Heritage Ridge Senior Living At Windy Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Philipsburg, Pennsylvania.
- Location
- 100 Dogwood Drive, Philipsburg, Pennsylvania 16866
- CMS Provider Number
- 395533
- Inspections on file
- 19
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Heritage Ridge Senior Living At Windy Hill during CMS and state inspections, most recent first.
Three residents who were transferred to the hospital did not receive required written notices of transfer or the facility's bed-hold policy at the time of transfer. Clinical record reviews and staff interviews confirmed that neither the residents nor their representatives were provided with these documents, as mandated by federal regulations.
A resident did not consistently receive the prescribed range of motion (ROM) program after discharge from therapy due to a communication breakdown between therapy and nursing. Documentation showed gaps in the delivery of both active and passive ROM exercises, with multiple days missed despite daily scheduling. The DON confirmed the failure to implement the recommended program as ordered.
A resident with severe protein-calorie malnutrition experienced significant weight loss and consistently low intake of meals and supplements. Facility staff did not follow policy for reweighing after significant weight changes, failed to document attempts to reweigh, and did not implement or update interventions in response to the resident's ongoing nutritional decline. The physician did not assess the severe weight loss until much later, and staff confirmed these lapses in care.
Surveyors found that the facility did not complete required annual performance evaluations for three nurse aides, as confirmed by personnel record review and interview with the administrator. Documentation was lacking to show that evaluations were performed at least once every 12 months, resulting in noncompliance with regulatory requirements.
The facility did not develop or implement individualized, person-centered care plans for dementia and cognitive loss for three residents with a diagnosis of dementia. Despite assessments indicating the need for such plans, documentation and staff interviews confirmed that these care plans were not in place prior to surveyor review.
Surveyors found that food items in the kitchen were not properly labeled or dated, with some stored in unsanitary conditions such as a walk-in freezer with ice accumulation and a dry goods area with significant debris. Equipment, including a dough cutter, was found with build-up and rust, and partially used containers lacked open dates. Additionally, required food temperature documentation was missing for several meal services, with no explanation provided by the Director of Dining Services.
Surveyors found that the facility did not offer updated pneumococcal immunizations to several residents, despite previous vaccinations and current CDC recommendations. Clinical records lacked documentation that residents or their representatives were engaged regarding updated vaccine options, resulting in a failure to meet immunization requirements.
Three nurse aides did not receive the required 12 hours of annual in-service training, as confirmed by a review of education records and interviews with the Administrator and DON. There was no documentation to show that the mandated training had been completed.
A resident experienced multiple unexplained bruises, and the facility's investigations were limited to statements from the staff who discovered the injuries, without obtaining additional witness accounts or evidence of comprehensive follow-up. The resident was unable to explain the cause of the injuries, and the lack of thorough investigation was confirmed by the Nursing Home Administrator.
A resident experienced a decline in eating ability, progressing from needing only supervision to requiring extensive staff assistance. The facility failed to document any assessment or intervention regarding this decline, as confirmed by staff and leadership interviews.
The facility did not follow physician-ordered parameters for medication administration for a resident with cardiovascular conditions, administering Metoprolol even when the resident's pulse was at or below the specified threshold without documented justification. Additionally, another resident with a cardiac pacemaker did not have physician orders in place for required pacemaker checks, despite this being part of the care plan. The DON confirmed the lack of documentation and orders in both cases.
A resident with COPD and an acute exacerbation was observed receiving oxygen at 2.5 LPM via nasal cannula, despite a physician order specifying 1.5 LPM. This inconsistency between the ordered and administered oxygen flow was confirmed through clinical record review and staff interviews.
A resident with PTSD reported being triggered by loud noises and nighttime screaming, leading to panic episodes. The facility did not identify these triggers in the care plan or collaborate with the resident and relevant professionals to develop individualized trauma-informed interventions.
A resident with Alzheimer's disease, cognitive impairment, and anxiety did not have required monthly medication regimen reviews completed by the consultant pharmacist for two consecutive months. This was confirmed through record review and staff interviews, with facility leadership unable to provide documentation of the missing reviews.
A resident with missing and broken teeth did not receive routine dental care as required by the state plan, despite having a physician's order and Medicaid coverage. The facility lacked documentation of routine dental cleanings, and the DON confirmed the deficiency.
Surveyors found that garbage and debris, including weeds, stagnant water, discarded items, and exposed rusted nails, were not properly contained or disposed of in the facility's main dumpster area. These conditions were observed and confirmed with the NHA and DON.
The facility did not maintain documentation regarding the personal belongings of two residents at admission or at discharge, and the DON confirmed the absence of records accounting for these items.
Two residents who were discharged did not have discharge summaries in their closed clinical records, as required. One resident left against medical advice, and another was sent to the hospital after a fall and did not return; in both cases, the records lacked a summary of the stay and final diagnosis, which was confirmed by the DON.
A resident's medication disposition was not documented upon discharge, with no record of how several prescribed drugs were handled. Additionally, the facility did not meet required NA-to-resident ratios on multiple shifts, as confirmed by staffing records and leadership interviews.
A review of staffing records and staff interviews revealed that the facility did not meet the required minimum LPN-to-resident ratios on multiple occasions, with insufficient LPN coverage during day, evening, and overnight shifts as confirmed by the DON and administrator.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on eight reviewed days, as confirmed by staffing records and interviews with the Nursing Home Administrator and DON.
A facility failed to ensure nursing staff had the necessary competencies for PICC line care, as required by state standards. A resident with a PICC line for intravenous antibiotics was cared for by an LPN who administered medication without documented specialized training or competencies. The facility's policy did not specify training requirements for LPNs in PICC care, and no evidence of such training was provided.
The facility's main kitchen was found to be unsanitary, with dried spills, food splatter, and debris on various surfaces and equipment. Additionally, staff members were observed with facial hair without protective coverings, violating hygiene standards. These issues were noted during observations and discussed with the Nursing Home Administrator and DON.
