Harmon House Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Pleasant, Pennsylvania.
- Location
- 601 South Church Street, Mount Pleasant, Pennsylvania 15666
- CMS Provider Number
- 395726
- Inspections on file
- 39
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Harmon House Health & Rehab Center during CMS and state inspections, most recent first.
A resident who was cognitively intact, incontinent, and at risk for pressure ulcers developed full-thickness moisture-associated skin damage to the sacrum and had a physician’s order for daily cleansing and Medi-honey application. Although treatment was documented on the TAR prior to discharge, the discharge instructions marked wound care as not applicable, and the drug disposition form did not show that Medi-honey was sent home. The resident was discharged home with home health after staff reviewed medications and instructions with family, but there was no documentation that wound care instructions or Medi-honey were provided, as confirmed by the NHA.
The facility failed to follow CDC-based COVID-19 infection control practices by not promptly testing symptomatic residents who had standing orders allowing COVID-19 testing as needed and by not ensuring proper PPE use in a COVID-19-positive room. One resident experienced fever, respiratory symptoms, and systemic complaints without being tested until later, when a rapid test was finally done and was positive. Another resident had several days of cough, congestion, malaise, and remaining in bed before a rapid COVID-19 test was ordered and found positive, despite active COVID-19 cases in the building. A third resident with cough, body aches, malaise, and wheezing was tested and found positive, and transmission-based precautions were ordered. During the outbreak, a laundry aide entered the shared COVID-19-positive room of two residents wearing only a surgical mask, despite posted droplet precautions and an isolation station with N95s, gowns, gloves, and eye protection, contrary to the facility’s stated requirement that all staff don full PPE when entering COVID-19-positive rooms.
A resident with an indwelling catheter, wound infection, MS, and a Stage 4 pressure ulcer required Enhanced Barrier Precautions per physician's orders. Although appropriate signage was present and the need for infection control was documented, there was no evidence that a comprehensive, individualized care plan addressing these precautions was developed, as confirmed by the DON.
A resident with impaired mobility and pain risk did not receive diclofenac sodium topical gel as ordered, as an LPN failed to use the dosing card to measure the prescribed amount, instead applying unmeasured amounts to the resident's knee. The DON confirmed the medication should have been measured to ensure the correct dose.
Staff failed to follow Enhanced Barrier Precautions and proper hand hygiene while providing high-contact care to a resident with an indwelling catheter, wound infection, and Stage 4 pressure ulcer. Two nurse aides wore only gloves, not gowns, during care activities such as wound dressing changes and incontinent care, and did not perform hand hygiene at appropriate times, contrary to facility policy and infection control guidelines.
A resident with quadriplegia and multiple sclerosis was injured during an improper transfer when a nurse aide attempted to use a mechanical lift without the required two-person assistance. The sling pad slipped, causing the resident to fall and sustain a head laceration requiring staples. The nurse aide was aware of the facility's policy but failed to follow it, resulting in the incident.
A resident with quadriplegia and multiple sclerosis was injured during a transfer using a Hoyer lift when only one nurse aide assisted, contrary to the facility's policy requiring a two-person assist. The sling pad slipped, causing the resident to hit his head and sustain a laceration requiring staples.
A facility failed to maintain the confidentiality of residents' medical information, resulting in the unauthorized disclosure of health information for two residents. Resident 6's information was mistakenly given to a family member of another resident, who then shared it with an outside physician. Additionally, Resident 7's information was erroneously provided to the same family member upon their return to the facility.
A resident with multiple sclerosis and quadriplegia required a condom catheter, which was not documented as being changed daily according to facility policy. The issue was identified when the resident's wife requested daily changes, revealing a lack of specific physician's orders and documentation on the MARs.
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization for seven residents. These residents, who had various medical conditions, were transferred to the hospital due to changes in their conditions, but there was no documented evidence of written notices being provided to their responsible parties. This deficiency was confirmed by the Nursing Home Administrator and violated resident rights and discharge policy regulations.
The facility failed to complete comprehensive admission and annual MDS assessments within the required timeframe for five residents. The assessments were completed between 17 to 21 days after admission, exceeding the 14-day requirement. This deficiency was confirmed through clinical records and staff interviews.
The facility failed to complete quarterly MDS assessments within the required timeframe for five residents, with each assessment being completed one day late. This non-compliance was confirmed by the Nursing Home Administrator.
