Highlands Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Laporte, Pennsylvania.
- Location
- 918 Main Street, Laporte, Pennsylvania 18626
- CMS Provider Number
- 395683
- Inspections on file
- 24
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Highlands Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to maintain emergency lighting in the basement mechanical room, affecting one floor. The emergency light did not function properly when the power was turned off, although it worked with the test button. This was confirmed during an interview with the facility administrator.
The facility failed to maintain its sprinkler systems, with deficiencies found in five locations across three floors. Missing escutcheons were noted in the 3rd floor Oxygen Storage room and corridor, an unsealed ceiling tile penetration was found in the 1st floor Dietary area, and the Basement Level had missing escutcheons and lacked a wrench for sprinkler head replacement. These issues were confirmed with the facility administrator.
The facility failed to maintain the soiled linen and rubbish chutes as the 1st floor laundry chute door did not latch properly, affecting three of four floors. This was confirmed during an interview with the facility administrator.
The facility was found to be in violation of building construction requirements as it was observed to be three stories in height, exceeding the maximum allowable story height for its documented construction type, Type II (000). This deficiency was confirmed by the facility administrator during an exit conference.
The facility failed to maintain or improve the range of motion and mobility for four residents due to unclear restorative nursing policies and inadequate documentation. Residents required specific ROM exercises and ambulation assistance, but the frequency and shift-specific instructions were not provided, leading to incomplete care across shifts.
A facility failed to provide written notice of its bed-hold policy to a resident and their representative during a hospitalization. The resident was transferred to the hospital with stroke-like symptoms, and although the resident's sister was informed of the transfer, there was no evidence of written communication regarding the bed-hold policy. The Bed Hold Notice contained conflicting information, and the facility could not provide evidence of compliance with resident rights.
A facility failed to ensure an accurate MDS assessment for a resident with Schizophrenia. The resident's PASRR Level 1 and Level 2 evaluations indicated a mental health condition and eligibility for services, but the MDS inaccurately stated the resident was not considered to have a serious mental illness. This discrepancy was confirmed by the Nursing Home Administrator and DON.
The facility failed to revise care plans for three residents, leading to deficiencies in care. A resident's care plan did not include interventions to minimize anxiety and aggression, another resident's dental issues were not addressed in their care plan, and a third resident's care plan was not updated to reflect missing dentures. Interviews confirmed these deficiencies.
A facility failed to maintain a resident's ability to perform daily activities, specifically ambulation, due to inadequate staff follow-through. Despite a good prognosis with consistent support, the resident reported infrequent assistance with walking. Documentation showed multiple instances where the ambulation program was not attempted or marked as refused without re-approaching the resident, resulting in limited program completion.
A facility failed to implement physician-ordered supplemental oxygen for a resident, as staff did not routinely assess the resident's oxygen saturation levels to determine the need for supplemental oxygen. Despite a physician's order to administer oxygen at two liters per minute to maintain saturation levels above 90%, records showed no routine assessments were conducted. An observation revealed no supplemental oxygen in use, and no evidence of saturation assessments was found in the clinical record.
A facility failed to create an individualized care plan for a resident with dementia, despite the diagnosis being confirmed in an MDS assessment. The lack of a person-centered care plan was only addressed after a surveyor highlighted the issue, which was acknowledged by the facility's administration.
A resident's partial dentures went missing for eight months to a year, and the facility failed to provide timely replacement. Despite assessments by the facility's dental provider, there was no documentation of when the dentures were lost, and the facility lacked a policy for handling such incidents.
The facility failed to document that two residents with severe cognitive impairment or their representatives were educated on the risks and benefits of influenza and pneumococcal vaccinations. One resident's consent form lacked a signature, and the other resident's forms were undated, with no evidence of education provided to their responsible parties.