The facility failed to ensure call bell accessibility for two residents, both requiring assistance due to medical conditions. Observations revealed that the call bells were out of reach, contrary to their care plans. A registered nurse was informed of these findings, which were also reviewed with the Nursing Home Administrator and DON.
The facility failed to provide written notice of its bed hold policy to the responsible parties of two residents who were hospitalized. One resident's bed hold forms were found at the facility's front desk, and there was no documented evidence for either resident that their responsible parties received the required information. This deficiency violates resident rights and the responsibility of the licensee.
A facility failed to refer a resident with a new diagnosis of paranoid schizophrenia for a PASRR Level II review, as required. Initially assessed with no disorders in 2004, the resident's condition changed in 2005, but the facility did not notify the appropriate agencies, violating PASRR guidelines. The Director of Nursing acknowledged this oversight during an interview.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying specific triggers in her care plan. The resident's PTSD was linked to past traumatic events, including an alleged rape and a motor vehicle accident, which were documented but not addressed in her care plan. This deficiency was confirmed by the DON.
The facility failed to ensure that two residents received or were offered pneumococcal conjugate vaccines, as there was no documentation in their clinical records. The issue was identified during a clinical record review and staff interview, and the DON was informed.
The facility failed to provide written transfer notices with all required components to the responsible parties of two residents transferred to the hospital. For one resident, the transfer forms were found at the facility's front desk, and the DON confirmed that notices are mailed if contact cannot be made. An admissions employee confirmed the lack of documentation for the other resident's transfer notice.
Failure to Provide Written Transfer and Bed-Hold Notices During Hospitalization
Penalty
Summary
The facility failed to provide required written notices of transfer and bed-hold policies to residents and/or their representatives at the time of transfer for three residents who were hospitalized. For one resident, documentation showed a change in condition that led to a 911 call and subsequent hospital admission for a urinary tract infection. The resident returned to the facility several days later, but there was no documentation that the resident or their representative received written notice of the transfer or the facility's bed-hold policy. This lack of documentation was confirmed by the Director of Nursing during an interview. Another resident was transferred to the emergency room for evaluation due to mental status changes, weakness, and frequent falls, and was admitted to the hospital for weakness and pneumonia. Again, there was no documentation that the resident or their representative received the required written notices at the time of transfer. The surveyor requested this documentation during meetings with facility leadership, but it was not provided. A third resident was transferred to the hospital for a change in condition and returned after a short stay. Review of the clinical record revealed no documentation that the resident's representative received written notice of transfer or the facility's bed-hold policy. Interviews with facility staff confirmed that these notices were not provided as required. The deficiency was identified through clinical record review and staff interviews, which consistently showed a lack of compliance with federal requirements for written notification during resident transfers.
Plan Of Correction
The facility provides a written Bed Hold Acknowledgment and Notice of Transfer document containing all the required elements, including the date of transfer, specific reason for discharge/transfer, location to be transferred, right to appeal process information, and the information pertaining to the Office of the Long-Term Care Ombudsman to the responsible party for those residents identified (#28, 59, and 65). A copy of the Bed Hold Acknowledgment and the Notice of Transfer Document was sent to residents #28, #59, and #65. Once a copy of the signed documents is returned, they will be filed in the resident's medical chart. A review of the facility's resident records, who were transferred over the past six (6) months, will be completed, and corrective actions will be taken if necessary. Education was provided by Social Services and the Admissions Director on the Notice Requirements before Transfer/Discharge Notification Program and the process to be completed upon each transfer. Education was provided to all Nursing Staff. Any future transfers will be reviewed by the Admission Director at the morning meeting (five days per week) to ensure proper procedures were followed for the Notice Requirements before Transfer/Discharge process, including the initial notification verification, and the written notification of the transfer/discharge and the reasons for the move. Audits will be completed on all transfers weekly for two months and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.
Failure to Provide Consistent Range of Motion Services
Penalty
Summary
A deficiency was identified when a resident with a physician-ordered range of motion (ROM) program did not consistently receive the prescribed services following discharge from physical therapy. The resident reported that after therapy ended, staff either did not perform the recommended exercises or did so inconsistently. Clinical records confirmed that the resident was to receive both active and passive ROM programs to the lower extremities, but documentation showed that these services were not provided from May 16 to May 31. This lapse was attributed to a communication issue between therapy and nursing, resulting in the ROM program not being initiated until June 1. Further review of documentation for June revealed that the resident did not receive the required active ROM exercises on multiple days throughout the month, despite being scheduled for daily sessions. The Director of Nursing acknowledged the communication breakdown and the resulting failure to implement the ROM program as recommended. The deficiency was based on the facility's failure to ensure that the resident received appropriate treatment and services to maintain or improve range of motion as required.
Plan Of Correction
The facility completed a review of resident #19's ROM/Mobility tasks in PointClickCare. Tasks were updated and staff implemented said tasks. No evidence or actual ill effects exist on any resident in our community due to lack of adherence to the requirements of increase/prevent decreases in ROM/mobility. A report was generated to indicate residents with range of motion or mobility issues, and those identified were reviewed individually. Any related issues were updated, and staff were instructed to implement said tasks. An education session was completed by the director of nursing or designee with clinical and therapy staff to ensure proper communication between nursing and therapy disciplines, documentation on Point of Care, and tasks being initiated on PointClickCare. A review of 10 records will be completed weekly for one month for any identified residents with ROM/Mobility tasks and bi-weekly for 3 months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.