The facility failed to follow physician's orders for four residents, leading to deficiencies in care. A resident did not receive required assessments every shift, another had insulin held incorrectly, a third received an antibiotic for too long, and a fourth was given blood pressure medication when it should have been held. These issues were confirmed by the DON.
The facility failed to document the administration of controlled medications for two residents. One resident, who was cognitively intact and frequently in pain, had oxycodone doses signed out without evidence of administration. Another resident, cognitively impaired and frequently anxious, had diazepam doses signed out with no documentation of administration. These discrepancies were confirmed by the DON.
A resident with decreased mobility was found with the call bell out of reach, contrary to her care plan and facility policy. Interviews with an LPN and the DON confirmed the call bell should have been accessible.
A resident, who was cognitively impaired and dependent on staff, refused their prescribed antidepressant medication on multiple occasions. The facility's policy required notifying the physician of such refusals, but there was no documented evidence that this was done. The DON confirmed the lack of notification.
The facility failed to accurately complete MDS assessments for two residents. One resident was incorrectly coded for PTSD instead of a traumatic brain injury, while another resident's anticoagulant medication was not coded despite being administered. These errors were confirmed by the RNAC and DON.
A facility failed to change a resident's midline catheter dressing when it became loose, as required by policy. The resident, who was receiving IV antibiotics for bacteremia, had a compromised dressing observed on multiple occasions. Staff interviews confirmed the dressing should have been changed but was not.
The facility failed to administer oxygen as prescribed for two residents. One resident with asthma and respiratory failure received oxygen at 4 liters per minute instead of the ordered 2 liters. Another resident on hospice care with pneumonitis received oxygen at 3 liters per minute instead of the prescribed 2 liters. These discrepancies were confirmed by LPNs and the DON, indicating non-compliance with physician orders.
A facility failed to secure a medication cart, leaving it unlocked and unattended while a nurse administered medications. An unmarked medication cup with various tablets and an expired bottle of Rolaids were found in the cart. The LPN and DON confirmed these issues, indicating lapses in medication security and management.
The facility failed to maintain sanitary conditions in food service, as a dietary aide was observed without a beard guard, and the sanitizer level in the sink was consistently above the recommended range. This was confirmed by the Dietary Manager and Nursing Home Administrator.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies in areas such as physician notification, quality of care, intravenous therapy, medication accountability, and infection control. Despite plans of correction involving audits and reviews, the committee was ineffective in addressing these issues.
An LPN failed to perform hand hygiene before administering oral medications and eye drops to a resident, contrary to the facility's infection control policy. The resident had a physician's order for Restasis for dry eyes. Both the LPN and the DON confirmed the lapse in protocol.
Failure to Provide Wound Care Instructions and Supplies at Discharge
Penalty
Summary
The deficiency involved the facility’s failure to provide complete discharge information and necessary wound care supplies to a resident being discharged home. The facility’s discharge planning policy required development and implementation of a discharge plan that focused on the resident’s discharge goals, preparation for transition to post-discharge care, and reduction of preventable readmissions. The resident’s admission MDS showed the resident was cognitively intact, incontinent of bowel and bladder, and at risk for developing pressure ulcers, with no existing pressure ulcers at that time. On a later date, the resident developed full-thickness moisture-associated skin damage on the sacrum measuring 6.2 x 3.6 x 0.2 cm, and a physician’s order was initiated for daily cleansing of the sacrum with soap and water, patting dry, and application of Medi-honey once a day. The TAR documented that Medi-honey was applied on two consecutive days prior to discharge. On the day of discharge, nursing documentation indicated the resident was discharged home, medications were reviewed with a family member, and discharge instructions were provided. However, the written discharge instructions, which indicated the resident was being discharged home with home health, did not reflect that the resident was receiving wound care, as the wound care section was marked “N/A.” The drug disposition form showed that medications were sent home with the resident, but there was no documentation that Medi-honey was provided. In an interview, the Nursing Home Administrator confirmed there was no documented evidence that the resident or family received Medi-honey or wound care instructions upon discharge, despite the active physician’s order for daily wound treatment to the sacrum.
