Haven Place Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lock Haven, Pennsylvania.
- Location
- 24 Cree Drive, Lock Haven, Pennsylvania 17745
- CMS Provider Number
- 395031
- Inspections on file
- 19
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Haven Place Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not complete required background checks and reference verifications for several newly hired staff, including not determining residency status or obtaining FBI checks when necessary, and failed to document reference checks as required by policy.
A resident's restorative nursing ambulation program, which required extensive assistance from two staff and a third person with a wheelchair, was not completed as ordered. Staff documented the intervention as not applicable on several occasions without explanation, and no further documentation was available to account for the missed sessions.
A resident with physician orders for Humira to treat psoriasis did not receive any doses over a two-month period due to ongoing issues with prior authorization and medication availability. Nursing documentation repeatedly noted the medication was unavailable, and there was no evidence that the physician was notified of the missed doses until much later. This resulted in a failure to provide the highest practical care related to the resident's medication regimen.
A resident did not consistently receive a prescribed restorative active ROM program, as documentation showed multiple days where the program was either not completed or not documented on both day and evening shifts. This deficiency was identified through record review and staff interviews, and facility leadership was informed.
The facility did not provide documentation confirming that RNs and LPNs had the required competencies for care activities such as enteral tube feeding, use of lifts, catheter care, medication administration, and dressing changes, despite having residents with these needs. This was confirmed by the NHA and DON during the survey.
Staff failed to store medications and treatments as required, with a resident's topical creams left unsecured on a nightstand and medication carts containing unsecured, unidentified pills and an unlabeled tube of Diclofenac. Facility policy mandates all drugs and biologicals be stored in locked compartments and properly labeled, but these requirements were not met, as confirmed by the DON and administrator.
Surveyors observed that food items in the main kitchen were left uncovered in the walk-in cooler, a chemical dispenser was leaking blue liquid onto the dishwasher and floor, expired and unlabeled food was found in the freezer, a broken container with jagged edges was used for crackers, and there was significant dust and debris accumulation in various kitchen areas. These issues were confirmed with facility leadership.
A resident with a court-appointed guardian, lacking capacity to make responsible decisions, was allowed to sign a binding arbitration agreement without evidence of understanding or proper explanation. The facility's arbitration agreement also failed to inform residents or their representatives that signing did not restrict communication with federal, state, or local officials. Staff confirmed these omissions and the resident was unaware of the agreement she signed.
The facility did not ensure that its QAPI committee included the medical director at least quarterly, as required. Review of meeting attendance records and staff interview confirmed that the medical director attended only one meeting during the review period.
A resident's privacy was not maintained during an enteral feed administration by an LPN, as the resident was left exposed without the privacy curtain pulled, and the roommate was present in the room observing the procedure. Facility policy requires privacy for non-oral medication administration, but this was not followed.
A resident with cerebral palsy who required substantial to maximum assistance for ADLs was observed with several days of beard growth and long, unclean fingernails. The resident stated he preferred to be clean shaven but could not access his razor, which was out of reach. There was no documentation or evidence that staff provided needed assistance with shaving or nail care, and facility leadership confirmed the resident's inability to perform these tasks independently.
A resident with Alzheimer's Disease and cognitive impairment experienced two falls when the required bed alarm was either not sounding due to low volume or not turned on. Staff failed to consistently document the alarm's presence and function, and statements confirmed the alarm was not effective during the incidents, leading to unassisted resident movement and falls.
A resident with dementia was observed using bilateral enabler bars, with initial assessment and informed consent documented. However, there was no evidence of ongoing monitoring or reassessment of the resident's need for bedrails or evaluation of associated risks, despite facility policy requiring such actions.
The facility did not conduct required annual performance evaluations for two nurse aides, as shown by a review of personnel records and confirmed by the administrator. Documentation of evaluations at least every 12 months was missing for both employees.
A resident with a diagnosis of dementia was admitted and assessed as needing a person-centered care plan to address cognitive loss, but the facility did not develop or implement such a plan. This lack of documentation was confirmed by facility leadership during the survey.
The facility failed to maintain a current water management program specific to its building, instead providing a plan from another facility and lacking required documentation and procedures to prevent water-borne contaminants like Legionella. Additionally, an LPN did not follow enhanced barrier precautions while providing enteral feeding to a resident with a PEG tube, despite clear signage and physician orders.