The facility failed to document that a resident's representative was educated on the risks and benefits of the COVID-19 vaccine, despite the resident's severe cognitive impairment. The resident, diagnosed with dementia, signed the consent form and received the vaccine without evidence of the responsible party's informed decision. The issue was confirmed by the infection preventionist and reported to the Nursing Home Administrator and DON.
The facility failed to provide timely written notifications to residents and their responsible parties regarding hospital transfers, as required by regulations. Five residents were transferred without proper documentation of notifications, including necessary information such as reasons for transfer, appeal rights, and contact details for the State Ombudsman. The Nursing Home Administrator confirmed the lack of compliance, and the facility did not submit transfer notices to the State Ombudsman until after the issue was identified during the survey.
A facility failed to complete a discharge summary within 30 days of a resident's death. A review of the resident's closed clinical record showed that while the resident was documented as deceased, the required discharge summary, including the final diagnosis and cause of death, was not completed in the specified timeframe. This deficiency was identified through record review and staff interviews.
The facility failed to meet the required nurse aide staffing levels during the evening and overnight shifts on specific days. Discrepancies in staffing calculations were identified, as staff were recorded as providing more hours than scheduled, leading to incorrect data. Despite multiple requests, accurate staffing information was not provided, confirming the shortfall in nurse aide staffing.
The facility did not meet the required LPN staffing levels on three separate days. During the day shift, the facility had insufficient LPNs for the resident census on two occasions, and during the overnight shift, the facility also fell short of the required LPNs for the resident census on one occasion. These deficiencies were identified through a review of nursing care hours and discussed with the Nursing Home Administrator and the DON.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient per day on four occasions. The review showed deficiencies in nursing care hours on specific days, with PPD hours falling short of the mandated requirement. These findings were discussed with the facility's administration.
A resident with dementia was found with a fractured arm after being pushed out of bed by her roommate, who has bipolar disorder. The incident was unwitnessed by staff, but the roommate later admitted to the act. The facility moved the aggressive resident to a different room and placed her on 15-minute checks, but failed to prevent the abuse.
The facility failed to maintain safe and comfortable temperature levels, with readings exceeding the recommended range on both the second and third floors. Residents expressed discomfort due to the heat, and the issue was attributed to the need for a replacement of the chiller and control panel. Approval for the chiller replacement was received, but no date was set for repairs, and approval for the control panel was pending.
The facility failed to ensure an effective infection control program for outbreak testing and transmission-based precautions. A resident had droplet precautions discontinued prematurely, and another resident had no documented evidence of transmission-based precautions. The facility did not initiate proper testing protocols after identifying symptomatic COVID-19 cases, leading to at least 55 reported cases.
The facility failed to implement their abuse policy and investigate an allegation of abuse between two residents. Despite a physical incident being reported and witnessed by a housekeeper, there was no documented evidence of an investigation or assessment of injuries. The housekeeper's statement was observed being written during the surveyor's visit, despite being dated for a previous year. Interviews with the Administrator and DON confirmed these findings.
A facility failed to administer the correct dosage of physician-ordered Morphine Sulfate for a resident. The MAR showed that a nurse administered 0.5 ml instead of the prescribed 0.75 ml on two occasions, with no evidence of as-needed doses being given. The Administrator confirmed no reported medication errors and verified the findings.
Emergency Lighting Deficiency in Mechanical Room
Penalty
Summary
The facility failed to maintain emergency lighting in the basement level mechanical room, affecting one of four floors. During an observation on January 29, 2025, at 10:50 am, it was noted that the emergency light did not function properly and failed to illuminate when the power was turned off in the room, although it worked when using the test button. This deficiency was confirmed during an interview with the facility administrator at the time of the exit conference on the same day.
