Greenwood Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewistown, Pennsylvania.
- Location
- 276 Green Ave Extended, Lewistown, Pennsylvania 17044
- CMS Provider Number
- 395373
- Inspections on file
- 29
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Greenwood Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
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.
A resident was observed receiving oxygen without a physician's order, and later found without oxygen in the dining room while the oxygen was still running in her room. The assistant director of nursing confirmed the findings and was unsure when the oxygen administration began.
The facility failed to provide appropriate pain management for a resident by not following physician-ordered pain medication protocols. The MAR showed multiple instances where Acetaminophen was administered for pain levels higher than 4, and Tramadol was administered for a pain level of 5, contrary to the physician's orders.
The facility failed to ensure the availability of necessary emergency supplies for two residents receiving hemodialysis. Both residents had recently moved rooms, and their emergency dialysis kits were not transferred with them. This deficiency was confirmed during observations and interviews with staff and residents.
The facility failed to identify triggers related to a resident's PTSD and did not provide culturally competent, trauma-informed care to mitigate re-traumatization. The care plan did not address specific trauma-related triggers despite the resident's history of severe trauma, including rape, physical abuse, and the loss of multiple pregnancies and a newborn son. This oversight was confirmed by the Director of Nursing.
The facility failed to assess the risk of side rail entrapment for three residents. Despite physician orders and initial assessments, there was no documentation or evidence that side rails were appropriate or that residents could use them. Observations and interviews revealed discrepancies and incomplete assessments, which were acknowledged by the DON.
The facility failed to ensure that two LPNs had the necessary competencies for enteral tube feeding, catheter care, medication administration, and dressing changes. The deficiency was confirmed through staff interviews and a review of facility documentation, affecting residents with specific medical needs.
A resident was prescribed an antibiotic for a urinary tract infection despite no supporting documentation or diagnosis. The resident was sent to the emergency room for abdominal pain and loss of appetite, and the final culture report showed no significant growth. The Director of Nursing confirmed the lack of information to justify the antibiotic order.
The facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines. Clinical record review revealed that the resident had a pneumovax 23 in 2007, but there was no evidence she was offered the conjugate vaccines. An RN confirmed these findings, indicating the facility did not follow up with the appropriate vaccinations.
The facility failed to provide written notifications to residents and/or their responsible parties for hospital transfers, affecting four residents. The required notifications, including reasons for transfer and contact information for the Ombudsman, were not documented. The DON confirmed these findings during interviews.
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.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident. Observation of the resident revealed that she was receiving oxygen at 3 liters per minute in her room, but later was seen in the dining room without oxygen while the oxygen was still running in her room. A review of the resident's clinical record showed no physician's order for oxygen administration. An interview with the assistant director of nursing confirmed these findings and indicated uncertainty about when the oxygen administration began, although documentation noted the resident started using oxygen on March 22, 2024. Nursing staff obtained an order for the oxygen after the surveyor's inquiry.
Failure to Follow Physician-Ordered Pain Management Protocols
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for Resident 91. The clinical record review revealed that the resident had physician orders for Acetaminophen for mild pain (1-4) and Tramadol for moderate to severe pain (6-10). However, the medication administration records (MAR) from August 2023 to March 2024 showed multiple instances where Acetaminophen was administered for pain levels higher than 4, and Tramadol was administered for a pain level of 5, which did not align with the physician's orders. This indicates a failure to follow the prescribed pain management protocols for the resident. During an interview with Employee 5, a registered nurse and assistant director of nursing, it was confirmed that the pain management parameters were not followed as per the physician's orders. The surveyor's review highlighted specific dates and times when the incorrect pain medication was administered, leading to the conclusion that the facility did not provide appropriate pain management for Resident 91. This deficiency was previously cited on April 14, 2023, under the regulation 483.25(k) Pain Management and 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.
Failure to Ensure Availability of Emergency Dialysis Kits
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for two residents receiving hemodialysis. Resident 70, who has an AV fistula in his left wrist, was ordered to have an emergency dialysis kit at his bedside. However, during an observation and interview on March 26, 2024, no emergency kit was found in his room. Similarly, Resident 90, who also has an AV fistula and is ordered to receive hemodialysis, did not have an emergency kit in his room during an observation on the same day. Both residents had recently moved rooms, and the emergency kits were not transferred with them. A follow-up observation on March 27, 2024, confirmed the absence of the emergency kits in both residents' rooms. Employee 6, a licensed practical nurse, acknowledged that the kits were not moved with the residents. The Nursing Home Administrator and Director of Nursing were informed of these findings on March 27, 2024. The facility's failure to ensure the availability of emergency dialysis kits for these residents constitutes a deficiency in providing safe and appropriate dialysis care.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder (PTSD) and did not provide culturally competent, trauma-informed care to mitigate re-traumatization. Clinical record review for Resident 50 revealed that she had an active diagnosis of PTSD, which was not adequately addressed in her care plan. The care plan did not identify specific triggers that could re-traumatize her, despite her history of severe trauma, including rape by family members, physical abuse in a past relationship, and the loss of multiple pregnancies and a newborn son. This lack of detailed care planning was confirmed by the Director of Nursing during an interview. Resident 50's psychiatric note indicated that she mourns the death of her son and multiple miscarriages, cycling through the grieving process on the anniversary dates of these events. Despite these significant emotional triggers, the care plan only noted her risk for adverse effects related to the use of antipsychotic medications for various diagnoses, including PTSD, without addressing her specific trauma-related triggers. This oversight in the care plan represents a failure to provide the necessary trauma-informed care for Resident 50, potentially leading to re-traumatization and inadequate management of her PTSD symptoms.
