the wall behind the coffee maker. In the walk-in cooler, surveyors observed extensive debris on the floor, including food debris, dust, dirt, and an unopened butter packet. Several food items were past their facility use-by dates or lacked clear dating, including peas and carrots, sage, basil, iodized salt without an opening date, and stacked baking pans with debris on their borders. The dry goods storage area also had dust accumulation on the air conditioning unit vents and ceiling vent. In the walk-in freezer, surveyors observed debris on the floor, a stainless steel pan with a foil lid and non-discernible food label, a shepherd's pie past its use-by date, hot dogs with a facility use-by date of 12/26, a roll of corned beef with no labels or dates, and a sliced loaf of bread with no labels or dates. Further observation in the kitchen found expired sanitizer test strips above the three-basin sink, dust buildup near the sink and on a ceiling vent, and a large container of thickener with no label or dates. A container of flour had a facility use-by date of 6/25. Outside the kitchen, the trash disposal area contained scattered debris around the dumpsters and a broken, partially collapsed wooden fence. On the 400 Nursing Unit, the ice cart was broken and jagged in several areas with scotch tape covering multiple broken areas. During lunch tray line observation, food temperatures were not readily available, and the cook stated they had not been written down yet. Review of temperature logs showed multiple missing meal temperatures over several weeks, and no further food temperature documentation could be provided.
Failure to Provide Ordered Care and Skin Treatment
Penalty
Summary
The facility failed to provide the highest practicable care related to physician-ordered medications for one resident and skin integrity care for another resident. Resident 122 reported very dry, itchy skin on her arms, hands, feet, and especially her elbows, and stated that no lotions or creams had been applied to those areas. During the interview, her hands, arms, and feet were observed to have flakey white skin that appeared to be peeling and flaking off. The clinical record showed no documented assessments related to the dry skin and no interventions in place, and the NHA and DON confirmed that no treatment for dry skin was in place at the time of the interview. For Resident 38, the clinical record showed a diagnosis of Type 2 Diabetes Mellitus and a physician order for accuchecks four times daily with notification of the physician if blood sugar was less than 400 mg/dL. The DON stated the order was incorrect and should have required notification if blood sugars were greater than 400 mg/dL. Review of the MAR showed multiple accucheck results above 400 mg/dL in December 2025 and January 2026, including readings of 467, 471, 478, 466, 487, 440, 444, 425, 467, 423, 420, 428, 440, 464, and 426. The DON confirmed these findings and was unable to provide documentation that the physician was notified when the resident's blood sugars were greater than 400.
Failure to Offer and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to offer COVID-19 immunizations to ensure residents were up to date with the most current available vaccine. Clinical record review showed that Resident 1’s last COVID-19 vaccine was a booster on May 31, 2024; Resident 2’s last booster was on November 10, 2021; Resident 3’s last booster was on October 21, 2022; and Resident 6’s last booster was on May 20, 2024. Resident 9 had no documentation showing receipt of any COVID-19 vaccine and no evidence that she refused vaccination. The DON confirmed during interview that these residents were not up to date on their COVID-19 vaccinations and that there was no evidence they were offered any further COVID-19 vaccinations. The facility also failed to maintain documentation of staff COVID-19 vaccination status and could not provide evidence that staff were offered the COVID-19 vaccine or information on how to obtain it. During interview, the DON stated that the facility did not have evidence showing it maintained staff vaccination documentation or that staff had been offered the vaccine or information about obtaining it. The surveyor reviewed these findings with the DON during the interview, and the deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Confidential Survey Records Left in Public Lobby
Penalty
Summary
The facility failed to ensure residents’ rights to secure and confidential personal and medical information in the main lobby area and for one resident reviewed for privacy concerns. Observation of the main lobby revealed a binder labeled Department of Health Survey Results, For Public Review that contained recent Federal or State survey results and any plan of correction in effect. Review of the binder showed the full health survey and complaint survey results, including a survey deficiency letter and Statement of Deficiencies from a survey completed on March 31, 2025. The letter included the full name and specific resident identifier for Resident 12 and 15 additional residents associated with the survey. The issue was reviewed with the DON.
Housekeeping Deficiencies in Medication and Supply Storage Room
Penalty
Summary
The facility failed to provide adequate housekeeping services to maintain a clean, safe, and orderly environment in the medication and medical supply storage room on the 400 Nursing Unit. During observation, surveyors found dust and debris accumulated on the floor and under the storage shelving, along with pieces of various paper products discarded on the floor. The area also contained several packaged medical items discarded on the floor, including a shower cap, toothbrush, a nutritional drink that had expired, a catheter protector cap, and rolled gauze. This finding was reviewed with the NHA and DON during the survey.
Failure to Ensure Timely Cataract Surgery
Penalty
Summary
The facility failed to ensure timely vision services for a resident with cataracts. Resident 9 reported that her cataract surgery kept being cancelled and that she did not know when it would be done. The clinical record showed an ophthalmology consult on November 27, 2024, documenting cataracts in both eyes and the need for surgery, and a later consult on June 3, 2025, stating the procedure was not performed because the resident ate breakfast. The record contained no documentation that the cataract procedure was rescheduled. The DON confirmed on interview that the surgery had not been rescheduled and that the facility knew the resident was to have cataract surgery on June 9, 2025, but did not obtain a physician order for NPO status before the procedure.