Plan Of Correction
Emergency light in basement was rewired on 1/31/2025 and is now functioning properly. Maintenance director completed an audit to verify emergency lights in the facility are functioning properly. Maintenance Director was educated on maintaining emergency lighting by NHA. Maintenance director/designee will audit functionality of emergency lights weekly x4 and monthly x3 and report findings to monthly QAPI committee.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its required sprinkler systems, as evidenced by observations and interviews conducted during a survey. The deficiencies were identified in five locations across three of the four floors of the facility. Specifically, on the 3rd floor, the Oxygen Storage room and a corridor near the Nurses' station were missing escutcheons. On the 1st floor, the Dietary area had an unsealed penetration of a ceiling tile near the dishwasher. In the Basement Level, the Maintenance Shop was missing an escutcheon, and the Tank Room's sprinkler box lacked a wrench for sprinkler head replacement. These deficiencies were confirmed during an exit conference with the facility administrator.
Plan Of Correction
Escutcheons were installed in the 3rd floor oxygen room, 3rd floor corridor, and maintenance shop on 2/3/2025. Ceiling tile in dietary was replaced on 1/30/2025. A sprinkler wrench was purchased and placed in the sprinkler box on 1/31/2025. The Maintenance Director audited facility sprinklers to verify escutcheons in place and ceiling tiles in the dietary department. The Maintenance Director was educated on maintaining the facility's sprinkler system by NHA. The Maintenance Director/designee will audit sprinklers to verify escutcheons are in place, the sprinkler box to verify the wrench is in place, and the dietary ceiling tiles weekly for 4 weeks and monthly for 3 months, and report findings to the monthly QAPI committee.
Failure to Maintain Laundry Chute Door Latching Mechanism
Penalty
Summary
The facility failed to maintain the soiled linen and rubbish chutes in compliance with NFPA 101 standards. During an observation on January 29, 2025, at 10:27 am, it was noted that the discharge laundry chute door on the 1st floor did not latch into the frame when tested. This issue affected three of the four floors in the facility. The deficiency was confirmed during an interview with the facility administrator at the time of the exit conference on the same day at 11:00 am.
Plan Of Correction
The laundry chute was repaired on 2/5/2025. Maintenance director/designee completed an audit to verify facility chutes function properly. Maintenance Director was educated on maintaining laundry chute latch by NHA. Maintenance director/designee will audit facility chutes to verify latching weekly x4 and monthly x3 and report findings to monthly QAPI committee.
Building Construction Type Violation
Penalty
Summary
The facility was found to be in violation of building construction requirements as it was observed to be three stories in height, which exceeds the maximum allowable story height for its documented construction type, Type II (000). According to the National Fire Protection Association (NFPA) 101 Life Safety Code, a Type II (000) building is not permitted to have any stories if it is non-sprinklered. This deficiency was identified during an observation on January 29, 2025, at 9:50 am. The facility administrator confirmed during an exit conference on the same day that the facility indeed exceeded the maximum allowable story height by one floor.
Plan Of Correction
FSES was completed on 8/26/2024. Facility will maintain an up to date FSES.
Failure to Maintain or Improve Residents' Range of Motion and Mobility
Penalty
Summary
The facility failed to provide adequate services to maintain or improve the range of motion (ROM) and mobility for four residents. The facility's policy on Restorative Nursing Services lacked specific guidelines on the frequency and expectations for completing restorative nursing program interventions. This lack of clarity contributed to the failure in implementing the necessary care for the residents. Resident 19 had a therapy restorative referral indicating a decrease in active ROM, requiring passive range of motion (PROM) exercises for their lower extremities. However, the frequency and specific shifts for these exercises were not documented, and the PROM task was only opened for completion during the day shift, leaving evening and night shifts without documentation of completion. Similarly, Resident 48 required ambulation assistance and PROM for their right elbow, but the frequency and specific shifts were not indicated, and the tasks were only documented during the day shift. Additionally, there was a failure to transition from an active ROM program to a PROM program as indicated by therapy. Resident 59's therapy referral indicated a decrease in ROM for their lower and right upper extremities, but the referral incorrectly implemented a program for the left upper extremity. The PROM task was only documented during day and evening shifts. Resident 74 required PROM exercises and orthotic application for their right hand, but the frequency and specific shifts were not indicated, and documentation was lacking for evening and night shifts. There was also no documentation for the application and removal of the orthotic, and several shifts were marked as not applicable or lacked documentation entirely.