Failure to Assess Side Rail Entrapment Risk
Penalty
Summary
The facility failed to assess the risk of side rail entrapment for three residents (Residents 74, 104, and 105). For Resident 105, although a physician ordered the use of bilateral side rails for positioning on January 30, 2024, there was no documentation indicating that the side rails were assessed for appropriateness or the resident's ability to use them. An observation on March 26, 2023, revealed the presence of bilateral side rails on the bed, despite the initial assessment indicating no need for side rails. The Director of Nursing was informed of these findings on March 29, 2024. For Resident 104, enabler bars were observed on both sides of the bed, but a family member indicated that the resident could not use them due to a lack of muscle ability. The clinical record showed severe cognitive impairment and extensive assistance required for bed mobility. The side rail consent form was incomplete, and the side rail assessment did not reflect the resident's physical inability to use the enabler bars. Similarly, Resident 74 had enabler bars on both sides of the bed, despite severe cognitive impairment and dependence on staff for bed mobility. The last side rail assessment contained inaccuracies, such as indicating no dementia despite a diagnosis and stating the resident refused bed rails while noting dementia as an alternative method. The Director of Nursing acknowledged that side rail assessments were completed on admission and the enabler bars were left on the beds without further assessment.
Lack of Competency Documentation for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, catheter care, medication administration, and dressing changes. Specifically, the facility was unable to provide documentation of competencies for two licensed practical nurses (Employees 11 and 12). The review revealed that the facility had 124 residents receiving medications, 10 residents with indwelling catheters, six residents with pressure ulcers, and two residents with enteral tube feedings. The deficiency was confirmed through staff interviews and a review of facility documentation, which showed a lack of evidence that Employees 11 and 12 had the necessary competencies to meet these residents' needs.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to monitor antibiotic use for a resident who was reviewed for a urinary tract infection. The resident was sent to the emergency room for abdominal pain and loss of appetite, where multiple studies and lab work were conducted, including a urinalysis with culture and sensitivity. The resident was returned to the facility with a diagnosis of hypernatremia, headache, and loss of appetite, but no diagnosis of a urinary tract infection. Despite this, a nursing note indicated that the resident was sent to the hospital with a diagnosis of a urinary tract infection, and the nurse practitioner ordered extra fluids while waiting for the culture and sensitivity results. The final culture and sensitivity report showed no significant growth, yet the resident was ordered Macrobid, an antibiotic, for a urinary tract infection on February 18, 2024. There was no documentation to support the need for this antibiotic, and the physician's note did not mention any new orders or the need for an antibiotic. The Director of Nursing confirmed that there was no information to justify the antibiotic order. The resident, who had a diagnosis of dementia since December 2022, was noted to be confused but had no complaints of urinary discomfort or burning. The facility failed to provide evidence or documentation to explain why the antibiotic was prescribed, leading to a deficiency in monitoring antibiotic use for the resident.
Failure to Offer Pneumococcal Conjugate Vaccines
Penalty
Summary
The facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines. Clinical record review for a resident revealed that the facility admitted her on October 6, 2022, and documented that she previously had a pneumovax 23 on March 1, 2007. However, there was no evidence in her clinical record that indicated she was offered pneumococcal conjugate vaccines. An interview with a Registered Nurse, Infection Preventionist, confirmed these findings. The facility did not follow up with the pneumococcal vaccinations for the resident and did not ensure she received the appropriate vaccinations as recommended.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and/or their responsible parties in writing of transfers to the hospital for four of six residents reviewed. Specifically, Residents 41, 60, 75, and 221 were transferred to the hospital due to changes in their conditions, but there was no documentation that the facility provided the required written notifications. These notifications should have included the reason for the transfer, the effective date, the location to which the resident was transferred, contact information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. The Director of Nursing confirmed the lack of documentation for these notifications during interviews with the surveyor. The facility also failed to notify the Office of the State Long-Term Care Ombudsman of the transfers for Residents 75 and 60. These deficiencies were identified through clinical record reviews and staff interviews, highlighting a systemic issue in the facility's process for handling hospital transfers and ensuring proper communication with residents and their representatives.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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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.
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