Failure to Provide Needed Foot Care
Penalty
Summary
The facility failed to arrange necessary foot care for Resident 122. During interview, the resident stated she had not seen the podiatrist in a very long time and believed her toenails were very long and needed clipping, with the left foot worse than the right. Observation showed the right foot had multiple elongated toenails, including the large toe and middle toe, with nails grown over the tip of the toe by 1 cm, and the left foot toenails were all overgrown with 1 cm of growth over the tips of the toes; all toenails had jagged edges. Review of the clinical record showed the resident was last seen by podiatry on May 23, 2025, and the podiatry consult note stated, "Non-professional treatment is hazardous to the patient." Interviews with the NHA and DON confirmed the facility had no evidence of any further podiatry services provided for Resident 122.
Failure to Identify PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to identify triggers related to a resident’s diagnosis of Post-Traumatic Stress Disorder and failed to provide culturally competent, trauma-informed care or eliminate or mitigate re-traumatization for one of six residents reviewed for mood and behavior. Resident 4 was admitted on June 2, 2025, and a diagnosis of PTSD was added to his diagnosis list on July 11, 2025. His quarterly MDS assessment also identified PTSD, and his care plan noted the diagnosis, but there were no identified triggers documented. Review of his psych visit notes from September 3, 2025, and November 11, 2025, showed no mention of PTSD. The DON confirmed these findings during interview on January 8, 2026, and the facility failed to identify and care plan triggers that may retraumatize Resident 4 related to his PTSD diagnosis.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss for Resident 4. Resident 4 was admitted on June 2, 2025, and a diagnosis of dementia was added to his diagnosis list on June 26, 2025. His quarterly MDS dated October 18, 2025, indicated that he had dementia, but review of his care plan showed that the facility did not develop person-centered interventions related to his dementia diagnosis. The DON confirmed on January 8, 2026, that the facility failed to develop a person-centered care plan related to dementia for Resident 4.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent. Surveyors determined the medication error rate was eight percent based on 25 medication opportunities with two medication errors involving two residents on the nursing unit. One error involved a resident with an order for Centrum Silver oral tablet, one tablet by mouth daily; during observation of the medication pass, an LPN prepared and administered a Senior Tab multivitamin substituted from house stock, and the product was found to have expired in [DATE]. A second error involved a resident with an order for Biotin oral tablet, 10,000 mcg, one tablet by mouth daily. During observation of the medication pass, the LPN prepared and administered Biotin 1000 mcg instead of the ordered dose. In a follow-up interview, the LPN confirmed that the 1000 mcg dose had been given and stated she would check with the RN to confirm the dose. The resident’s record later showed the Biotin order was changed after surveyor questioning to Biotin 1 mg (1000 mcg) daily.
Failure to Obtain Dental Referral for Resident with Fractured Teeth
Penalty
Summary
The facility failed to obtain dental services for one of nine residents reviewed for dental concerns, Resident 122. During an interview, Resident 122 stated she was concerned about her teeth chipping and breaking, and observation at that time showed multiple teeth that appeared chipped and broken. Record review showed the resident’s last dental services were on May 13, 2025, when the dental exam identified five fractured teeth that were not restorable. The consultant requested a referral to an oral surgeon for radiographic imaging and extractions of any teeth with a less than favorable prognosis, but interview with the Nursing Home Administrator and DON confirmed there was no evidence that a referral to an oral surgeon had been attempted.
Failure to Provide Routine and Specialty Dental Services
Penalty
Summary
The facility failed to obtain professional dental services for three residents reviewed for dental concerns. Resident 28 reported decayed and broken teeth that caused pain, and observation confirmed the condition. Dental records showed repeated in-facility dental visits over several months in which the dentist documented that extractions had not been completed and that the resident needed referral to an oral surgeon before dentures could be made. After an oral surgeon later determined the resident was too medically complex for treatment in his office and recommended referral to a hospital-based oral surgery practice, the Director of Nursing stated the resident was not currently scheduled for oral surgery and there was no evidence the facility attempted to schedule her at a hospital-based oral surgery practice. Resident 9 was observed with several broken and missing teeth and stated she was unhappy with the facility dental services because the dentist only looked at her teeth and never fixed them, despite her report of broken teeth and cavities. Her dental record showed an initial exam with recommendations for routine cleaning and fluoride varnish, but no further dental visits occurred for an extended period except for one note indicating she was not treated because she was not brought to the treatment room. Resident 125, who could not be interviewed due to cognitive status, was observed with her own teeth and had no documented dental care available prior to a late initial exam and cleaning. The DON confirmed there was no further information showing that Residents 9 and 125 received routine dental services every six months as allowed by the State plan.