Failure to Follow COVID-19 Symptom Testing Protocols and PPE Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to follow CDC-based infection prevention and control guidelines for early detection, testing, and appropriate PPE use during a COVID-19 outbreak. CDC guidance cited in the report emphasizes routine assessment of all residents for COVID-19 symptoms, prompt testing of anyone with even mild symptoms regardless of vaccination status, and use of N95 respirators, gowns, gloves, and eye protection for all HCP entering rooms of residents with suspected or confirmed COVID-19. The facility had 18 residents develop COVID-19 between late December and early January and 11 active cases at the time of the on-site visit, yet staff practices and testing decisions did not consistently align with these guidelines. For Resident 4, who had a standing physician order allowing COVID-19 testing as needed per protocol, nursing documentation on one date showed a low-grade fever, body aches, chills, shortness of breath, and a dry cough. Despite these symptoms and the standing order, no COVID-19 test was performed at that time. Later in the month, the resident again exhibited symptoms including headache, fatigue, malaise, cough, and a temperature of 100.4°F, at which point a rapid COVID-19 test was performed and was positive, and isolation/combined droplet/contact precautions were ordered. During interview, the IP and DON stated that symptomatic residents would typically be tested, but that this depended on the practitioner, and the DON confirmed that Resident 4 had standing orders for testing that were not used on the earlier symptomatic date. For Resident 10, who also had a standing order permitting COVID-19 testing as needed, multiple nursing notes over several days documented cough, congestion, malaise, pale skin, and remaining in bed due to not feeling well, while the facility already had active COVID-19 cases. COVID-19 testing was not obtained until several days after the onset of these symptoms, when the CRNP was notified and ordered a rapid COVID-19 swab that resulted positive, and isolation/combined droplet/contact precautions were then ordered. For Resident 11, a nursing note documented that the resident did not feel well, had a moist productive cough, body aches, malaise, and expiratory wheezing; a rapid COVID-19 swab was ordered and was positive, and transmission-based precautions were ordered. Additionally, an observation showed a laundry aide entering the shared COVID-19-positive room of Residents 10 and 11 wearing only a surgical mask, despite droplet precaution signage and an isolation station with N95 masks, gowns, gloves, and eye protection at the door. The laundry aide acknowledged he should have gowned and possibly worn an N95 and confirmed he did not initially realize the PPE was available, while the IP confirmed that all staff entering COVID-19-positive rooms were required to don gloves, an N95, eye protection, and a gown.
Failure to Develop Comprehensive Care Plan for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with specific and individualized interventions for a resident who required Enhanced Barrier Precautions. The facility's policy required that each resident have a care plan with measurable goals and timetables to address their medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. For the resident in question, the quarterly MDS assessment documented significant care needs, including an indwelling catheter, a wound infection, Multiple Sclerosis, and a Stage 4 pressure ulcer in the sacral region. Physician's orders specified the use of Enhanced Barrier Precautions, and signage was observed outside the resident's room indicating the required infection control measures for high-contact care activities. Despite these documented needs and orders, there was no evidence in the clinical record that a comprehensive care plan addressing the resident's Enhanced Barrier Precautions had been developed. This was confirmed by the Director of Nursing during an interview, who acknowledged the absence of such documentation. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Measure and Administer Topical Medication per Physician Order
Penalty
Summary
A deficiency was identified when staff failed to follow physician's orders and manufacturer’s directions for administering diclofenac sodium topical gel 1 percent to a resident. The physician's order specified that four grams of the gel should be applied to the resident's right knee four times daily, and the manufacturer's instructions required the use of a dosing card to measure the correct amount. During a medication administration observation, an LPN applied the gel to the resident's knee without using the dosing card, instead squeezing unmeasured amounts onto her gloved finger and applying it to the resident’s knee. The resident involved had impaired mobility and was at risk for pain, as documented in the care plan and Minimum Data Set assessment. The LPN confirmed in an interview that she did not use the dosing card, believing it was only provided with prescription strength gel, not the over-the-counter version supplied by the facility’s pharmacy. The DON also confirmed that the gel should have been measured to ensure the correct dose was administered as ordered.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC, as well as its own policy, during the care of a resident with an indwelling catheter, wound infection, Multiple Sclerosis, and a Stage 4 pressure ulcer. The resident had physician's orders for Enhanced Barrier Precautions (EBPs), which require staff to wear gloves and gowns during high-contact care activities. Despite clear signage and policy, two nurse aides entered the resident's room wearing only gloves and proceeded to provide high-contact care, including rolling the resident, removing soiled dressings, providing incontinent care, and handling a mechanical lift sling, without donning gowns as required. Additionally, one of the nurse aides failed to remove gloves and perform hand hygiene after removing wound dressings and providing incontinent care, before continuing with other care tasks. Both aides only removed their gloves and used hand gel after several care activities had already been performed. These actions were confirmed by the Director of Nursing to be inconsistent with facility policy and infection control guidelines, specifically regarding the use of gowns and proper hand hygiene during care for residents on EBPs.