A resident at Haven Place experienced significant weight loss due to inadequate monitoring and assessment of their nutritional status. Despite being on a full liquid diet with specific dietary supplements, the resident continued to lose weight, and there was no evidence of adjustments to their dietary plan. Concerns from the resident's responsible party about nutritional supplement delivery were noted, but further interventions were not documented.
A nurse aide at an LTC facility recorded and broadcasted live TikTok videos while providing care to two cognitively impaired residents, exposing them to potential humiliation and degradation. The aide did not inform the residents of the recording nor obtain their consent, violating their rights to privacy and dignity. The incident was reported anonymously, leading to an investigation and suspension of the aide.
A nurse aide at a facility used a personal electronic device to record and broadcast a live TikTok video, showing two residents during care, including incontinence care, without their consent. This action violated privacy regulations and facility policies, as confirmed by the Nursing Home Administrator and DON.
The facility did not meet the required minimum staffing levels for nurse aides during specific shifts. On certain day, evening, and overnight shifts, the number of nurse aides was below the required levels for the resident census. These deficiencies were confirmed during an interview with the Nursing Home Administrator and DON.
A resident's advance directive documentation was inconsistent, with conflicting DNR and CPR orders in their records. Despite the resident's expressed wish for CPR, the facility failed to update the physician order, leading to confusion about the resident's resuscitation preferences.
A resident who requires extensive assistance for personal hygiene was not shaved as needed due to dull razors, leading to cuts. Despite a care plan and MDS assessment indicating the need for substantial assistance, the facility failed to provide an electric razor in the resident's room, resulting in unmet hygiene needs.
The facility failed to provide appropriate pain management for two residents by not adhering to physician orders and failing to document pain levels accurately. For one resident, staff administered Oxycodone without documenting pain levels or for incorrect pain levels. For another resident, Oxycodone was given for a pain level outside the prescribed range, and Acetaminophen was administered without documenting a pain level.
A resident with COVID-19 was not properly protected due to staff failing to adhere to transmission-based precautions. A nurse aide entered the resident's room with only an N95 mask, and an LPN entered without any PPE, despite clear signage. Another nurse was unsure about handling used N95 masks, indicating a lack of proper infection control training.
Failure to Complete Required Staff Background and Reference Checks
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not conducting thorough investigations into the employment history of five newly hired employees. Review of personnel records for these employees revealed that there was no evidence the facility attempted to obtain personal or professional reference information, as required by their own policy. Additionally, the facility's policy mandates criminal background screening and reference checks prior to employment, but these steps were not consistently documented or completed for the reviewed staff. Further review showed that the facility did not determine whether the five employees had resided in Pennsylvania for the previous two years, nor did it complete the required FBI background checks for those who may not have met the residency requirement. One employee's criminal background check was not completed until several months after hire, contrary to state regulations that require such checks within 30 days of employment. These findings were confirmed by the facility's human resources staff during an interview.
Failure to Complete Restorative Ambulation Program as Ordered
Penalty
Summary
The facility failed to complete a restorative nursing ambulation program as ordered for one resident. Clinical record review showed that the resident was to be ambulated with extensive assistance of two staff for 20-40 feet using a front wheeled walker, with a third person following with a wheelchair, and this was to occur during the day shift. Documentation for the resident's restorative ambulation program in August 2025 indicated that staff marked the intervention as not applicable (NA) on multiple dates without providing any explanation. Further review and interviews with the Nursing Home Administrator and Director of Nursing confirmed that there was no additional staff documentation to account for the missed ambulation sessions.
Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
The facility failed to provide the highest practical care related to medication administration for a resident with a physician's order for Humira to treat psoriasis. The resident was admitted on November 11, 2024, and had multiple physician orders for Humira beginning June 30, 2025, including changes in dosage and frequency. Despite these orders, nursing documentation repeatedly noted that Humira was unavailable due to pending prior authorization from the pharmacy, with entries on June 30, July 8, July 21, August 4, August 18, and September 1, 2025, all indicating the medication was not available and had not been administered. Throughout this period, there was no documentation that the resident's physician was notified of the ongoing unavailability of Humira until September 1, 2025, despite the medication never being administered since the initial order. The deficiency was confirmed by interviews with the Nursing Home Administrator and Director of Nursing, who were unable to provide evidence of timely physician notification regarding the missed medication doses.
