Guy And Mary Felt Manor, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Emporium, Pennsylvania.
- Location
- 110 East Fourth Street, Emporium, Pennsylvania 15834
- CMS Provider Number
- 395356
- Inspections on file
- 19
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Guy And Mary Felt Manor, Inc during CMS and state inspections, most recent first.
Two residents experienced a decline in range of motion (ROM) that was not addressed by facility staff after discharge from physical therapy. In both cases, assessments documented new bilateral impairments, and recommended interventions such as a walk to dine program were not implemented by nursing staff, as confirmed by staff interviews.
The facility did not follow CDC guidelines for COVID-19 work exclusions and outbreak testing, failed to implement proper transmission-based and enhanced barrier precautions for residents with infections or wounds, did not communicate critical lab results after a resident's hospital stay, and handled soiled personal laundry in a manner that did not prevent infection spread. Staff returned to work before meeting return-to-work criteria, did not use required PPE, and laundry was stored in open hampers without proper containment.
Three residents were not offered updated pneumococcal vaccines in line with current CDC recommendations, despite facility policy requiring immunization review and documentation. Clinical records and staff interviews confirmed the absence of offers or documentation for PCV15, PCV20, or PCV21, and the facility's policy did not reference these newer vaccines.
Two residents had POLST forms in their physical charts indicating a desire for CPR but refusal of intubation (DNI), while their electronic medical records and active physician orders instructed staff to implement Full Code treatment without any restriction. Staff confirmed they would follow the electronic orders, which did not reflect the residents' DNI preferences, leading to inconsistent documentation and potential disregard of resident wishes.
A resident reported $80 missing from their purse after receiving money from their spouse for personal use. Despite being notified of the missing funds, facility staff did not promptly initiate or document a thorough investigation as required by policy, and necessary notifications to agencies were delayed until after the issue was raised by surveyors.
A resident reported missing funds from their purse, but the facility did not document or report the suspected misappropriation to the appropriate authorities within the required timeframe. The delay in reporting was only addressed after a surveyor became aware of the concern and notified facility leadership.
Surveyors identified that two residents did not have comprehensive care plans addressing all their needs. One resident experienced multiple falls and had significant medical conditions, including anticoagulant use and a pacemaker, which were not reflected in her care plan. Another resident with a history of MRSA urinary tract infection and on contact isolation also lacked appropriate care plan documentation for these issues.
Surveyors found that pharmacy recommendations regarding unnecessary medications and appropriate diagnoses were not properly addressed for two residents. In one case, a pharmacist's suggestion to discontinue supplements and update medication indications was not reflected in physician orders. In another, a pharmacist's request for an appropriate diagnosis for an antipsychotic was met with a physician response, but the facility did not document follow-up. These deficiencies were confirmed through record review and staff interviews.
A registered nurse failed to lock a treatment supply cart containing biologicals while performing wound care for a resident, leaving the cart unattended and unsecured in the hallway.
Two nurse aides did not receive the required 12 hours of annual in-service training, with one completing only 9.5 hours and the other 11 hours, as confirmed by review of training records and staff interviews.
A facility failed to implement necessary mobility treatment and services for a resident, as adjustments to the resident's wheelchair were not made, and physical therapy services were not documented. The resident's wheelchair seat was too high, preventing effective self-propulsion, and despite evaluations, no modifications were documented. Additionally, a physician's order for continued physical therapy was not followed, contributing to the deficiency.
Failure to Maintain or Address Decline in Range of Motion for Two Residents
Penalty
Summary
The facility failed to provide appropriate services to maintain or improve range of motion (ROM) for two residents with identified ROM concerns. For one resident, initial assessments indicated no impairment in ROM, but a subsequent quarterly assessment showed a decline with bilateral impairments in both upper and lower extremities. Despite this decline, there was no evidence in the clinical record that the facility addressed the resident's decreased ROM after discharge from physical therapy. Similarly, another resident was assessed as having no ROM impairment on an annual assessment, but a later quarterly assessment documented a decline with bilateral impairments. Physical therapy discharge documentation recommended a walk to dine program for this resident, but there was no evidence that this program was implemented by nursing staff. Interviews with facility staff confirmed that the recommended interventions were not carried out for either resident.