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that residents were free from abuse or neglect, as evidenced by an incident involving a resident who was transferred incorrectly, resulting in a fall and a head laceration requiring staples. The facility's policy on mechanical lifts required a two-person assist for all mechanical lifts, including Hoyer lifts. However, during the transfer of a resident with quadriplegia and multiple sclerosis, Nurse Aide 1 attempted to transfer the resident alone using a mechanical lift. This resulted in the sling pad slipping from under the resident, causing him to hit his head on the headboard and sustain a laceration. The resident, who was cognitively intact and dependent on staff for daily care needs, was transferred to the emergency room where he received three staples to the back of his head. The incident report confirmed that Nurse Aide 1 was aware of the facility's policy requiring two-person assistance for transfers but failed to adhere to it. The Director of Nursing confirmed that Nurse Aide 1 should have had a second person assist with the transfer, as per the facility's policy.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for a resident who was dependent on staff for care, including transfers and bed mobility, due to quadriplegia and multiple sclerosis. The facility's policy required a two-person assist for all mechanical lifts, including Hoyer lifts. However, an incident occurred where the resident was transferred using a Hoyer lift by only one nurse aide. During the transfer, the sling pad slipped from under the resident, causing him to hit his head on the headboard and sustain a laceration that required staples. The resident was cognitively intact and understood by others, as indicated in a recent Minimum Data Set assessment. The incident report confirmed that the transfer was conducted by a single staff member, contrary to the facility's policy. The Director of Nursing confirmed that two people should have been involved in the transfer, highlighting the failure to adhere to established safety protocols for resident transfers using mechanical lifts.
Confidentiality Breach of Residents' Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information, affecting two of the seven residents reviewed. The incident involved the unauthorized disclosure of health information for two residents. Specifically, Resident 6's health information was mistakenly provided to a family member of another resident, Resident 1, who then shared it with an outside physician. Additionally, when the family member returned to the facility, they requested Resident 1's health information but were erroneously given Resident 7's health information instead. The facility's policy on privacy, dated January 22, 2024, stipulates that protected health information should only be used and disclosed as permitted under HIPAA rules. However, the investigation dated September 15, 2024, revealed that these policies were not adhered to, resulting in the breach of confidentiality for Residents 6 and 7. The Nursing Home Administrator confirmed the breach during an interview, acknowledging that the health information of Residents 6 and 7 was improperly disclosed to Resident 1's family member.
Incomplete Documentation of Condom Catheter Care
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident who required the use of a condom catheter. The facility's policy stated that condom catheters should be changed daily and as needed. However, a review of the resident's Medication Administration Records (MARs) for several months revealed no documented evidence that the catheter was being changed daily as per the policy. This discrepancy was identified when the resident's wife requested daily changes, leading to the realization that there was no specific physician's order for this practice. The resident, who had multiple sclerosis and quadriplegia, was understood to require an external catheter due to neuromuscular dysfunction of the bladder. Despite the care plan and physician's orders indicating the need for catheter care every shift, the lack of documentation on the MARs until a specific order was obtained highlighted a gap in adherence to the facility's policy. Interviews with staff confirmed that the catheter was being changed during routine catheter care, but this was not properly documented until the issue was addressed following the family's request.
Failure to Notify Residents and Guardians of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization, as required by regulations. This deficiency was identified for seven residents during a review of clinical records and staff interviews. The residents involved were cognitively intact and required assistance with daily care needs, with various medical conditions such as diabetes, myocardial infarction, pressure sores, dementia, chronic obstructive pulmonary disease, and infections. For each of the seven residents, nursing notes documented instances where they were transferred to the hospital due to changes in their medical conditions, such as shortness of breath, increased confusion, unresponsiveness, and infections. Despite these transfers, there was no documented evidence that written notices were provided to the residents' responsible parties, explaining the reasons for the transfers. This lack of documentation was confirmed during an interview with the Nursing Home Administrator. The specific cases included residents being sent to the hospital for issues like a large area under a cast needing debridement, an unstageable diabetic pressure ulcer, and abnormal lab results indicating renal failure. The facility's failure to provide the required written notifications violated resident rights and discharge policy regulations, as outlined in 28 Pa. Code 201.25 and 28 Pa. Code 201.29(f)(g).