Failure to Address Severe Weight Loss and Poor Nutritional Intake
Penalty
Summary
The facility failed to implement interventions to promote acceptable parameters of nutritional status for a resident with severe protein-calorie malnutrition. The resident was admitted with this diagnosis and had documented low meal and supplement intake over several months. Staff recorded that the resident consumed zero to 25 percent of meals and less than 25 percent of prescribed nutritional supplements on numerous occasions. Despite these findings, there was no evidence that the facility took timely action to address the resident's poor intake or significant weight loss. Weight assessments for the resident showed a marked decline, with a loss of 28 pounds (over 24 percent of body weight) in two months. The facility's policy required reweighing residents after significant weight changes and evaluating undesirable weight changes, but there were gaps in weight documentation and no evidence of reweighing as required. Some weights were crossed out by the registered dietitian, who believed them to be inaccurate, but no reweighs or further assessments were documented for an extended period. There was also no documentation that the resident refused weights during this time. Additionally, the resident's physician did not assess the severe weight loss until much later, and there was no update to the nutrition plan of care or implementation of new interventions in response to the ongoing weight loss and poor intake. Staff interviews confirmed these findings, and the lack of timely intervention and documentation was acknowledged by the registered dietitian.
Plan Of Correction
Upon identification of noted issue re: resident #28, IDT members, including the PA were notified of weight loss. Facility Physician Assistant assessed resident noting dx of Adult FTT and Severe Protein-Calorie Malnutrition. The provider discussed potential use of enteral/tube feedings to support resident nutrition status. Resident declined tube feeding/nutritional enteral support. Continue to assist resident #28 with feeding, continue to encourage meal, fluid, and supplement intake, and encourage oral fluids q 1hours. Comfort measures were orders by provider on July 17, 2025. Residents are weighed upon admission and at intervals determined by the IDT. Any weight change of 5# or more since the last assessed weight is retaken the next day for confirmation. The facility EMR notifies staff of significant changes in weight status as well. The weight alerts are reviewed and assessed by the facility Registered Dietitian along with other members of the IDT. If a significant change in weight is confirmed, the IDT including the resident physician and/or physician assistant will be notified. The current nutrition plan of care will be reviewed and adjusted as necessary. The facility Registered Nurse Assessment Coordinator will determine if resident qualifies for a significant change assessment and notify IDT members. Education and training was provided to clinical staff regarding the facility's weight program, and the need for timely resident reweighs was emphasized as part of this training. Weight reviews and trends will continue to be a part of the facility's Quality Assurance and Performance Improvement program. Audits will be completed on 5 charts weekly for one month and biweekly for 3 months in regard to the appropriate weights for monitoring and reporting purposes. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
Surveyors determined that the facility failed to complete annual performance evaluations for three nurse aides, as required by federal and state regulations. Personnel record reviews showed that for three employees, there was no documented evidence of a performance evaluation being completed at least once every 12 months. The specific employees had hire dates ranging from 1991 to 2017, and their last recorded evaluations did not meet the annual requirement. During an interview, the Nursing Home Administrator confirmed that annual performance evaluations were not completed for the three nurse aides in question. This deficiency was identified through a review of employee records and direct confirmation from facility leadership, with no evidence provided to show compliance with the required evaluation schedule.
Plan Of Correction
No evidence of any actual ill effect exists on any residence in our community due to the lack of adherence to the requirements of completion of performance evaluations for staff members identified as #7, 8, and 9. Performance evaluations were completed on these staff members to ensure they meet such requirements. Performance evaluations are being conducted/completed on the current CNA staff. Information on a deficiency basis on these evaluations will be utilized for future training purposes. In addition, performance evaluations will be scheduled with staff on their original anniversary date. Management staff have been educated about the need for annual performance evaluations, and a system of tracking and scheduling is created to ensure human resources send out monthly reminders of those required. A tracking tool will be reviewed monthly for six months to ensure performance evaluations are completed and filed in the individual staff records. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Develop Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans to address dementia and cognitive loss for three residents who had been admitted with a diagnosis of dementia. Clinical record reviews for these residents showed that, although the facility assessed each resident as having dementia and determined that a care plan would be developed, there was no evidence in the care plans that such individualized plans addressing dementia and cognitive loss were actually created or implemented. This lack of documentation was confirmed by both the Nursing Home Administrator and the Director of Nursing during interviews, who acknowledged that no further documentation existed to show that appropriate care plans had been developed prior to surveyor inquiry. For one resident, the care plan was only developed after the surveyor raised concerns, and it was noted that the plan should have included family involvement in its development. The findings were confirmed through interviews with facility staff, including a social worker, who acknowledged that the individualized dementia care plan was created only after the issue was brought to their attention by the surveyor. The deficiency centers on the facility's failure to provide appropriate, individualized treatment and services for residents with dementia as required.
Plan Of Correction
Newly completed individualized dementia care plans were developed for residents #33, #52, and #61 by the facility's social worker. No evidence of any actual ill effect exists on any of the residents in our community due to the lack of adherence to the requirements of said individualized care plans. A review of the residents admitted within the past six (6) months was conducted to ensure all residents with a current diagnosis of dementia have individualized care plans in place. Future admissions or residents with newly diagnosed dementia will have a new care plan completed within 72 hours. An education session was completed by the director of nursing or designee with social services on the importance of accuracy of diagnosis on care plans and ensuring that they are individualized to each resident. Audits will be completed on five (5) charts weekly for one month and biweekly for three (3) months relating to the residents with a diagnosis of dementia and ensure the care plan has been appropriately annotated. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Deficient Food Storage, Sanitation, and Documentation in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, equipment sanitation, and food preparation practices in the facility's main kitchen. During an initial tour, a walk-in freezer was found to contain a cardboard box with several items in slide lock plastic bags, including baked beans and peeled bananas, none of which were labeled or dated. The Director of Dining Services was unable to clarify when these items were packaged or their intended use-by dates. Additionally, several packages of sliced flavored bread stored on a shelf under circulating fans in the freezer had significant ice accumulation. In the dry goods storage area, the floor beneath four shelving units was found to have a significant accumulation of debris, including dust, unopened soda cans, discarded paper products, condiment packets, a butter packet, and several plastic spoons. A kitchen shelf held two partially used vinegar containers and a partially used syrup container, all lacking open dates. An expandable dough cutter in a drawer was found with extensive build-up of a batter-like substance and multiple areas of rust. A review of tray line food temperature logs revealed missing documentation for dinner temperatures on several dates. The Director of Dining Services confirmed that food temperatures should be documented for each meal service but was unable to explain the missing records. These findings were discussed with the Nursing Home Administrator and Director of Nursing. The report also notes that similar deficiencies had been previously cited.