Plan Of Correction
1. Residents 19, 48, 59, and 74 had their restorative programs reevaluated. 2. DON/designee audited current residents on a restorative program and were reevaluated with specific frequency. 3. Therapy/licensed staff will be re-educated on providing nursing with a frequency the restorative nursing program should be conducted. 4. NHA/designee will audit 5 random residents receiving restorative services to verify there is a frequency weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice regarding its bed-hold policy to a resident and the resident's representative during a hospitalization event. The resident, who was hospitalized with symptoms suggestive of a stroke, was transferred to the hospital from the facility. Nursing documentation indicated that the resident's sister was informed of the transfer, but there was no evidence that written information about the bed-hold policy was provided to her. A review of the Bed Hold Notice revealed inconsistencies, as it was documented that the resident was unable to sign, and the notice contained conflicting information about the resident's wishes regarding bed retention. The surveyor requested evidence of written communication to the resident's representative, but the facility could not provide it. This failure to provide written notice within 24 hours of the emergency transfer constitutes a deficiency in the facility's compliance with resident rights and responsibilities.
Plan Of Correction
1. Facility cannot retroactively correct bed hold notification to resident 63. 2. Business office manager/designee completed an audit of the last month of discharges and any missed bed hold notifications were addressed. 3. Nursing staff will be re-educated on providing bed hold notification to residents and resident representatives upon transfer out of the facility. 4. DON/designee will conduct random audits of transfers to verify proper bed hold notification weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Inaccurate MDS Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one resident. Resident 34, who was admitted with a diagnosis of Schizophrenia, had a PASRR Level 1 form indicating a mental health condition that could lead to a chronic disability, necessitating a PASRR Level 2 evaluation. The PASRR Level 2 evaluation confirmed the presence of a mental health condition and eligibility for mental health services. However, the resident's last comprehensive MDS assessment inaccurately stated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. This discrepancy was identified during a review of the resident's clinical record and confirmed by the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Resident 34's MDS was corrected. 2. Social services/designee completed an audit of residents with PASRR level 2 to verify Section A1500 is correct. 3. Social Service director was re-educated on completing accurate MDS assessments. 4. Social worker/designee will conduct random audits of PASRR level 2 residents to verify Section A1500 accuracy weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. For Resident 79, the care plan did not include interventions to minimize anxiety and aggression by attempting care with one staff member or offering diet soda as suggested by the resident's daughter. Despite documentation indicating these suggestions, the care plan was not updated, and staff continued to provide care with two staff members without offering the diet soda. Resident 81's care plan was not developed to address dental health concerns despite multiple indications of dental issues, including tooth pain and decaying teeth. The facility's consultant dentist had documented these issues, but the registered nurse assessment coordinator did not review the dental progress notes when completing the MDS assessment, resulting in an inaccurate assessment that did not trigger a dental care plan. Resident 86's care plan was not revised to reflect the loss of her partial dentures, which had been missing for eight months to a year. Although the facility's consultant dental provider had assessed Resident 86 for new dentures, the care plan still indicated that she had partial dentures, failing to address her current needs. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these deficiencies in care plan revisions.