Infection Control Failures in COVID-19 Management, Precautions, and Laundry Handling
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in COVID-19 management, transmission-based precautions, enhanced barrier precautions, communication of pertinent clinical information, and laundry handling. Employees who tested positive for COVID-19 returned to work before meeting CDC criteria for healthcare personnel, including the absence of required negative tests and insufficient isolation periods. The facility also did not conduct appropriate outbreak testing for staff and residents during three separate COVID-19 outbreaks, and testing logs did not align with CDC guidelines regarding timing and inclusion of vaccinated staff. Transmission-based precautions were not properly followed for a resident with a urinary tract infection caused by MRSA. Staff failed to don required personal protective equipment, such as gowns, when entering the resident's room and did not use dedicated equipment, resulting in potential contamination of shared medical equipment and surfaces. Additionally, enhanced barrier precautions were not observed during wound care for another resident, as staff did not use gowns and failed to perform hand hygiene between glove changes, contrary to facility policy and CDC recommendations. The facility also lacked a process to obtain and communicate pertinent clinical information following a resident's acute care hospital treatment for a urinary tract infection, resulting in the continued administration of an antibiotic that was not the most effective for the identified organism. Furthermore, the handling and processing of residents' personal laundry did not adhere to infection control standards, with soiled laundry stored in open, unlidded hampers and staff not using appropriate protective equipment or following manufacturer guidelines for laundry processing. These failures were confirmed through staff interviews, record reviews, and direct observations.
Failure to Offer Updated Pneumococcal Vaccines per CDC Guidance
Penalty
Summary
The facility failed to offer pneumococcal vaccines in accordance with current CDC recommendations to three of five residents reviewed for immunizations. Facility policy required that all residents receive appropriate pneumococcal vaccines unless contraindicated or refused, with immunization status determined at admission and documented in the electronic medical record. However, clinical record reviews revealed that one resident, admitted at age 83, had only received a PPSV23 vaccine prior to admission, with no evidence of being offered additional recommended pneumococcal vaccines such as PCV15, PCV20, or PCV21. Two other residents, both of whom had received PCV13 and PPSV23 prior to admission, also had no documentation indicating they were offered the newer pneumococcal vaccines as recommended by current CDC guidance. Interviews with the infection control prevention coordinator confirmed that there was no additional evidence of these residents being offered the appropriate pneumococcal immunizations. The facility's active policy did not reference the newer available vaccines (PCV15 or PCV21), and there was no documentation of offers or administration of these vaccines in the residents' medical records. These findings were based on a review of facility policies, clinical records, and staff interviews.
Inconsistent Advance Directive Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that residents' wishes regarding advance directives were clearly established and consistently reflected in both the physical and electronic medical records for two of four residents reviewed. For one resident, the physical chart contained a POLST form signed by both the physician and the resident, indicating a desire for CPR but a refusal of intubation (DNI). However, the electronic medical record and active physician orders instructed staff to implement Full Code treatment without any restriction on intubation. Staff interviews confirmed that in the event of a medical emergency, they would follow the electronic orders, which did not reflect the resident's DNI preference. Similarly, another resident's physical chart included documentation that a POLST was completed with the resident and her son, designating CPR with limited interventions and a DNI order. The POLST was signed by the physician and the resident's responsible party. Despite this, the electronic medical record and active physician orders indicated Full Code treatment without any restriction on intubation. Staff confirmed that, based on the electronic orders and absence of a physical chart indicator, they would provide Full Code CPR without honoring the DNI preference. These discrepancies were reviewed with facility leadership during the survey.
Failure to Promptly Investigate and Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate and notify the appropriate agencies regarding an incident of potential misappropriation of a resident's money. A resident reported that $80 was missing from their purse, which had been given to them by their spouse for use at the beautician. The resident discovered the missing funds approximately one week prior to notifying the facility and subsequently sent the purse home with their spouse. The resident and their spouse had previously declined to set up a resident fund account or use a key-locked drawer for securing personal funds, and there was no documentation of any prior incidents involving missing funds for this resident. Upon notification of the missing money, the facility's social worker re-educated the resident and spouse about available options for securing funds, but both continued to decline these services. Despite the facility's policy requiring prompt and thorough investigation of misappropriation allegations, there was no documentation that an investigation was initiated or conducted prior to several days after the incident was reported. Documentation of required investigative steps, such as interviews and searches, was not provided until after the surveyor's request, indicating a delay in the facility's response to the reported misappropriation.