Plan Of Correction
The facility dietary department conducted a thorough cleaning of the entire department to include the dry storage area and under the walk-in freezer fan. In addition, all areas such as the freezer, refrigerators, coolers, and storage areas were inspected, and any corrections needed to labels, etc., were made at that time. No action could be taken on the failure to document the tray line food temperatures. The expandable dough cutter was removed and disposed of. If needed, a new cutter will be ordered for use in the kitchen. Corrective actions were taken in the areas identified, and education was provided at a mandatory meeting with staff to address the importance and necessity of proper cleaning techniques. In addition, the session included the sanitary and safe operations of the kitchen to include all documentation requirements and temperature recordings. Audits of the kitchen area's
Failure to Offer Updated Pneumococcal Immunizations per CDC Guidance
Penalty
Summary
Surveyors determined that the facility failed to offer recommended pneumococcal immunizations to five residents who were reviewed for immunizations. The facility's policy required that residents be assessed for eligibility to receive the pneumococcal vaccine upon admission and, when indicated, be offered the vaccine within 30 days. The policy also stated that administration of the vaccine should follow current CDC recommendations. However, clinical record reviews revealed that several residents had received previous pneumococcal vaccines prior to admission, but there was no documentation that the facility offered updated pneumococcal vaccinations in accordance with the latest CDC guidance. Specifically, the records for five residents showed that although they had received earlier versions of the pneumococcal vaccine (such as Prevnar 13 and PPSV23), there was no evidence that the facility assessed or offered updated vaccines as recommended by the CDC's October 2024 guidance. For example, one resident had received Prevnar 13 in 2016 and PPSV23 in 2001, but there was no documentation of an offer for an updated vaccine. Another resident had received Prevnar 13 in 2022, but the record did not show that the facility offered the required follow-up vaccine (PCV20 or PCV21) one year later. The lack of documentation extended to all five residents reviewed, with no evidence that the facility engaged with the residents or their representatives to decide on updated pneumococcal vaccination, as required. This deficiency was identified through clinical record review, policy review, and staff interviews, and it was noted that the facility had previously been cited for a similar issue.
Plan Of Correction
Residents 11, 18, 19, and 29 (or their resident representative) have been contacted by the facility's medical records representative and provided education and handouts, as well as an offer for the updated vaccine. As the resident or representative's decision is conveyed, the outcome was/will be annotated in the medical chart on the Pneumococcal Consent, in the administration record, and under the immunization tab in each resident's chart. Resident #23 has ceased to breathe on July 21, 2025. A facility audit was completed on 7/22/25 to identify all residents who are due for Pneumococcal Immunization. Residents due for the vaccine will be offered a Prevnar 20 per the recommendation of the Medical Director. Resident education will be provided with each resident's consent. Education was provided to clinical staff and the admissions director, ensuring they are familiar with and aware of the Prevnar 20 vaccine and the need to offer the vaccine to incoming residents or their responsible parties. Weekly audits will be conducted for one month and bi-weekly for three months on all new residents to assure compliance with the requirements set forth in the vaccine program. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides received the required minimum of 12 hours of annual in-service training. During a meeting with the Nursing Home Administrator and DON, the surveyor requested documentation of in-service training hours for three nurse aides. It was confirmed through interview and review of employee education records that there was no documented evidence these nurse aides had completed the mandated training within the past year. This deficiency was identified based on the absence of required training records for the specified employees.
Plan Of Correction
There is no evidence of any actual ill effect on any resident in our community due to the lack of adherence to the requirements of in-service training for nurse aides and staff within the facility. Staff 7, 8, and 9 were provided with additional training to meet this requirement. Upon review of the CNA records, those needing documented training were scheduled for the upcoming (monthly) "Annual Training" session, and each were provided additional training to ensure they received the requirement to meet the regulatory guidelines. Education was provided to the Human Resource Rep on the requirement for and adherence to the Inservice Training requirements. Monitoring of this requirement will be conducted by use of an audit to include monthly file reviews for the CNAs' annual training as well as new employees being scheduled in accordance with their hire date for a six-month period. The newly appointed ADON will also be assisting in the monitoring of this requirement. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Thoroughly Investigate Resident Injuries of Unknown Origin
Penalty
Summary
Heritage Ridge Senior Living at Windy Hill was found noncompliant with federal and state regulations regarding the development and implementation of abuse and neglect policies. The facility failed to thoroughly investigate injuries of unknown origin for a resident. Specifically, after a resident was admitted, nursing documentation showed that staff discovered a bruise on the resident's inner thigh, but the facility's investigation only included a single witness statement from the nurse aide who found the bruise. The resident was unable to explain how the bruise occurred. No further statements or evidence of a comprehensive investigation were documented. Later, the same resident was found to have a large bruise on the left shoulder and back during evening care. The facility's investigation into this incident included only two witness statements from the nurse aides who discovered the bruise, with no additional staff statements or documentation of staff education. The resident again could not recall how the injury occurred. The Nursing Home Administrator confirmed that the investigations were not thorough, and there was a lack of evidence to rule out abuse or prevent further injuries.