Infection Control Failure During Nail Care
Penalty
Summary
The facility failed to follow proper infection prevention practices for nail care equipment for two residents. During observation of the 500 Hall, Employee 1, a nurse aide, retrieved nail clippers from a staff member near a med cart and trimmed Resident 48’s fingernails, then walked to Resident 29 and trimmed his fingernails without cleaning the reusable clippers or washing and drying her hands between residents. The facility policy for Care of Fingernails/Toenails states that reusable equipment and supplies are to be cleaned and that hands are to be washed and dried thoroughly during the procedure. Resident 29 stated that he has his own personal nail clippers in his room but said staff must have used the nurses’ clippers that day. Resident 48 was not interviewable.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in both the main kitchen and a solarium pantry. Observations revealed that leftover foods in the walk-in freezer were not cooled according to FDA guidelines, with temperatures not reaching the required 41 degrees Fahrenheit within six hours. Additionally, the cooling log lacked proper temperature assessments for several food items. The dry storage area contained expired and improperly labeled food products, and a thickener container was found with a scoop stored inside, in direct contact with the food product. The main kitchen's dishwasher was observed to operate below the required temperatures for both wash and rinse cycles, failing to meet the minimum 120 degrees Fahrenheit stipulated by the equipment's labeling. This issue was acknowledged by the facility's dietitian and dietary manager, who had contacted the dishwasher maintenance contractor but had not resolved the issue by the time of the survey. Furthermore, the facility's ice machine lacked a visible air gap between the indirect waste pipe and the floor drain, a requirement under the International Plumbing Code. In the solarium pantry, communal condiments were found without decipherable dates to ensure safe consumption, and there was no monitoring of expiration dates for these items. Additionally, a male dietary worker was observed on the food service line with facial hair not contained under a covering, which was addressed by the dietitian. These deficiencies were discussed with the Nursing Home Administrator during the survey.
Deficiency in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in a deficiency in maintaining a clean, safe, and orderly environment on three of five nursing halls. Observations revealed that the drywall in Resident 91's room was marred and gouged, a condition that existed before their admission. Similarly, Resident 42's room had marred drywall behind the head of the bed. The Director of Nursing acknowledged these drywall concerns during a concurrent interview. Further observations in Resident 16's room showed marring and uneven drywall, cobwebs, dirt, and debris in the bathroom, and a non-functioning light bulb. A follow-up observation confirmed that these issues remained unchanged. In Resident 101's room, loose dirt, a candy wrapper, and marred walls were noted, along with a patched but unpainted bathroom wall. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Facility Lacks Qualified Activity Director
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program. Employee 6, who was promoted from a nurse aide position to the role of Activity Director, did not possess the necessary qualifications as per regulatory requirements. This was confirmed during an interview with Employee 6 on March 28, 2025, where she stated her promotion occurred on February 17, 2025. Further confirmation came from the Director of Nursing, who acknowledged that Employee 6's qualifications were limited to being a certified nurse aide, which did not meet the regulatory standards for overseeing the facility's activity programs.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine prophylactic dental services for three residents, leading to a deficiency in dental care. Resident 39, who was edentulous and had dentures, was not provided with or offered routine dental services. The Director of Nursing confirmed that there was no evidence of Resident 39 receiving such services. Resident 10, who had natural teeth and a history of extractions, had not received professional dental cleanings in the past year despite being at moderate risk for dental issues. Although a plan was in place for an annual exam, there was no evidence that it occurred, and a scheduled appointment was missed due to the resident's conjunctivitis, with no rescheduling documented. Resident 109, who had natural teeth and a chipped front tooth, had not received professional dental services since admission to the facility. Despite consenting to services in January 2025, the facility did not add her to the list for the contracted dental provider's visit in February 2025, and there was no evidence of an attempt to obtain services in March 2025. The facility's failure to provide routine dental care for these residents was confirmed through interviews with the Director of Nursing and the residents themselves.
Failure to Provide Personal Funds Statement and Authorization
Penalty
Summary
The facility failed to provide a personal funds quarterly statement for a resident, identified as Resident 25, who was assessed as incapable of understanding her rights and responsibilities. Her sister, designated as her responsible party and first emergency contact, reported never receiving an accounting statement of her sister's personal funds. Despite Resident 25's social security income being automatically forwarded to the facility for her care, her sister was unaware of the balance in the personal funds account. The facility was unable to provide evidence that Resident 25's sister had signed an authorization for the establishment of a personal fund. The facility's resident fund management service report indicated that the facility was the representative payee, but the statement did not include Resident 25's sister's name or address. Interviews with the business office manager revealed that the authorization form for the personal funds account was signed only by a facility representative, lacking the signature of Resident 25's responsible party. The facility could not provide an authorization signed by either Resident 25's mother, who was previously responsible, or her sister, who took over after the mother's death.
Failure to Involve Resident in Advance Directives
Penalty
Summary
The facility failed to involve a resident in establishing advance directives, specifically regarding resuscitation preferences. Resident 93, who was cognitively intact with a BIMS score of 15, was admitted to the facility and initially had a POLST indicating a full code status, signed by the resident's sister. There was no evidence that Resident 93 was involved in this decision, despite being cognitively capable. Subsequently, the resident's resuscitation status was changed to DNR, as indicated by a new POLST signed by the resident's son. Again, there was no evidence that Resident 93 was involved in this decision or that she was deemed incapable of making her own health decisions. The facility staff could not provide documentation to show the resident's involvement in these critical decisions, leading to the deficiency noted in the report.