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive admission and annual Minimum Data Set (MDS) assessments were completed within the required time frame for five residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 12, 53, 65, 69, and 77 were completed beyond this timeframe, with delays ranging from 17 to 21 days after admission. The deficiency was confirmed through a review of clinical records and staff interviews, which revealed that the comprehensive MDS assessments for these residents were completed late. The Nursing Home Administrator acknowledged the late completion of these assessments during an interview. This failure to adhere to the mandated assessment schedule was identified as past non-compliance.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for five residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 calendar days after the ARD. However, the assessments for Residents 2, 17, 47, 59, and 72 were completed 15 days after their respective ARDs, exceeding the allowed timeframe. The specific instances of non-compliance included Resident 2's assessment, which was completed one day late, and similar delays for Residents 17, 47, 59, and 72. These delays were confirmed during an interview with the Nursing Home Administrator. The deficiency was identified as past non-compliance, indicating that the facility had previously failed to adhere to the required timelines for completing MDS assessments.
Failure to Follow Physician's Orders for Medication and Assessments
Penalty
Summary
The facility failed to adhere to physician's orders for four residents, leading to deficiencies in care. For Resident 17, the facility did not consistently perform the required full head-to-toe assessments with vital signs every shift, as ordered by the physician. Documentation showed that the assessment was only completed once, despite the order for it to be done per shift. Resident 37, who was moderately cognitively impaired and had diabetes, had their insulin held on multiple occasions when their blood sugar levels were above the threshold that required holding the medication, contrary to the physician's orders. Resident 40, who was cognitively intact and receiving antibiotics, was administered Cipro for 11 days instead of the prescribed 10 days, resulting in two additional doses. Resident 46, who was cognitively impaired and had hypertension, received metoprolol tartrate on several occasions when their systolic blood pressure was below the threshold that required holding the medication, as per the physician's orders. These actions were confirmed through interviews with the Director of Nursing, who acknowledged the discrepancies between the physician's orders and the care provided.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents, as revealed through a review of policies, clinical records, and staff interviews. For one resident, who was cognitively intact and frequently experienced pain, there were physician's orders for oxycodone to be administered as needed. However, the controlled drug record indicated that doses were signed out on several occasions, but there was no documented evidence in the clinical record that these doses were actually administered. This discrepancy was confirmed by the Director of Nursing during an interview. Similarly, another resident, who was cognitively impaired and frequently experienced anxiety, had physician's orders for diazepam to be applied as needed. The controlled drug record showed that doses were signed out on specific dates, but again, there was no documented evidence in the clinical record that these doses were administered. This lack of documentation was also confirmed by the Director of Nursing. These findings indicate a failure to adhere to the facility's policy and applicable laws regarding the documentation and administration of controlled substances.
Failure to Ensure Call Bell Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring that the call bell was within reach. Resident 8, who required maximum assistance for transfers and toileting due to decreased mobility, was observed on June 24, 2024, with the call bell hanging off the back of the bed onto the floor, out of her reach. The resident's care plan specified that the call bell should be within reach, and the facility's policy, dated August 14, 2023, also required that the call light be within easy reach. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the call bell should have been accessible to the resident.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner about a change in the resident's condition, specifically the refusal of medication. According to the facility's policy dated August 14, 2023, the physician should be notified if a resident refuses medication for more than 24 hours. Resident 52, who was cognitively impaired and dependent on staff assistance, was receiving an antidepressant, Lexapro, as per physician's orders dated June 23, 2023. The resident refused the medication on multiple occasions in June 2024, specifically on the 1st, 2nd, 3rd, 4th, 17th, and 18th. However, there was no documented evidence that the physician was informed of these refusals. This was confirmed during an interview with the Director of Nursing on June 26, 2024.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment incorrectly indicated a diagnosis of post-traumatic stress disorder (PTSD) in Section I16100, despite a social service note stating that the resident had not experienced or witnessed a life-threatening or traumatic event. The Registered Nurse Assessment Coordinator confirmed that the section should have been coded for a traumatic brain injury instead. For another resident, the MDS assessment failed to code for anticoagulant medication in Section N0415E1, even though the resident had been receiving Warfarin, an anticoagulant, as per physician's orders during the seven-day look-back period. The Director of Nursing confirmed that the resident had received the medication and should have been coded accordingly.