Plan Of Correction
Attempts were made to collect additional investigative statements on resident #12's without success, and education was provided to the nursing staff on this situation. A review of incident reports since the transition to our current company was completed for accuracy and investigation completion for educational purposes to the staff. Education based on the incidents review was conducted as well as the facility policies content was explained to ensure clinical, and non-clinical staff are aware as well as staff in general of the need and necessity to report these matters immediately and the need for thorough statements from anyone with knowledge of such situations and incidents. Audits will be performed on incident reports requiring follow-up and investigation on a weekly basis for 1 month and bi-weekly for 3 months thereafter. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Assess and Address Decline in Resident's Eating Ability
Penalty
Summary
A deficiency was identified when a resident experienced a decline in their ability to eat independently, moving from requiring only supervision and set-up help to needing extensive assistance from one staff member. The clinical record review showed that there was no documented evidence that the facility identified or assessed this decline in the resident's ability to perform the activity of daily living related to eating. Staff interviews confirmed that the decline was not assessed or addressed prior to the survey, and the facility was unable to provide any documentation showing that measures were implemented to mitigate the resident's loss of eating ability. The lack of assessment and intervention was confirmed by both the registered nurse assessment coordinator and facility leadership during the survey process.
Plan Of Correction
The facility identified the item noted, and Resident #12 has had a new screening for speech therapy completed and changes were implemented. No evidence or actual ill effects exist on any resident in our community due to lack of adherence to the requirements of activities of daily living. Education was conducted by the director of nursing or designee on MDS assessments and the process on how changes in condition should be documented, and interventions should be implemented to mitigate declines. Audits on five medical charts will be conducted to ensure compliance with appropriate assessments from identified findings weekly for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Follow Physician Orders for Medication and Pacemaker Care
Penalty
Summary
The facility failed to provide care in accordance with physician orders and professional standards for two residents. For one resident with a history of hypertension and paroxysmal atrial fibrillation, the care plan required administration of Metoprolol Succinate ER as ordered by the physician, with specific parameters to hold the medication if the systolic blood pressure was less than or equal to 110 or the heart rate was less than or equal to 70. Despite these parameters, the medication was administered multiple times when the resident's pulse was below or at the threshold, and there was no documentation explaining why the medication was given outside of the prescribed parameters. The Director of Nursing confirmed that there was no documented evidence to justify these actions. For another resident, clinical records indicated the presence of a cardiac pacemaker, as noted on a chest x-ray ordered due to tachycardia and fever. The resident's care plan included an intervention to monitor pacemaker checks, but there were no physician orders in place for such monitoring. The Director of Nursing was initially unaware of the resident's pacemaker and later confirmed that no orders for pacemaker checks existed. These findings demonstrate a failure to provide the highest practicable care regarding both medication administration and pacemaker management.
Plan Of Correction
The facility verified the need for resident #384's order for pacemaker checks and obtained an order for such actions to be performed, and the care plan was updated. Resident #43's MAR was reviewed, and again no documented evidence as to why this was occurring could be found. It was reiterated to clinical staff that if no specific order exists, and the medication will be administered in accordance with the physician specified parameters. No ill effect is evident for either resident #43 or resident #384. A review of resident charts was conducted by nursing staff for any potential medication being given outside the parameters of order as given by the provider. Any noted infractions were discussed with the provider and corrected. Residents with pacemakers and pacemaker care plans were reviewed for appropriate provider orders to monitor pacemaker checks. Corrective actions were taken on any identified resident charts affected by this review. Education was provided to licensed staff on the facility's policy and procedures on the correct monitoring and adherence to residents with pacemakers and medication administration. Audits on five medical charts will be conducted to ensure compliance with appropriate assessments from identified findings weekly for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident diagnosed with chronic obstructive pulmonary disease (COPD) with an acute exacerbation. Clinical record review showed that the resident was admitted with this diagnosis and had a current physician order for continuous oxygen administration at 1.5 liters per minute (LPM) via nasal cannula. However, observations on two separate days revealed that the resident was receiving oxygen at 2.5 LPM, which was not consistent with the physician's order. This discrepancy was confirmed through review of the clinical records and direct observation of the resident by surveyors. The findings were discussed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
The facility reviewed the orders in relation to the continued oxygen rate for resident #23 and corrective actions were taken. There was no evidence of any ill effect on these residents. A review of the orders for any residents with the diagnosis of chronic obstructive pulmonary disease (COPD) with exacerbation was conducted, and any variances from the order were corrected and noted in the charts. Education was provided by the Director of Nursing or designee on the adherence to the written order for oxygen and the adherence to the facility policy. Audits will be completed on 5 charts weekly for one month and biweekly for 3 months relating to the appropriate management of respiratory care, in particular the monitoring of oxygen levels. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
A deficiency was identified when the facility failed to provide trauma-informed care for a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD). The resident reported that his PTSD was triggered by loud noises and other people screaming during the night, which caused him to wake up panicked. Despite this information, the facility did not identify or document these specific triggers in the resident's care plan. Additionally, there was no evidence in the clinical record that the facility collaborated with the resident, his family, friends, or relevant healthcare professionals such as psychologists or mental health professionals to develop and implement individualized interventions. The lack of identification of triggers and absence of a collaborative, individualized care approach resulted in the facility not meeting the requirements for culturally competent, trauma-informed care for this resident.
Plan Of Correction
Staff completed a review of resident #59's medical record to identify triggers related to the resident's diagnosis of PTSD (Post Traumatic Stress Disorder). An updated care plan was completed by social services to provide individualized care. A review of current residents with the diagnosis of PTSD has been completed. Any findings were addressed with a revised care plan to include potential triggers relating to the resident's diagnosis that may retraumatize the resident. Education was provided by the director of nursing or designee to the clinical and nursing management staff on the basis of identifying potential triggers for residents with the diagnosis of PTSD and the proper annotation within the care plans. Audits will be completed on 5 charts weekly for one month and biweekly for 3 months relating to the residents with diagnosis of PTSD and ensure the care plan has been appropriately annotated. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
A deficiency was identified when a consultant pharmacist failed to complete the required monthly medication regimen reviews for a resident diagnosed with Alzheimer's disease, cognitive impairment, and anxiety. The resident was admitted in early April, and documentation showed that a medication regimen review was completed by the pharmacist in April. However, there was no documentation of completed monthly medication regimen reviews for the months of May and June. The absence of these reviews was confirmed through clinical record review and interviews with the Director of Nursing, who acknowledged that no further documentation existed to indicate the reviews were performed for those months. The surveyor requested the missing documentation during meetings with facility leadership, but none could be provided, confirming the deficiency.