Failure to Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate and notify the appropriate agencies regarding an incident of potential misappropriation of property involving a resident. The resident, who is significantly visually impaired, reported losing money from his wallet on two occasions. Despite the resident's allegations and the facility's policy requiring prompt reporting and thorough investigation of such incidents, there was no evidence of a completed investigation or notification to local law enforcement or the Department of Health field office. The resident had previously reported a similar incident a year prior, but there was no documentation of any follow-up or resolution. The facility's active policy on abuse prevention mandates that all reports of misappropriation of resident property be promptly reported and thoroughly investigated. However, in this case, the facility did not adhere to its policy. The resident's clinical record did not document any incidents of reported misappropriation, and the investigation documentation provided by social services lacked evidence of staff or roommate statements, or any review of staff schedules. The Director of Nursing confirmed the absence of a completed investigation or required notifications, highlighting a significant lapse in the facility's responsibility to protect residents' belongings.
Failure to Conduct Required FBI Background Check for New Hire
Penalty
Summary
The facility failed to complete the required background check screening for a newly hired employee, identified as Employee 3, who was a licensed practical nurse. According to the facility's policy and state regulations, a criminal background check must be obtained from the Pennsylvania State Police for applicants who have been residents of Pennsylvania for more than two years. For those who have not been residents for the past two years, an FBI background check is required. Employee 3, who had a previous address in Virginia, signed a consent for a criminal background check and a provisional employment form indicating she was not a Pennsylvania resident for the past two years. However, her personnel record lacked evidence of an FBI criminal background check. Interviews with the human resources staff and the Director of Nursing confirmed that the facility did not identify the need for an FBI background check for Employee 3 until questioned by the surveyor. The facility's failure to obtain the necessary FBI background check for Employee 3, who had not been a Pennsylvania resident for the required period, resulted in a deficiency under the regulations governing abuse and neglect policies.
Failure to Provide Adequate ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal and oral hygiene assistance to three residents who were dependent on staff for activities of daily living (ADL). Resident 110 was observed with long and discolored fingernails, despite having a care plan that required staff to check and trim his nails during bathing assistance. The resident confirmed that staff had promised to trim his nails but had not done so until after the surveyor's observation. Resident 93 was found with a significant buildup of plaque on her lower teeth, and she reported not brushing her teeth nor receiving assistance from staff. Her dental records indicated a need for staff assistance with oral hygiene, which was not provided, as evidenced by the continued plaque buildup after a recent dental cleaning. Resident 36 was observed with significantly overgrown and discolored fingernails, and he reported being unable to see and dependent on staff for nail care. His quarterly MDS assessment confirmed his dependency on staff for personal hygiene due to severe vision impairment. The facility's failure to provide necessary ADL care for these residents was previously cited as a deficiency, indicating a pattern of non-compliance with regulatory requirements for nursing services.
Lack of Evening Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the individual needs and interests of residents, specifically for one resident in the memory care unit. Concerns were raised by the responsible party of a resident about the lack of evening activities on the 200 hall, which is the memory care unit. A review of the facility's activity calendars for January, February, and March 2025, confirmed that no activities were scheduled after 4:00 PM. Interviews with the Director of Nursing and the Activity Director corroborated these findings, indicating a deficiency in the activity program for the residents in the memory care unit. This deficiency was identified under the regulation 28 Pa. Code 201.29 (a) concerning resident rights, as the facility did not meet the needs of the residents by failing to provide an adequate activity program in the evenings.
Failure to Follow Physician Orders and Monitor Cardiac Pacemaker
Penalty
Summary
The facility failed to provide the highest practicable care for Resident 42 by not adhering to physician orders for the use of Geri sleeves on all four extremities and bilateral fall mats while the resident was in bed. Observations on multiple occasions revealed that Resident 42 was either in bed or in a wheelchair without the prescribed Geri sleeves and fall mats, indicating a lack of compliance with the care plan designed to address skin alterations and fall prevention. Additionally, the facility did not adequately address the care needs of Resident 30, who had an implanted cardiac pacemaker. The clinical records and care plans did not include any provisions for monitoring the pacemaker, and there were no physician orders related to its management. Resident 30 reported having a machine at home for pacemaker checks, but there was no evidence of monitoring or arrangements for such checks while the resident was in the facility. This oversight was confirmed during interviews with the resident and facility staff.
Failure to Implement Fall Prevention Interventions for Residents
Penalty
Summary
The facility failed to implement effective interventions to prevent future falls or accidents for two residents, leading to repeated incidents. Resident 93, who had a history of falls, was admitted to the facility after repeated falls at her previous residence. Despite multiple falls within the facility, including one that resulted in a laceration requiring stitches, the facility did not implement new interventions beyond reminders to use the call bell and placing a sign in her room. The resident continued to experience falls, including incidents where she was found on the floor after attempting to transfer herself, indicating a lack of adequate supervision and intervention. Similarly, Resident 110 experienced a fall on March 1, 2025, but the facility did not implement any new fall prevention interventions until after a subsequent fall on March 3, 2025. The facility's plan of care for Resident 110 only included new interventions such as fall mats, a low bed, and a toileting program after the second fall. The Director of Nursing confirmed the absence of new interventions following the initial fall, highlighting a deficiency in the facility's response to fall incidents.