Failure to Complete Ordered Restorative Range of Motion Program
Penalty
Summary
The facility failed to complete a restorative active range of motion (ROM) program as ordered for one resident. Clinical record review showed that the resident was prescribed a restorative ROM program for both upper and lower extremities, with specific instructions for repetitions and frequency. However, documentation revealed multiple instances across June, July, and August 2025 where the program was either marked as not applicable (NA) or lacked any documentation on both day and evening shifts. These gaps in documentation and implementation indicate that the ordered restorative ROM program was not consistently provided as required. The deficiency was identified through clinical record review and staff interviews, and the facility's Nursing Home Administrator and Director of Nursing were made aware of the concerns during a meeting.
Lack of Documented Nursing Staff Competencies for Specialized Resident Care
Penalty
Summary
The facility failed to ensure that nursing staff, including registered nurses and licensed practical nurses, possessed the appropriate competencies and skill sets necessary for the care and assessment of residents requiring enteral tube feeding, use of lifts, catheter care, medication administration, and dressing changes. Documentation review showed that the facility had residents with these specific care needs, including 72 residents receiving medications, 17 utilizing lifts, two with indwelling urinary catheters, seven requiring dressing changes, and one with enteral tube feeding. However, the facility was unable to provide any documentation of competencies for five employees responsible for these care activities. This lack of documentation was confirmed by the Nursing Home Administrator and Director of Nursing during the survey.
Improper Storage and Labeling of Medications and Treatments
Penalty
Summary
Facility staff failed to properly store resident medications and treatments on one of two nursing units. During observation of a resident's room, a tube of Triamcinolone Acetonide cream, Vitamin A&D ointment, and Dermacerin cream were found on top of the resident's nightstand. The resident stated that staff applied these creams and that he did not place them there. Facility policy requires all medications to be stored in the pharmacy or medication rooms according to manufacturer’s recommendations and in locked compartments under proper temperature controls. The Director of Nursing confirmed that these items should not have been stored on the nightstand. Additionally, two medication carts on the same nursing unit were observed to contain unsecured and unidentified medication tablets in the bottom drawers, including various colored and shaped pills. One cart also contained a partially used tube of Diclofenac cream that was not labeled with a resident identifier. These findings were confirmed in meetings with the Nursing Home Administrator and Director of Nursing. The facility’s failure to store drugs and biologicals in accordance with policy and regulatory requirements was identified through clinical record review, policy review, observation, and staff and resident interviews.
Deficient Food Storage and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to store food and maintain food service equipment in a safe and sanitary manner in the main kitchen. During an observation with the Dietary Manager, multiple individually prepared food items such as bowls of fruit, coleslaw, pudding, peaches, and pasta salad were found open to the ambient air in the walk-in cooler, leaving them unprotected from environmental contamination. A plastic chemical dispenser on top of the dishwasher was leaking blue liquid, which pooled on the dishwasher and the floor. In the walk-in freezer, a box labeled gluten bread was found past its due date, and a bag of frozen corn lacked any date or labeling. A plastic container holding saltine crackers was broken with jagged edges. Additionally, a large vent cover in the kitchen had a significant build-up of greasy dust, and an area between two stainless-steel countertops contained extensive dust and debris, including condiment packets and a butter container accumulating on the floor. These findings were reviewed with facility leadership, confirming multiple lapses in food storage, equipment maintenance, and overall kitchen sanitation.
Failure to Ensure Resident Understanding and Proper Execution of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident or their representative understood the binding arbitration agreement at the time of signing. Specifically, the arbitration agreement provided to residents did not include information clarifying that signing the agreement does not prevent residents or their representatives from communicating with federal, state, or local officials, such as surveyors or ombudsmen. Review of the agreement and interviews with facility staff confirmed that this information was omitted, and the facility did not ensure that residents or their representatives acknowledged understanding of the agreement as required by regulation. For one resident, who had a court-appointed guardian due to lacking capacity to make or communicate responsible decisions, the facility allowed the resident herself to sign the arbitration agreement. Clinical records confirmed the existence of the guardianship, and staff interviews verified that the guardianship was still in effect. An interview with the resident revealed she did not know what an arbitration agreement was or that she had signed one, indicating she did not understand the document. This demonstrates the facility's failure to ensure the agreement was explained in a manner the resident or her representative could understand and that the appropriate party signed the agreement.