Plan Of Correction
No evidence of any actual ill effect exists on any of the residents in our community due to lack of adherence to the requirements of monthly medication regimen review. Resident #65's medications have been reviewed and will be reviewed going forward by the facility's new pharmacy consultant. The facility's current new pharmacy consultant has assured us that they will complete the residents' medication regimen reviews monthly. The first consultant report was provided on July 21st. An educational session was conducted by the Director of Nursing or designee with nursing staff on the importance of ensuring all residents have monthly medication regimen reviews by a pharmacy consultant. Audits of the drug regimen reviews will be completed monthly for 6 months, and any deficiencies will be addressed immediately and reported to the Director of Nursing for corrective action. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions, and to the Director of Nursing for corrective action.
Failure to Provide Routine Dental Care per State Plan
Penalty
Summary
A deficiency was identified when a resident with several missing and broken bottom teeth reported not remembering the last time dental services were offered. Clinical record review showed the resident was admitted with Medicaid coverage and had a physician's order for a dental consult and follow-up. However, the last documented dental visit was nearly a year prior, and there was no evidence that the resident received routine prophylactic dental cleanings as covered under the State plan. Observation and interviews confirmed that the facility did not assist the resident in obtaining routine dental care in accordance with regulatory requirements. The Director of Nursing acknowledged that the resident did not receive dental care as required, and the facility failed to provide documentation supporting the provision of routine dental services.
Plan Of Correction
The facility was unable to take actions for residents 23 due to the resident ceasing to breathe within the facility. A review of the residents potentially needing dental care services was completed. Upon identification of needs for such service, it was discussed with the provider and actions were taken to ensure that the resident was scheduled and/or received dental care. Education was provided by the director of nursing and/or designee to clinical staff and our scheduling team on the importance of residents being offered dental services either within the facility or outside to their personal dentist. Audits will be completed weekly for one month and bi-weekly for an additional three months focusing on the identification of residents needing service and being scheduled for dental care. Any findings will be reported to our Quality Assurance Performance Improvement committee for further discussion.
Improper Garbage Disposal and Unsafe Dumpster Area
Penalty
Summary
Surveyors observed that the facility failed to properly contain and dispose of garbage in the main dumpster area located outside the rear egress door from the main kitchen. The inspection revealed debris and garbage scattered on the ground around the dumpster, including four-foot-tall weeds, stagnant water approximately one to two inches deep in a metal containment area beneath the generator fuel supply container, and seven wooden fence boards each with three rusted nails protruding, totaling 21 exposed nails. Additional items found on the ground included an accumulation of dead leaves, discarded cardboard, hair nets, gloves, paper products, and pieces of wood. These findings were confirmed during a meeting with the Nursing Home Administrator and the DON.
Plan Of Correction
Upon identification of the deficient practice, the facility's maintenance department cleaned and sanitized the area surrounding the main dumpster. All visible debris, trash, and waste (e.g., gloves, hairnets) were properly disposed of. The standing water was removed from the generator's fuel containment area, and all exposed nails were removed from the fencing. Residents did not have direct access to this area and were not directly affected. Staff education was completed on July 22, 2025, for dietary, maintenance, and housekeeping departments regarding proper waste disposal procedures, environmental hazard identification, and reporting procedures for unsafe conditions. Weekly environmental inspections/audits of the dumpster area will be completed for one month and bi-weekly for 3 months. All findings will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee. The QAPI Committee will review trends and recommend corrective actions if future deficiencies are identified.
Failure to Document Disposition of Resident Personal Belongings at Discharge
Penalty
Summary
A deficiency was identified when, upon review of closed clinical records and staff interviews, it was found that the facility failed to document the disposition of personal belongings for two out of three discharged residents. Specifically, there was no evidence indicating what personal items were brought in by the residents at admission, nor was there documentation accounting for these belongings at the time of discharge. The Director of Nursing confirmed that there was no record of the personal property for these residents upon their discharge.
Plan Of Correction
A search of the storage areas in which resident belongings are secured until picked up by family members was conducted, and there was no evidence of any belongings of identified residents #82 or 83. The facility has implemented a new inventory of personal effects forms that will be completed by the nursing department upon admission. Education was provided to clinical staff on the proper documentation of the personal properties/belongings of newly admitted residents. Included in the education is the process for logging and updating the form as additional items are provided to the residents. An explanation of the appropriate actions to take upon discharge or death will be included in the education. Audits of newly admitted residents' inventory sheets will be completed on a weekly basis for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions. P 1210
Incomplete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to ensure the completion of discharge summaries for two discharged residents. For one resident who was admitted and later signed out against medical advice, the closed clinical record did not contain a discharge summary, including a summary of the stay or final diagnosis. This omission was confirmed during an interview with the Director of Nursing. Another resident was admitted, experienced a fall and a change in condition, and was subsequently sent to the hospital. The resident did not return and was discharged, but the closed clinical record also lacked a discharge summary with a summary of the stay or final diagnosis. This finding was similarly confirmed by the Director of Nursing during an interview.