Plan Of Correction
1. Resident 79's care plan was updated to include attempt care with 1 staff member and their tasks updated to include providing a diet coke. Resident 81's care plan was updated with a dental plan of care. Resident 86's care plan was updated with her current dental status. Resident 81's care plan was updated to include a dental plan. Resident 86's care plan was updated with her current dental status. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary. 2. Care conferences and consultant dental visit notes from the last 30 days were reviewed by RNAC/designee to verify any interventions/changes that were noted were added to the resident's care plan. 3. DON or designee will re-educate IDT and licensed staff on care planning and consultant dental visit interventions/changes. 4. DON or designee will complete random audits of care plan meetings and consultant dental visit notes to verify interventions/changes are discussed are added to the resident's care plan and captured on the MDS weekly X 4 then monthly X 3. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to maintain or improve the ability of a resident to perform activities of daily living, specifically ambulation, due to insufficient staff follow-through. Resident 12, who was discharged from physical therapy with a home exercise program (HEP) and a good prognosis contingent on consistent staff support, reported that staff rarely assisted her with walking due to staffing shortages. Documentation revealed that on multiple occasions, staff marked the ambulation program as not applicable or noted the resident's refusal without re-approaching her to encourage participation. Throughout November 2024 to January 2025, there were numerous instances where Resident 12's ambulation program was either not attempted or marked as refused without further attempts to engage her. This lack of consistent follow-up and encouragement from staff resulted in the resident completing the program on only a fraction of the days reviewed. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to provide adequate care and services to maintain or improve the resident's functional abilities.
Plan Of Correction
1. Facility cannot retroactively provide restorative program to Resident 12 the days restorative was not completed. Resident 12 is currently receiving physical therapy. 2. DON/designee audited documentation from the last week of residents receiving restorative nursing program to verify residents are provided their program. 3. CNAs will be re-educated on the documentation of and providing restorative nursing services. 4. DON/designee will audit 5 random residents on a restorative nursing program weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Implement Physician-Ordered Supplemental Oxygen
Penalty
Summary
The facility failed to implement physician-ordered supplemental oxygen for a resident, identified as Resident 63, in accordance with professional standards of practice. A physician's order dated November 11, 2024, required staff to administer supplemental oxygen at two liters per minute as needed to maintain oxygen saturation levels above 90 percent. However, a review of the resident's medication and treatment administration records for November 2024, December 2024, and January 2025 revealed that staff did not routinely assess the resident's oxygen saturation levels to determine the need for supplemental oxygen. On January 13, 2025, an observation of Resident 63 showed no supplemental oxygen in use, and there was no evidence in the clinical record that staff had assessed the resident's oxygen saturation to confirm that supplemental oxygen was not needed. This deficiency was discussed with the Nursing Home Administrator and the Director of Nursing on January 14, 2025.
Plan Of Correction
1. Resident 63's order was revised to evaluate the need for supplemental oxygen. 2. DON/designee conducted an audit of residents receiving oxygen to verify evaluation is conducted when indicated. 3. Nursing staff will be re-educated on obtaining oxygenation saturation assessments if indicated. 4. DON/designee will audit 5 random residents on oxygen to verify evaluation of oxygenation saturation when indicated weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The resident was admitted on October 31, 2024, with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. The resident's most recent annual Minimum Data Set Assessment, dated November 6, 2024, confirmed the diagnosis of dementia. Despite this, the facility did not create a specific care plan to address the resident's cognitive loss until it was pointed out by a surveyor on January 15, 2025. This oversight was acknowledged by the Nursing Home Administrator and Director of Nursing during a review of the findings.
Plan Of Correction
1. Facility made revisions to individualize resident 43's care plan relating to her dementia. 2. Social services/designee reviewed residents with a dementia diagnosis to verify each had individualized dementia care plans. 3. Nursing staff and social services will be re-educated on implementing individualized person-centered care plans to address dementia and cognitive loss. 4. DON/designee will conduct random audits of 5 residents with dementia to verify their care plans are individualized weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Routine Dental Services for Resident
Penalty
Summary
The facility failed to provide routine dental services for a resident, specifically concerning the replacement of missing partial dentures. Resident 86, who had partial dentures for both the upper and lower jaw, reported that her dentures had been missing for a period ranging from eight months to a year. Despite the resident's indication that the facility's consultant dental provider was supposed to be making new dentures, there was no documentation or grievance form available to confirm when the dentures went missing. An observation of Resident 86 revealed that she had natural teeth and was missing some teeth, which corroborated her claim of missing dentures. The clinical record review showed that the resident's plan of care, created upon admission, acknowledged her need for partial dentures. A progress note from the facility's consultant dental provider dated October 29, 2024, indicated that an assessment of the resident's bite for the molds of new partial dentures had been conducted, marking it as the second assessment. However, the facility lacked a policy or procedure to address the loss or damage of resident property, including dentures, as confirmed by the Nursing Home Administrator and the Director of Nursing. This deficiency highlights the facility's failure to ensure the timely replacement of essential dental appliances for the resident.