Failure to Maintain IV Catheter Care
Penalty
Summary
The facility failed to ensure proper maintenance and assessment of intravenous catheters for a resident, as evidenced by a review of Resident 120's clinical record and facility policies. The policy on Midline Dressing Changes required that a midline catheter dressing be changed 24 hours after insertion and then every five to seven days, with documentation of the date, time, description of the insertion site, and any complications. However, there was no documented evidence in Resident 120's clinical record to indicate that the nursing staff changed the midline IV access dressing, flushed the ports before and after medication administration, or monitored the site for signs and symptoms of infection. Resident 120 had a midline placed for IV access on October 29, 2024, with a physician's order to administer Rocephin daily for ten days. The resident's plan of care, dated November 5, 2024, specified that the IV dressing should be changed every seven days, and the ports should be flushed before and after medication administration. Despite these directives, the facility did not adhere to the plan of care, as confirmed by the Director of Nursing during an interview. This oversight in following the established protocols for IV care led to the deficiency noted in the report.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for Resident 42, as observed during a survey. The clinical record review revealed that Resident 42 had current physician orders to change the oxygen tubing weekly and as needed, specifically every Sunday during the night shift, and to change the humidifier bottle weekly. However, observations on March 25, 26, and 27, 2025, showed that the oxygen tubing was not changed as per the schedule, with the tubing dated March 16, 2025, and later backdated to March 23, 2025, without an actual change. Additionally, there was no humidification bottle attached to the resident's oxygen during any of the observations. The Director of Nursing (DON) acknowledged that the staff did not change the tubing on March 23, 2025, and that the tubing was changed between surveyor observations on March 25 and 26, 2025, but was incorrectly backdated. Furthermore, the DON revealed that Resident 42 was not supposed to have humidified oxygen ordered or administered, indicating a discrepancy in the care provided versus the documented orders. This failure to adhere to physician orders and proper respiratory care protocols was previously cited on March 29, 2024, under the regulation 483.25(i) for Respiratory/tracheostomy Care and Suctioning.
Failure to Assess Bed Rail Entrapment Risks
Penalty
Summary
The facility failed to thoroughly assess the potential entrapment risks from the use of bed rails for a resident reviewed for accident hazards. The facility's policy on bed safety, last reviewed without changes, indicated that the resident's sleeping environment should be assessed by the interdisciplinary team, considering various factors including safety and medical conditions. However, the facility did not document an assessment for zone 6, which is the space between the end of the rail and the side edge of the headboard or footboard, despite the resident's bed being equipped with a headboard. The FDA's guidance on hospital bed systems identifies seven zones where there is potential for patient entrapment, with zone six posing a risk of neck or chest entrapment. The facility's maintenance staff were responsible for measuring six potential zones for resident bed entrapment, but these measurements were not documented in the resident's medical record. Additionally, the facility did not have defined measurements to determine when a space posed a risk versus passed inspection. The resident in question had a medical history of conversion disorder with seizures or convulsions and was on medication for a seizure disorder. Despite this, the Side Rail and Entrapment assessments failed to include her diagnosis of epilepsy, and the second question of the Entrapment Risk Assessment was not completed. This oversight in the assessment process contributed to the deficiency identified by the surveyors.
Failure to Develop Person-Centered Care Plans for Dementia
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Resident 39 was admitted on October 12, 2024, and was diagnosed with dementia on October 22, 2024. Despite the facility's determination to create a care plan for dementia and cognitive loss as indicated in the admission Minimum Data Set Assessment dated October 18, 2024, there was no evidence of a person-centered care plan being developed or implemented for Resident 39. Similarly, Resident 99, who was admitted on September 3, 2024, with a diagnosis of dementia, also lacked a person-centered care plan addressing her dementia and cognitive loss. The facility had determined the need for such a care plan during the admission MDS assessment, but no plan was developed or implemented. These findings were confirmed during interviews with the Director of Nursing and the Nursing Home Administrator, highlighting the facility's failure to address the specific needs of residents with dementia.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with infection control concerns. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, nursing care facilities are required to use EBP, including gown and glove use, for residents with chronic wounds or indwelling medical devices during high-contact care activities. Resident 173, who had a surgical wound that had not healed since November 2024, was observed without any evidence of EBP in place. The resident had undergone a laminectomy and presented with an open surgical incision that was draining clear fluids, indicating a possible abscess. An interview with a licensed practical nurse confirmed the absence of any indication at the resident's doorway or in her room to alert staff or visitors about the need for EBP. The clinical record review revealed that a physician's order to implement EBP was only made after the surveyor's questioning. This deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to adhere to infection prevention and control protocols for Resident 173.