Plan Of Correction
The need for a discharge summary was reviewed and the provider(s) completed a summary for both Resident #82 and #83. The discharge summary form was updated and provided to the nursing staff to be utilized for all residents being discharged under the supervision of a consultant physician, and all resident deaths under the supervision of the medical director and her PA for the purpose of providing the final diagnosis. The Medical Director and her PA provide a detailed discharge note with discharges that provides all of the information required per regulatory guidelines. Education was provided to licensed clinical nursing staff as to how and when the discharge summary should be utilized in accordance with facility discharge policy. Auditing will occur with a review of all discharges on a weekly basis for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Medication Disposition Documentation and Nurse Aide Staffing Deficiencies
Penalty
Summary
The facility failed to document the accounting and disposition of medications for a resident who signed out against medical advice. Upon review of the closed clinical record for this resident, there was no evidence regarding the disposition of several prescribed medications, including Atorvastatin, Diltiazem, Methimazole, Mirtazapine, and Lasix. The Director of Nursing confirmed that the facility could not provide documentation of how these medications were handled upon the resident's discharge. Additionally, the facility did not meet the required nurse aide-to-resident ratios for several shifts over a three-month period. Specifically, there were multiple instances during the day, evening, and overnight shifts where the number of nurse aides scheduled was below the minimum required based on the resident census. This was confirmed through a review of staffing records and interviews with facility leadership.
Plan Of Correction
Attempts were made to obtain documented evidence that a disposition of resident #82's medication was completed; however, it was unsuccessful. Education was provided to all registered nurses and licensed practical nurses, conducted by the director of nursing on the implementation of the disposition of medications at the time of discharge. Auditing will be completed with a review of all discharges on a weekly basis for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions. P 5280 P 5520 There is no evidence of any ill effect on any residents within the community due to lack of adherence to the ratio requirement for the CNA staff on the dates indicated. Current CNA ratios are presented and reviewed at the morning leadership meeting to assure compliance in accordance with the daily DOH Staffing Hours report. Identified concerns are highlighted and discussed with management for additional planning purposes. Outliers are addressed for resolution of the current daily needs. Upon identification of continued staffing needs, immediate mass texts are sent to all current staff including full-time, part-time, and PRN. In addition, needs are posted on agency sites and one-on-one conversations are held with staff to ensure staff needs are met. If continued needs exist, the group will touch base again mid-day to ensure corrective actions have been taken. Also, during the meeting, the following 3 days are reviewed to highlight any potential upcoming outlier concerns. An audit of the DOH Staffing Hour Calculator Report will be reviewed daily for two weeks and weekly for one month at the morning meeting for presentation and discussion of any variances with the established compliance requirements and actions taken to attempt to eliminate any variances. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations and explanation of any identified variance infractions.
Penalty
Summary
Empty report provided.
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum LPN-to-resident staffing ratios on several occasions, as determined by a review of nursing staff care hours and staff interviews. Specifically, during the day shift, the number of LPNs scheduled was below the required ratio for three days, with examples including 3.00 LPNs for 86 residents (required 3.44), 2.81 LPNs for 89 residents (required 3.56), and 3.00 LPNs for 84 residents (required 3.36). On the evening shift, the facility scheduled 2.38 LPNs for 88 residents when 2.93 were required, and on the overnight shift, 1.94 LPNs were scheduled for 88 residents when 2.20 were required. These findings were confirmed in an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not meet the regulatory LPN-to-resident ratios on the identified days. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
There is no evidence of any ill effect on any residents within the community due to lack of adherence to the ratio requirement for the LPN staff on these dates. Current LPN ratios are presented and reviewed at the morning leadership meeting to assure compliance in accordance with the daily DOH Staffing Hours report. Identified concerns are highlighted and discussed with management for additional planning purposes. Outliers are addressed for resolution of the current daily needs. Upon identification of continued staffing needs, immediate mass texts are sent to all current staff including full-time, part-time, and PRN. In addition, needs are posted on agency sites and one-on-one conversations are held with staff to ensure staff needs are met. If continued needs exist, the group will touch base again mid-day to ensure corrective actions have been taken. Also, during the meeting, the following 3 days are reviewed to highlight any potential upcoming outlier concerns. An audit of the DOH Staffing Hour Calculator Report will be reviewed daily for two weeks and weekly for one month at the morning meeting for presentation and discussion of any variances with the established compliance requirements and actions taken to attempt to eliminate any variances. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day for eight out of twenty-one days reviewed. Specifically, on several dates in April, May, and July 2025, the total nursing care hours per patient day fell below the mandated threshold, with recorded hours ranging from 2.91 to 3.12 per resident per day. This deficiency was confirmed through a review of nursing staff care hours and interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not meet the required staffing levels on the identified days. No additional information regarding the medical history or condition of specific residents was provided in the report.
Plan Of Correction
There is no evidence of any ill effect on any residents within the community due to lack of adherence to the PPD requirement for staff on the eight dates indicated. Daily compliance to the PPDs is presented by the Human Resource representative during the morning leadership meeting for discussion and recommendations to ensure we are compliant with the required nursing care hours. Identified concerns are highlighted and discussed with management for planning purposes. Upon identification of continued staffing needs, immediate mass texts are sent to all current staff including full-time, part-time, and PRN. In addition, needs are posted on agency sites and one-on-one conversations are held with staff to ensure staff needs are met. If continued needs exist, the group will touch base again mid-day to ensure corrective actions have been taken. Additional days are also reviewed for verification of the facility's adherence. An audit of the DOH Staffing Hour Calculator Report will be reviewed daily for two weeks and weekly for one month at the morning meeting for presentation and discussion of any variances with the established compliance requirements and actions taken to attempt to eliminate any variances. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
Deficiency in PICC Line Care Competency
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not providing adequate training and competencies for licensed nursing staff in the care and management of a peripherally inserted central catheter (PICC). The deficiency was identified during a review of policies, clinical records, and staff interviews. The facility's policy on intravenous device care did not specify whether licensed practical nurses (LPNs) were permitted to utilize and care for a PICC or if any specialized training was required. Interviews with the Director of Nursing and nursing staff revealed that the facility followed state guidelines for PICC care but did not provide documentation of any specialized training or competencies for LPNs, specifically for Employee 3, who was involved in administering medication through a PICC line. The deficiency involved a resident who was admitted to the facility with a PICC line for the administration of intravenous antibiotics due to osteomyelitis. The resident's medication administration record indicated that an LPN, Employee 3, administered the antibiotic Cefepime intravenously multiple times. However, the facility could not provide evidence of any intravenous or PICC line competencies or specialized training completed by Employee 3, as required by Pennsylvania Code. This lack of documentation and training was confirmed by the Nursing Home Administrator and the Director of Nursing during interviews with the surveyor.