Failure to Ensure Required QAPI Committee Membership and Attendance
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee included the required minimum members, specifically the medical director, at least quarterly as mandated. Review of QAPI meeting attendance records from October 30, 2024, to July 24, 2025, showed that the medical director attended only one meeting during this period. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the medical director (or designee) did not attend QAPI meetings at least quarterly as required by regulation.
Resident Privacy Not Maintained During Medication Administration
Penalty
Summary
The facility failed to ensure the privacy of a resident during a medication pass on the First Floor nursing unit. During observation, a licensed practical nurse was seen administering an enteral feed to a resident whose shirt was pulled up, leaving him exposed to anyone passing by in the hallway. The privacy curtain was not pulled, and the resident's roommate was present in the room, watching the procedure. The facility's policy requires nursing staff to maintain privacy when administering medications by routes other than the mouth, but this was not followed in this instance. The nurse confirmed during an interview that she is supposed to pull the curtain to ensure privacy.
Failure to Provide ADL Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with cerebral palsy, who was dependent on staff for activities of daily living (ADLs), was not provided with necessary assistance for personal hygiene. Observation revealed the resident had several days of beard growth and long fingernails with brown substances underneath. The resident expressed a preference to be clean shaven but was unable to access his razor, which was found out of his reach. There was no documentation indicating that staff were providing assistance with shaving or nail care. Clinical record review showed the resident required substantial to maximum assistance for personal hygiene due to limited mobility, weakness, deconditioning, and cerebral palsy. The care plan and MDS assessment confirmed the resident's need for help with these tasks. Interviews with facility leadership confirmed the resident's inability to perform shaving or nail care independently, and acknowledged the lack of staff assistance in these areas.
Failure to Ensure Proper Use and Monitoring of Bed Alarm for Fall Prevention
Penalty
Summary
The facility failed to properly implement and monitor a fall prevention intervention for a resident with Alzheimer's Disease, cognitive impairment, and mobility issues. The resident had a physician's order for a bed alarm to be checked for functioning every shift, and the care plan identified the resident as being at risk for falls due to incontinence, unawareness of safety needs, and sensory deficits. Despite these interventions, there were two documented incidents where the resident was found on the floor in their room. In the first incident, the bed alarm was present but the volume was turned down, so it did not sound when the resident attempted to get out of bed. In the second incident, the alarm was on the bed but not turned on, resulting in no alert when the resident left the bed. Further review of clinical documentation revealed multiple instances over a three-month period where staff failed to document that the bed alarm was in place and functioning as required by the physician's order. Staff statements confirmed that the alarm was either not sounding or not turned on during the incidents. These failures in ensuring the alarm was properly set and functioning, as well as lapses in required documentation, contributed to the resident's unassisted movement and subsequent falls.
Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing assessments to ensure that bedrails were used appropriately and that risks associated with their use were continually evaluated for a resident with dementia. Observations on two separate days confirmed that the resident's bed was equipped with bilateral enabler bars. The resident's clinical record indicated a diagnosis of dementia and an MDS assessment showed the resident was rarely or never understood, highlighting significant cognitive impairment. A physician's order for the enabler bars was present, and informed consent had been obtained from the resident's responsible party. However, after the initial assessment and consent in January 2024, there was no further documentation of ongoing monitoring or reassessment of the resident's need for bedrails or evaluation of associated risks. Facility documentation referenced a policy of ongoing monitoring and adjustment, but no evidence was found to support that this was carried out for the resident in question. The Nursing Home Administrator confirmed that no additional documentation existed to demonstrate ongoing assessment or monitoring of the bedrail use for this resident.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for two nurse aides, as required by policy. Review of employee personnel records showed that one nurse aide was hired in July 2019 and another in March 2022, but there was no documented evidence of performance evaluations being conducted at least once every 12 months for either employee. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the required annual evaluations had not been completed for the two nurse aides reviewed.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident who was admitted with a diagnosis of dementia. Clinical record review showed that the resident was admitted with dementia and cognitive loss, and the facility's assessment indicated that a care plan addressing these needs would be created. However, upon review, there was no evidence that such a care plan had been developed or implemented for the resident. This deficiency was confirmed by both the Nursing Home Administrator and the Director of Nursing, who acknowledged the absence of documentation regarding a person-centered care plan for the resident's dementia prior to the surveyor's inquiry.