Failure to Notify State Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the State Ombudsman of hospital transfers for three residents, which is a requirement under the regulations. Resident 77 was transferred to the hospital on February 13, 2025, due to a change in condition, but there was no documentation of written notification to the State Ombudsman. Similarly, Resident 93 was sent to the hospital on February 6, 2025, for a change in condition, and again, no notification was documented. The Director of Nursing confirmed these findings during interviews conducted on March 27 and 28, 2025. Resident 110 was admitted to the hospital on January 17, 2025, for dehydration, hypotension, and altered mental status, with an elevated BNP level indicating potential heart failure. Despite these significant health concerns, the facility did not notify the State Ombudsman of the hospitalization. Interviews with the Director of Nursing revealed that the person responsible for notifications only did so for permanent discharges, not temporary hospital transfers. This oversight was previously cited on March 29, 2024, indicating a recurring issue with compliance.
Failure to Follow Physician Orders Leads to Resident Harm
Penalty
Summary
The facility failed to provide the highest practicable care for Resident CR1 by not following physician orders for diagnostic testing. Despite multiple orders from different healthcare providers to obtain an oropharyngeal specimen for influenza and COVID-19 testing, the facility did not carry out these tests. This oversight was significant as Resident CR1 was later admitted to the hospital with a diagnosis of bilateral pulmonary embolus and influenza A, conditions that could have been identified earlier with the appropriate testing. In the case of Resident 1, the facility did not implement the medication changes as per the hospital discharge instructions. Upon readmission to the facility, Resident 1's medications, including Digoxin, Lisinopril, Metformin, and Potassium Chloride, were continued despite instructions to discontinue them. This failure to adjust medications led to Resident 1's rehospitalization with severe conditions including hyperkalemia, acute kidney injury, and digoxin toxicity. The hospital's cardiology consult confirmed that the continued administration of these medications contributed to Resident 1's critical condition. Interviews with facility staff confirmed the deficiencies in care for both residents. Employee 2 admitted that the discharge instructions for Resident 1 were not properly reviewed or initialed, which is his customary practice. The facility's failure to follow physician orders and discharge instructions resulted in significant harm to the residents, highlighting a critical lapse in the facility's medication management and diagnostic testing processes.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance for a dependent resident, identified as Resident 1, who required extensive assistance due to her diagnoses of dementia and Parkinson's disease. The plan of care for Resident 1 indicated a preference for showers, and she was scheduled to receive a shower weekly. However, documentation from the nurse aide staff revealed inconsistencies in providing the required bathing assistance. Specifically, there was no evidence of bathing assistance on several occasions, including July 1, 22, and 29, 2024; August 26, 2024; and September 2, 2024. These findings were confirmed during an interview with the Nursing Home Administrator and the Director of Nursing.
Failure to Monitor Vital Signs as Ordered
Penalty
Summary
The facility failed to provide the highest practicable care for a resident by not adhering to a physician's order for vital signs monitoring. The physician's order, dated May 2, 2024, required that the resident's vital signs, including body temperature, pulse rate, respiration rate, and blood pressure, be measured every eight hours for three days. However, the clinical documentation revealed that the facility only recorded the resident's vital signs once, on May 2, 2024, at 6:00 PM, during the specified period from May 2 to May 5, 2024. This deficiency was confirmed by the Director of Nursing during an interview on May 29, 2024.
Failure to Maintain Sanitary Food Storage and Service Conditions
Penalty
Summary
The facility failed to store food to prevent the potential spread of foodborne illness and maintain food service/storage equipment in a sanitary manner. Observations in the main kitchen revealed several issues, including a large white bin labeled as flour with an expired use-by date, an unlabeled bin containing thickener, and an air vent on the industrial ice machine covered in dust. Additionally, the lower shelf of a preparation table was dusty and contained dried particles, and a shelf with plastic containers of spices had debris and an expired container of rotisserie chicken seasoning. The walk-in cooler had soiled liners, a cardboard box with pooled red liquid, and dried brown liquid spots on a shelf. A clear plastic container labeled as cornmeal was also found with an expired use-by date. Various other areas, including a three-tier cart, steam table, metal storage rack, and flooring, were observed with dust, debris, and black buildup. The vent unit in the dish machine hood and the wall behind the dish machine were covered in thick dust and black buildup, respectively. In the walk-in freezer, several plastic storage bins labeled with various food items were found without evidence of proper cooling procedures to prevent foodborne illness. The kitchen cool-down log did not show that the products were cooled to the required temperatures within the specified time frames. Additionally, the 100/300 hall dining room area had a refrigerator with dried liquid spills in the door, lower shelf, and back wall. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, indicating a failure to maintain food storage and service areas in a sanitary condition, potentially leading to the spread of foodborne illness.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for three residents. Resident 41 was transferred to the hospital after a change in condition, and there was no documentation that the facility provided written notice regarding a bed hold. Similarly, Resident 221 was transferred to the hospital after a change in condition, and there was no documentation of a written bed hold notice. Resident 75 was transferred to the hospital due to a fall, and again, there was no documentation of a written bed hold notice. The Director of Nursing confirmed during interviews that the facility did not provide the required written notices to the residents or their responsible parties.