Sanitation and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, leading to potential food contamination. Observations revealed that a speed rack beside the ovens held trays of potatoes and a container with various equipment, all of which were contaminated with dried spills and food splatter. Additionally, a drawer unit under a preparation table was found to be dusty and contained dried food debris. Lower shelves of preparation and storage tables were also observed with dust, crumbs, and dried spills. The flooring throughout the kitchen, including under preparation tables, steam tables, ovens, coolers, and along wall edges, was dirty with debris buildup, dried food, wrappers, a soiled plastic spoon, and dried spills. A three-tier cart beside the dishwashing area, which held clean plate bases and lids, was soiled with debris and dried food. Furthermore, a table storing open boxes of sugar and hot chocolate packets was covered in significant dust and debris. The facility also failed to ensure that kitchen staff adhered to proper hygiene standards. Employee 3, the production manager, was observed walking in and out of the kitchen multiple times without a beard covering, despite having a full beard. Similarly, during a follow-up observation, Employee 4 and Employee 5, both dietary aides, were seen preparing lunch service trays with visible facial hair and no protective covering. These observations were reviewed with the Nursing Home Administrator and Director of Nursing, indicating a lack of adherence to sanitary protocols and personal hygiene standards in the kitchen area.
Failure to Ensure Call Bell Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring the accessibility of their call bells, as required by their care plans. Resident 25, who requires assistance with personal care due to weakness and muscle contracture, was observed on two occasions with the call bell out of reach. On July 31, 2024, the call bell cord was tucked between the resident's right side rail and mattress, with the activator hanging under the bed. A similar observation was made on August 1, 2024, when the call bell was again out of reach, and the resident was unable to access it when asked. A registered nurse was informed of the situation and assisted the resident. Similarly, Resident 53, who has dementia and muscle weakness, was observed twice on August 1, 2024, with the call bell out of immediate reach. The activator was hanging below the bed, making it inaccessible. This resident's care plan also included an intervention to keep the call bell within reach due to risks associated with gait abnormality and cognitive deficits. The registered nurse was notified of this finding as well. These observations were reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to the responsible parties of two residents who were hospitalized. Resident 8 was admitted to the hospital on July 23, 2024, and at the time of the full health survey, there was no documented evidence in her clinical record indicating that her responsible party received written information about the bed hold policy. An observation on August 2, 2024, confirmed that Resident 8's bed hold forms were still at the facility's front desk. The Director of Nursing confirmed that if a responsible party cannot be contacted, the notice is sent via mail. Similarly, Resident 13 was admitted to the hospital on May 31, 2024, and there was no documented evidence in her clinical record that her responsible party was provided with written information on the bed hold policy. An interview with an admissions employee on August 2, 2024, confirmed these findings for Resident 13. This deficiency is a violation of the 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.29(f) Resident rights.
Failure to Refer Resident for PASRR Level II Review
Penalty
Summary
The facility failed to identify and refer a resident with a diagnosed mental disorder for a Level II review, as required by the Pre-Admission Screening and Resident Review (PASRR) program. The clinical record review and staff interview revealed that Resident 10, who was initially assessed in November 2004 with no disorders triggering a Level II review, was later diagnosed with paranoid schizophrenia in January 2005. Despite this significant change in condition, there was no evidence that the facility notified the appropriate agencies regarding the resident's new diagnosis, which is a requirement under the PASRR guidelines. The PA-PASRR-ID form, revised in September 2018, mandates that nursing facilities ensure the accuracy of information reported and communicate any changes in a resident's condition that affect their target status. The facility is required to notify the Department of Human Services using the MA 408 form within 48 hours of such a change. However, the facility did not fulfill this obligation for Resident 10, as acknowledged by the Director of Nursing during an interview. This oversight indicates a failure to comply with the regulatory requirements for PASRR compliance, specifically in ensuring that residents with serious mental disorders are appropriately evaluated and referred for necessary services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The clinical record review revealed that the care plan for the resident, who had a history of PTSD, did not identify specific triggers that could potentially retraumatize her. The resident's PTSD was linked to two significant past events: an alleged rape by another resident at a personal care home and a motor vehicle accident in 1987 that resulted in head trauma. Despite these events being documented in a physician's progress note, they were not included in the resident's care plan as potential triggers for her PTSD. An interview with the Director of Nursing confirmed these findings, indicating a lack of appropriate identification and management of triggers related to the resident's PTSD diagnosis.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 7 and Resident 168, received or were offered pneumococcal conjugate vaccines, which are administered to prevent pneumonia. Resident 7 was admitted to the facility on March 12, 2024, and Resident 168 on July 17, 2024. Upon review of their clinical records, it was found that there was no documentation related to the administration or offering of the pneumococcal conjugate vaccines for either resident. This deficiency was identified during a clinical record review and staff interview, and the Director of Nursing was informed of the issue on August 2, 2024, at 1:01 PM.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide a written notice of transfer that included all the required components to the resident and/or the resident's responsible party for two residents. Resident 8 was transferred to the hospital on July 23, 2024, and there was no documented evidence that the facility attempted to provide the responsible party with a transfer notice containing the necessary information, such as the State long-term care appeal agency contact and the Office of the State Long-Term Care Ombudsman details. An observation confirmed that Resident 8's transfer forms were still at the facility's front desk, and the Director of Nursing confirmed that notices are mailed if the responsible party cannot be contacted. Similarly, Resident 13 was transferred to the hospital on May 31, 2024, without documented evidence of a transfer notice being provided to the responsible party. An interview with an admissions employee confirmed the lack of documentation for Resident 13's transfer notice.
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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