Failure to Timely Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to develop and/or implement policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, specifically regarding the misappropriation of resident property. A resident reported that $80 was missing from their purse, which had been given to them by their spouse for use at the facility's beautician. The resident notified the facility of the missing funds, but there was no documentation in the clinical record of any incident or reported misappropriation at the time of notification. The facility's policy required immediate reporting of such allegations to the administrator and to the State Agency and law enforcement within 24 hours if the event did not result in serious bodily injury. Despite being notified of the missing funds, the facility did not report the reasonable suspicion of misappropriation to the Department of Health, Department of Aging, or law enforcement until almost five days after the initial notification by the resident. The required agencies were not notified until after the surveyor became aware of the concern and informed the facility. This delay in reporting was confirmed through interviews with facility leadership and review of the facility's electronic reporting system and mandatory abuse reports.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in deficiencies related to unmet care needs. For one resident, clinical records showed multiple falls from her wheelchair, with documented interventions after each incident instructing staff to encourage her to lie in bed when appearing sleepy. However, these interventions were not incorporated into her official care plan. Additionally, despite the resident's use of an anticoagulant and the presence of a cardiac pacemaker, her care plan did not address these significant medical factors. Another resident was admitted with a urinary tract infection caused by MRSA, requiring antibiotics and contact isolation precautions. Documentation confirmed the presence of MRSA in her urine and the implementation of contact precautions, including signage and the use of personal protective equipment by staff. Despite these measures being in place, the resident's care plan did not include her history of urinary tract infections with a multi-drug-resistant organism or the need for contact isolation. Interviews with facility leadership and staff confirmed the absence of these critical interventions and medical conditions in the residents' care plans. The lack of comprehensive and updated care plans for both residents was identified through clinical record review, observation, and staff and resident interviews.
Failure to Address Pharmacy Recommendations for Medication Use
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were properly addressed by the attending physician for two residents reviewed for unnecessary medications. For one resident, the consultant pharmacist identified that daily supplements of Vitamin D and oyster shell calcium may be unnecessary and requested the physician to consider discontinuation, but there was no documented physician response. Additionally, the pharmacist requested an updated diagnosis to justify the combined use of Prozac and Zyprexa for treatment-resistant major depressive disorder. Although the physician indicated that orders were updated, the active orders continued to list previous diagnoses, and there was no evidence that the orders were revised to reflect the pharmacist's recommendation. For another resident, the consultant pharmacist noted that Risperidone was prescribed for dementia, which is not an approved diagnosis for this medication, and requested clarification. The physician later indicated the medication was for depression, but there was no documentation that the facility addressed or followed up on the physician's response to the pharmacist's recommendation. These findings were confirmed through clinical record review and staff interviews, indicating a failure to ensure that pharmacy recommendations were appropriately addressed and documented.
Unsecured Treatment Cart During Wound Care
Penalty
Summary
A registered nurse was observed gathering wound care supplies from a treatment supply cart located in the hallway and entering a resident's room to perform wound care. The nurse shut the door and began the procedure, leaving the treatment supply cart unattended and unlocked in the hallway. After completing the dressing change, the nurse confirmed in an interview that the cart had not been locked while unattended. This failure to secure the treatment cart resulted in treatment biologicals being left unsecured during the wound care process.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of annual in-service training, as evidenced by a review of employee education records and staff interviews. Specifically, two out of three nurse aides reviewed did not meet the annual training requirement: one received only 9.5 hours and the other 11 hours of in-service training in the past year. During meetings with the Nursing Home Administrator and the DON, it was confirmed that there was no additional documentation to show that these nurse aides had completed the mandated training hours. This deficiency was identified through a review of training records and confirmed by staff interview.
Failure to Implement Mobility Treatment and Services
Penalty
Summary
The facility failed to implement necessary treatment and services for a resident's mobility, as evidenced by the lack of adjustments to the resident's wheelchair and the absence of physical therapy services. The resident, identified as CR1, had a physical therapy discharge summary indicating that her wheelchair seat was too high, preventing her from self-propelling. Although an outside resource assessed the situation and adjustments were pending, there was no evidence in the clinical record that these adjustments were made. Furthermore, a physician's order for continued physical therapy was not followed, as there was no documentation of therapy services being provided after a certain date. An interview with a physical therapy assistant revealed that the resident had decreased mobility and used her feet to propel her wheelchair. However, the height of the wheelchair seat caused her knees to remain bent, limiting her ability to self-propel effectively. Although a customized wheelchair was provided to stretch her legs, it reduced her feet's contact with the floor. The facility evaluated the chair again but did not document any modifications to improve the situation. The lack of documentation and follow-up on the resident's physical therapy needs contributed to the deficiency identified by the surveyors.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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