Failure to Change Compromised IV Dressing
Penalty
Summary
The facility failed to adhere to its policy regarding the timely changing of IV dressings for a resident, leading to a deficiency. The policy required that midline catheter dressings be changed weekly and whenever the dressing's integrity was compromised, such as when it became wet, loose, or soiled. Additionally, staff were expected to assess the midline insertion site with each medication administration. However, observations on multiple occasions revealed that the midline dressing on a resident's right arm was loose and had lost its integrity, indicating that the dressing was not changed as required by the facility's policy. The resident involved was moderately cognitively impaired and had medical conditions including bilateral stasis leg ulcers and bacteremia, for which they were receiving intravenous antibiotics. Despite the physician's orders for the administration of Zosyn three times a day, the compromised dressing was not addressed promptly. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the dressing was visibly loose and should have been changed when its integrity was compromised, but it was not, leading to the deficiency finding.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to ensure that residents received oxygen as ordered by the physician for two residents. Resident 8, who was cognitively intact and had diagnoses including asthma and respiratory failure, was observed receiving oxygen at a flow rate of 4 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by both a Licensed Practical Nurse and the Director of Nursing, indicating a failure to adhere to the physician's orders. Similarly, Resident 70, who was severely cognitively impaired and on hospice care with diagnoses including pneumonitis and anxiety, was observed receiving oxygen at a flow rate of 3 liters per minute instead of the ordered 2 liters per minute. This was also confirmed by a Licensed Practical Nurse and the Director of Nursing. These findings demonstrate a failure to provide respiratory care in accordance with physician orders, as required by the facility's policy and state regulations.
Medication Security and Management Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications in one of the four medication carts reviewed. During an observation, it was noted that the lower level medication cart was left unlocked and unattended while a nurse was administering medications to residents in a room with the door shut, blocking the nurse's view of the cart. This lack of supervision could potentially lead to unauthorized access to medications. Additionally, an undated and unmarked medication cup containing various tablets was found in the top drawer of the cart, indicating a lapse in proper medication labeling and handling procedures. Further inspection of the stock drawer in the same medication cart revealed an opened bottle of Rolaids with an expiration date that had already passed. Interviews with the LPN and the Director of Nursing confirmed these findings, acknowledging that the medication cart should have been kept in full view while in use, and that expired medications and unmarked medication cups should not have been present in the cart. These observations highlight deficiencies in the facility's adherence to pharmacy and nursing service regulations.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served under sanitary conditions, as required by professional standards for food service safety. Observations in the main kitchen revealed that a dietary aide did not have a beard guard covering his beard, which was confirmed by the Dietary Manager. Additionally, the sanitizer level in the three-compartment sink was consistently recorded at 500 parts per million (ppm) on multiple dates, exceeding the manufacturer's recommended level of 200-400 ppm. This was confirmed by the Nursing Home Administrator, who acknowledged that the sanitizer level was not within the recommended range on the specified dates.
Repeated Deficiencies in Quality Assurance Processes
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in multiple surveys. These deficiencies included issues with notifying the physician or responsible party about changes in a resident's condition, quality of care, intravenous therapy, accountability of controlled medications, proper storage and labeling of medications, food preparation and storage under sanitary conditions, and infection control practices. Despite developing plans of correction that included audits and reporting results to the QAPI committee, the facility was unable to effectively address these recurring issues. The deficiencies were identified in surveys conducted on various dates, including July 20, September 18, and October 25, 2023, as well as the current survey ending June 27, 2024. The facility's plans of correction consistently involved completing audits and reviewing the results as part of quality assurance, but the QAPI committee was ineffective in implementing these plans to ensure ongoing compliance with the regulations. The repeated nature of these deficiencies indicates a systemic issue within the facility's quality assurance processes.
Infection Control Lapse in Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration, as observed during a survey. The facility's policy, dated August 14, 2024, required staff to perform hand hygiene before administering medications, including eye drops. However, on June 26, 2024, an LPN was observed administering oral medications and eye drops to Resident 15 without performing hand hygiene. Resident 15 had a physician's order for Restasis, an eye medication for dry eyes, to be administered twice daily. The LPN confirmed during an interview that she did not perform hand hygiene as required. The Director of Nursing also confirmed the lapse in protocol during a subsequent interview.
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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