Failure to Provide Adequate Bathing and Transfer Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance for residents who were dependent on staff for their activities of daily living. Resident 60, who required a bed bath due to wound dressings, did not receive his scheduled bed baths on multiple Fridays in March 2024. The Director of Nursing confirmed this lapse in care. Similarly, Resident 96, who needed partial to moderate assistance for bathing, did not receive any documented baths or showers in January, February, and March 2024, despite her care plan indicating she should receive a bath on Mondays. Observations revealed that her hair was unkempt, indicating a lack of proper hygiene care. Resident 64 also reported not having had a shower in five weeks, despite her care plan scheduling a shower every Wednesday evening shift since January 22, 2024. There was no documentation to indicate she had been offered or refused a shower in the last 30 days. Resident 52, who required substantial assistance for bathing and had a special shampoo order for dandruff, did not receive his scheduled showers or the medicated shampoo as prescribed. His bathing records showed no evidence of showers from February 28 to March 27, 2024, and his hair appeared greasy with extensive dandruff during an observation. The Director of Nursing confirmed the lack of documentation and the inconsistency in providing the medicated shampoo. Resident 92, who was dependent on staff for transfers due to multiple sclerosis, reported frequently having to wait until the second shift to be transferred out of bed, despite her preference to be up by 10:00 AM. Observations confirmed that she was still in bed late into the day on multiple occasions. The Nursing Home Administrator and the Director of Nursing acknowledged the issues with timely transfers and bathing assistance during interviews. The facility's failure to provide necessary care and assistance for activities of daily living for these residents was evident through clinical record reviews, observations, and interviews with staff and residents.
Failure to Develop and Implement Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for residents diagnosed with dementia. Clinical record reviews and staff interviews revealed that four residents (Residents 17, 43, 44, and 94) were admitted with diagnoses of dementia. Despite the facility's assessment and determination that care plans for dementia and cognitive loss would be developed, there was no indication that such care plans were created or implemented for these residents. Resident 17 was admitted on July 19, 2022, and her most recent MDS assessment dated June 9, 2023, confirmed a diagnosis of dementia. Resident 43 was admitted on July 11, 2020, and his MDS assessment also confirmed dementia. Resident 44 was admitted on June 9, 2022, with a similar diagnosis confirmed by his MDS assessment. Resident 94 was admitted on June 22, 2023, and her MDS assessment confirmed dementia. In all cases, the facility failed to develop and implement the necessary person-centered care plans. These findings were confirmed by the Director of Nursing during a meeting on March 28, 2024.
Failure to Implement Effective Water Management Program
Penalty
Summary
The facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella. The CDC's Water Management Program Toolkit outlines steps to build an effective Legionella water management program, including a description of the building's water system, identification of potentially hazardous conditions, control measures, and corrective actions. However, the facility's documentation was outdated and incomplete. The Director of Maintenance provided documents from 2003 and 2006, which were not relevant to the current water management program. Additionally, the provided Legionella Water Management Plan was missing a page, and the facility could not locate the previous maintenance director's information or last year's test results. The Director of Maintenance also admitted that the facility did not have a flow diagram of the water system and could not provide evidence of identifying potentially hazardous conditions, control measures, control limits, or corrective actions. The surveyor reviewed these concerns with the Nursing Home Administrator, highlighting the facility's failure to develop and maintain a water management program to reduce the risk of Legionella growing and spreading within their water system and devices. The facility did not have a comprehensive plan to monitor and control water-borne contaminants, putting residents at risk. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee, 28 Pa. Code 201.18(b)(1) Management, and 28 Pa. Code 211.10(d) Resident care policy.
Failure to Provide Required In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that all nurse aide staff completed a minimum of 12 hours of in-service education training each year for three nurse aides. During an interview with the Nursing Home Administrator and the Director of Nursing, it was confirmed that there was no evidence of any in-service education for three nurse aides hired between December 2021 and March 2022. The missing training included essential areas such as dementia training, abuse prevention training, and addressing areas of weakness or resident special care needs. This deficiency was confirmed during an interview with the Director of Nursing on March 29, 2024.
Failure to Investigate Injuries and Conduct Background Checks
Penalty
Summary
The facility failed to investigate a resident's injuries of unknown origin and did not implement its abuse prohibition policy regarding employee screening. Specifically, Resident 75 was observed with multiple bruises on her upper arms and right hand, but the facility had no evidence of an investigation to rule out abuse. This was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. Additionally, the facility did not complete a required background check for Employee 1, an activity assistant, before hiring and allowing access to residents. This was verified through a review of Employee 1's personnel record and confirmed during an interview with the Director of Nursing.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 25 residents reviewed. Resident 110 was admitted on January 12, 2024, and her admission MDS assessment dated January 18, 2024, incorrectly noted that she utilized a limb restraint less than daily. Observations on March 26 and March 27, 2024, revealed no evidence of a limb restraint being used. Additionally, a review of Resident 110's physician orders showed no evidence of a restraint being prescribed. An interview with the Director of Nursing on March 28, 2024, confirmed that the MDS was incorrect and that Resident 110 never utilized a restraint.