Deficiencies in Water Management and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella. During a review of documents, it was found that the water management plan provided by the Director of Maintenance was for another facility, and the current plan could not be located following a change of ownership. The Director of Maintenance indicated an intention to adapt the incorrect plan for the facility, and the Nursing Home Administrator confirmed the absence of a current, facility-specific water management plan. This failure to develop and maintain a water management program was not in accordance with CDC guidelines, which require a detailed description of the water system, identification of hazardous conditions, and establishment of control measures and corrective actions. Additionally, the facility did not implement enhanced barrier precautions for a resident who required them. Observation revealed that an LPN was administering enteral feeding to a resident on enhanced barrier precautions without wearing a gown, despite signage and available personal protective equipment at the room. The LPN confirmed knowledge of the requirement but did not follow it. The resident had a physician's order for enhanced barrier precautions due to a PEG tube. These findings were confirmed in interviews with facility leadership.
Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
Haven Place was found to be non-compliant with the requirements for maintaining nutritional and hydration status for a resident, identified as Resident 1, during an abbreviated survey following a complaint. The facility failed to adequately monitor and assess the resident's nutritional status, resulting in significant weight loss over several months. Resident 1, who had diagnoses including dysphagia, GERD, vitamin D deficiency, hypokalemia, and dementia with psychotic disturbance, experienced a weight loss of 11.4 pounds, equating to a 10.32% decrease over 4.5 months. The facility's speech therapist, Employee 1, had ordered a full liquid diet with thin liquids and pureed food for pleasure, noting that Resident 1 required specific cues and assistance when drinking. Despite these interventions, dietary notes indicated that Resident 1 was refusing most food and only accepting certain nutritional supplements. The interim registered dietician, Employee 2, documented Resident 1's underweight status and significant weight loss but did not adjust the dietary plan or discuss advanced directives with the interdisciplinary team. There was no evidence of changes to the nutritional supplements to address the weight loss. Concerns were raised by Resident 1's responsible party about the resident not receiving Ensure on their tray, which was addressed by the Director of Nursing. However, there was no documentation of further dietary interventions or assessments by Employee 2 or Employee 3, the newly hired dietician, after March 11, 2025. The Nursing Home Administrator confirmed that Employee 3 had not reviewed Resident 1's clinical record for weight loss concerns, and the dietician worked remotely without a scheduled visit until later in April.
Plan Of Correction
1. Resident # 1 was re-weighed, re-assessed by Dietician for nutritional needs. Diet updated to include Yogurt, Pudding and Jello. Care plan meeting was held with family and discussed progression of resident's Dementia. Per family wishes the resident was assessed and admitted under hospice services. 2. Dietician audited residents with significant weight loss to ensure appropriate interventions are in place. 3. Education will be provided to dietician and IDT on the process for capturing residents that are at risk for significant weight loss. 4. Dietician will provide weekly report to IDT for any resident that is at risk for significant weight loss. IDT will meet weekly to review residents at risk during risk meeting to ensure that the appropriate interventions are in place. 5. Results will be discussed at QAPI.
Mental Abuse via Unauthorized Recording
Penalty
Summary
The facility failed to protect the rights of two residents to be free from mental abuse by a staff member, resulting in actual harm. The incident involved a nurse aide, referred to as Employee 1, who recorded and broadcasted live TikTok videos while providing care to the residents. The videos captured the residents in vulnerable situations without their consent, exposing them to potential humiliation and degradation. Employee 1's actions were in direct violation of the residents' rights to privacy and dignity, as outlined in the facility's policies and federal regulations. Resident 1, who was severely cognitively impaired, was recorded during incontinence care and while being assisted to bed. The video showed Employee 1 interacting with the resident and responding to comments on the live TikTok feed, without informing the resident of the recording. Similarly, Resident 2, who was moderately cognitively impaired, was recorded during a brief change and while being assisted with her nightgown. The video exposed Resident 2's incontinence brief and groin area, and captured her struggling to stand, all while Employee 1 engaged with the live TikTok audience. The facility's investigation revealed that Employee 1 did not inform the residents of the recording, nor did she obtain their consent. Employee 1 admitted to regularly posting similar content on TikTok and claimed ignorance of the wrongdoing. The incident was reported to the Nursing Home Administrator by an anonymous caller, prompting an immediate review and suspension of Employee 1. The actions of Employee 1 were found to be in violation of the facility's policies on personal electronic device usage and social networking, as well as federal regulations protecting residents from mental abuse.
Plan Of Correction
It is the policy of this facility to ensure the highest quality of care is afforded to our residents. The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident(s) 1 and 2 had clinical assessments completed to ensure no noted signs of harm/abuse from incident. Employee 1 was terminated. 2. Upon discovery of social media post, on 11/19/2024, leadership immediately implemented staff reeducation related to social media and personal electronic devices. 3. All RNs, LPNs, CNAs, ***(Addendum) Activities staff, therapy staff, maintenance staff, Social Service, and Dietary staff will be educated by the Director of Nursing or designee on protecting residents from mental abuse specific to social media. The Directed in-service will be completed by Lewis Litigation Support and Clinical Consulting, LLC on F 600 Freedom from Abuse and Neglect / Exploitation. All RN, LPNs, and CNAs will be required to attend the directed in-service. The live in-service will be recorded and available for those who are unable to attend the live presentation. The Directed In-service will be conducted on Wednesday, January 8, 2025 by Mariah Zimmerman, BSN-RN, WCC. ***(Addendum) Activities staff, therapy staff, maintenance staff, Social Service, and Dietary staff will also be required to attend the directed in-service. Education will then be given on hire and annual thereafter.**** 4. Director of Nursing or designee will conduct a walking round audit. 10 staff members will be interviewed weekly regarding their understanding of protecting residents from mental abuse specific to social media. The audit/interviews will be completed for 4 weeks or until substantial compliance is achieved. Results will be reviewed in QAPI meeting. 5. Date of compliance is 1/20/2025.
Privacy Breach During Resident Care
Penalty
Summary
Haven Place was found to be non-compliant with federal and state regulations regarding resident privacy and confidentiality. The facility failed to ensure the privacy of two residents during care and services, specifically during incontinence care. This deficiency was identified through a review of facility policies, clinical records, and staff interviews, which revealed that the facility did not adequately protect the residents' right to personal privacy as required by 42 CFR Part 483, Subpart B. The incident involved a nurse aide, referred to as Employee 1, who used a personal electronic device to record and broadcast a live TikTok video. During this video, Employee 1 showed the faces and bodies of two residents, including one resident being assisted from the bathroom and another receiving incontinence care. The video exposed the incontinence brief and groin area of one resident, violating their privacy. The video was 17 minutes long, and at no point did Employee 1 inform the residents they were being recorded or obtain their consent. The facility's policies on personal electronic device usage and social networking were reviewed and found to be inadequate in preventing this breach of privacy. Employee 1's actions were in direct violation of these policies, as well as federal and state regulations. The Nursing Home Administrator and Director of Nursing confirmed these findings during interviews and observations conducted on December 19, 2024.
Plan Of Correction
It is the policy of this facility to ensure the highest quality of care is afforded to our residents. The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident(s) 1 and 2 had clinical assessments completed to ensure no noted signs of harm/abuse from incident. Employee 1 was terminated. 2. Upon discovery of social media post, on 11/19/2024, leadership immediately implemented staff reeducation related to social media and personal electronic devices. 3. All CNA's, LPN's, RN's (Addendum) Activities staff, therapy staff, maintenance staff, Social Service, and Dietary staff will be educated by the Director of Nursing or designee on protecting residents' privacy during care specific to social media and use of personal electronic devices. (Addendum) Education will be given on hire and annual thereafter. 4. Director of Nursing or designee will conduct a walking round audit. 10 staff members will be interviewed weekly regarding their understanding of protecting residents' privacy during care specific to social media and use of personal electronic devices. The audit/interviews will be completed for 4 weeks or until substantial compliance is achieved. Results will be reviewed in QAPI meeting. 5. Date of compliance 1/20/2025.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides during specific shifts, as mandated by the regulation effective July 1, 2024. During the review of nursing staffing hours for the periods of November 17-23, 2024, November 24-30, 2024, and December 13-19, 2024, it was found that on December 14, 2024, the day shift had 6.5 nurse aides for a resident census of 72, falling short of the required 7.2 nurse aides. On the evening shifts of November 23, 2024, and December 15, 2024, the facility had 5 and 6 nurse aides for resident censuses of 69 and 72, respectively, both below the required numbers of 6.27 and 6.55 nurse aides. Additionally, on the overnight shift of November 28, 2024, there were 4 nurse aides for a census of 71, whereas 4.73 nurse aides were required. These deficiencies were confirmed during an interview with the Nursing Home Administrator and Director of Nursing on December 19, 2024.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Facility ensures that sufficient personnel are provided on a 24-hour basis to provide nursing care to meet the needs of all residents. At the time of the finding, the ratios and total nursing hours for the current working schedule were reviewed, and no issues were noted. 