Failure to Implement Comprehensive Care Plan for Resident with Emotional Distress
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 50, who expressed significant emotional distress related to past traumatic events. A psychiatry note indicated that Resident 50 wanted to die to be with her deceased babies, mourned the loss of her infant son and multiple miscarriages, and experienced auditory and visual hallucinations of her deceased mother. Despite these serious concerns, the resident's care plan did not address her emotional and psychological needs, nor did it include measures to monitor her for worsening symptoms of depression or suicidal ideation. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that Resident 50's care plan lacked provisions to address her mental health issues. The failure to include a safety plan or any specific interventions in the care plan left Resident 50 without the necessary support to manage her emotional distress, thereby failing to maintain the highest practicable care for her.
Failure to Involve Responsible Party in Care Plan Development
Penalty
Summary
The facility failed to promote resident and/or responsible party involvement with care plan development for Resident 101. Clinical record review revealed that care plan meetings were conducted on August 4, 2023, September 6, 2023, and November 20, 2023, without inviting Resident 101's responsible party. During a telephone interview on March 26, 2024, the responsible party indicated that she only attended one care plan meeting, which she had to request herself. The Director of Nursing confirmed that there was no evidence of invitations being sent for the other meetings. This deficiency was identified during a survey conducted on March 27, 2024, and March 29, 2024.
Failure to Maintain Resident's Range of Motion
Penalty
Summary
The facility failed to provide services to maintain a resident's range of motion for one of the five residents reviewed. Clinical record review revealed that Resident 44 was assessed as having no upper or lower extremity impairments in a quarterly MDS dated August 2, 2023. However, after being discharged from physical therapy on August 4, 2023, with a good prognosis for maintaining his current level of function with consistent staff follow-through, the resident's condition declined. The physical therapy discharge summary noted that the facility does not offer restorative nursing programs. Subsequent MDS assessments indicated that Resident 44 developed a limited range of motion in his bilateral lower extremities, which was not addressed by the facility's staff. An interview with the director of rehabilitation confirmed that he was not made aware of Resident 44's decline in range of motion. Additionally, it was confirmed that the facility does not have a restorative nursing program to maintain residents' level of function after discharge from therapy services. The findings were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to ensure Resident 44 received appropriate treatment and services to maintain his range of motion or prevent further decline.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate interventions to prevent falls for a resident who was dependent on staff for bed mobility and hygiene. The resident, who had impaired range of motion in both upper extremities, was assessed as requiring extensive assistance from two or more staff members for bed mobility. Despite this, a nurse aide was providing incontinence care alone when the resident rolled out of bed, resulting in injuries including a skin tear on the left hand and a hematoma on the head. The incident occurred when the nurse aide turned away to plug in a call bell that had come out of the wall, leaving the resident unattended momentarily. Clinical records and facility documentation confirmed that the resident had a physician's order requiring two staff members to be present during care due to behavioral interventions. However, at the time of the incident, only one staff member was present, and there was no evidence of another staff member being involved as required. The Director of Nursing was informed of these findings, which highlighted the facility's failure to adhere to the prescribed care plan and ensure adequate supervision to prevent accidents.
Failure to Assess and Implement Bowel and Bladder Continence Interventions
Penalty
Summary
The facility failed to assess and implement individualized interventions to promote bowel and bladder continence for Resident 115. The care plan initiated on March 4, 2024, indicated that Resident 115 was incontinent of bowel and bladder. However, a bowel and bladder program screener dated March 9, 2024, indicated that she was always continent of bladder and never incontinent of bowel. Task documentation from March 3 to 27, 2024, showed that Resident 115 was documented as being incontinent of bowel and bladder 15 times each. The most recent MDS dated March 3, 2024, revealed that Resident 115 was occasionally incontinent of bowel and frequently incontinent of bladder, with a BIMS score of 15 indicating she was cognitively intact. An interview with the Director of Nursing on March 29, 2024, confirmed the inconsistencies related to Resident 115's bowel and bladder continence. The DON also confirmed that there was no evidence that the facility further assessed Resident 115 to implement interventions to promote bowel and bladder continence. The facility did not have a policy on evaluating resident bowel and bladder incontinence, leading to the failure to appropriately assess and implement individualized interventions for Resident 115.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement interventions to promote acceptable parameters of nutrition for a resident. The resident was admitted on January 23, 2024, with an initial weight of 145 pounds. Over the following weeks, the resident experienced significant weight loss, dropping to 122.6 pounds by February 13, 2024. A registered dietician recommended fortified foods and later double protein portions due to the resident's lactose allergy. However, there was no evidence that the facility implemented the dietician's recommendation. An assistant director of nursing confirmed the lack of documentation addressing the resident's severe weight loss.
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Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lewistown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| William Penn Nursing And Rehab | 1.8 mi | ★★★★★ | 9 | 0 |
| Valley View Haven, Inc | 7.3 mi | ★★★★★ | 5 | 0 |
| Locust Grove Retirement Village | 8.4 mi | ★★★★★ | 0 | 0 |
| Brookline Nursing And Rehab | 11 mi | ★★★★★ | 13 | 0 |
| Foxdale Village | 19.2 mi | ★★★★★ | 0 | 0 |
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