2. The scheduler and RNs will be re-educated on the July 1, 2024 nurse aide ratios of 1:10 and the importance of monitoring staffing as the day and/or shift progress. Education will be completed by the Director of Nursing and/or designee. 3. The Director of Nursing and/or designee will audit the current CNA working schedule, and the deployment sheets prior to the day and after the day is complete to ensure compliance. 4. Audits will be completed 3 times per week for one month, and weekly thereafter or until substantial compliance is achieved. Results will be reviewed in QAPI meeting. 5. Date of compliance is 1/20/2025.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to establish clear and consistent documentation of a resident's wishes regarding advance directives, specifically for Resident 34. A review of the resident's electronic clinical record showed a physician's order indicating a DNR status, while the paper clinical record also had a DNR sticker. However, a POLST form within the paper record indicated the resident chose CPR, creating conflicting information about the resident's resuscitation preferences. This inconsistency was not addressed, as the physician order for life-sustaining treatment was never updated to reflect the resident's wishes for CPR as indicated on the POLST form. The Director of Nursing and the assistant nursing home administrator were made aware of the conflicting documentation. The Director of Nursing stated that staff would follow the most recent form, which was the physician order indicating DNR. Despite this, a nurse practitioner later confirmed with Resident 34 that the resident wished for CPR and full treatment, leading to the completion of another POLST form. The deficiency highlights the facility's failure to maintain accurate and consistent records of the resident's advance directives, as required by regulations.
Failure to Provide Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide a dependent resident with necessary assistance for activities of daily living, specifically personal hygiene. Resident 35, who requires extensive to total dependence on staff for personal hygiene, was observed with several days of beard growth despite having had a shower that morning. The resident expressed a preference for being clean-shaven, but his family reported that staff did not shave him due to dull razors that caused cuts. The resident's care plan, initiated in March 2024, and the most recent MDS assessment from August 2024, both indicated a need for substantial assistance with personal hygiene, including shaving. An interview with the Director of Nursing and an assistant nursing home administrator revealed that electric razors were supposed to be available in each resident's room. However, an observation of Resident 35's room confirmed the absence of an electric razor, contributing to the facility's failure to meet the resident's personal hygiene needs.
Inadequate Pain Management Documentation and Administration
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for two residents. For Resident 59, the clinical record review revealed multiple physician orders for pain medications, including Acetaminophen and Oxycodone, with specific instructions for administration based on pain levels. However, there was no documentation indicating which medication should be administered for mild, moderate, or severe pain, nor was there identification of the availability of multiple medications for the same pain parameter. The medication administration record (MAR) for May 2024 showed instances where staff administered Oxycodone without documenting the pain level or administered it for pain levels that did not match the prescribed parameters. Similarly, for Resident 63, the clinical record review showed physician orders for Acetaminophen and Oxycodone with specific pain level parameters. The MAR for September 2024 indicated that staff administered Oxycodone for a pain level of 4, which was outside the prescribed range for that medication, and Acetaminophen was given without documenting a pain level. These findings were reviewed with the Director of Nursing, highlighting the facility's failure to adhere to physician orders and document pain levels accurately, leading to inappropriate pain management for the residents.
Inadequate Infection Control Practices for COVID-19 Precautions
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection for a resident under COVID-19 transmission-based precautions. The resident, who tested positive for COVID-19, was observed in a room with appropriate signage and personal protective equipment (PPE) available. However, a nurse aide entered the resident's room wearing only an N95 mask, neglecting to don a gown and gloves as required. The aide then handled the resident's meal tray and other items without proper PPE, potentially spreading infection by touching surfaces outside the resident's room. Additionally, a licensed practical nurse entered the same resident's room without any PPE, despite the clear signage indicating the need for a mask, gown, and gloves. Another nurse, while adhering to PPE requirements, was unsure about the proper handling of her used N95 mask, placing it uncovered next to clean masks. These actions demonstrate a lack of adherence to airborne and contact precautions, as well as insufficient staff education on infection control procedures.
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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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