Plan Of Correction
1. Resident 86 has a follow up dental appointment to receive her new partials. 2. Social services/designee conducted an audit of residents with partial/ dentures to verify all are accounted for. Findings were addressed at the time of the audit. 3. Social services will be re-educated on notifying dental services within 3 days after partial/dentures are reported missing. 4. Unit manager/designee will conduct random audits of 5 residents with partial/ dentures to verify they are accounted for weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Document Immunization Education for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation that residents' representatives were provided education regarding the risks and benefits of immunizations. This deficiency was identified for two residents with severe cognitive impairment. Resident 21's clinical record showed no evidence that she or her responsible party received education about the risks and benefits of the influenza vaccination before it was administered. Despite a psychiatric note indicating that Resident 21 was awake, alert, and oriented, she was unable to confirm if she consented to the vaccination during an interview. Similarly, Resident 46's records revealed that she signed the consent forms for both influenza and pneumococcal vaccinations, but the forms lacked dates, and there was no evidence that her responsible party was informed about the risks and benefits of these vaccinations. Given Resident 46's diagnosis of dementia and severe cognitive impairment, she was not capable of making informed medical decisions independently. The facility's failure to provide the necessary education to the residents' representatives was confirmed by the infection preventionist during an interview.
Plan Of Correction
1. Facility cannot retroactively provide Influenza vaccine informed consent to resident 21 and 46's representatives. Facility cannot retroactively provide Pneumococcal vaccine informed consent to resident 46's representative. 2. Infection preventionist/designee conducted an audit of the last two weeks of influenza and pneumococcal vaccines given to verify resident representatives were provided the informed consent. 3. Infection preventionist will be re-educated on educating resident representatives on the Influenza and Pneumococcal vaccine informed consents prior to vaccination. 4. DON/designee will conduct random audits of Influenza and Pneumococcal vaccination consent forms weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Document COVID-19 Vaccine Education for Resident's Representative
Penalty
Summary
The facility failed to ensure that a resident's medical records included documentation that the resident's representative was provided education regarding the risks and benefits of receiving a COVID-19 immunization. This deficiency was identified for one of five residents reviewed for immunization concerns. Specifically, Resident 46, who had a severe cognitive impairment as indicated by a BIMS score of three, signed a consent form for the COVID-19 vaccine. However, the facility did not provide evidence that the resident's responsible party was educated about the vaccine's risks and benefits, which was necessary given the resident's incapacity to make informed medical decisions. The clinical record review revealed that Resident 46 had a diagnosis of dementia and was alert with confusion. Despite this, the resident signed the COVID-19 vaccine consent form, and the vaccine was administered. An interview with the facility's infection preventionist confirmed the lack of documentation regarding the education of the resident's responsible party. The Nursing Home Administrator and Director of Nursing were informed of these concerns, which were previously cited as a deficiency in February 2024.
Plan Of Correction
1. Facility cannot retroactively provide the COVID vaccine informed consent to resident 46's representative. 2. Infection preventionist/designee conducted an audit of the last two weeks of COVID vaccines given to verify resident representatives were provided the informed consent. 3. Infection preventionist will be re-educated on educating resident representatives on the COVID vaccine informed consent prior to vaccination. 4. DON/designee will conduct random audits of COVID vaccination consent forms weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents and their responsible parties regarding transfers to the hospital, as required by regulations. This deficiency was identified for five residents, who were transferred to the hospital due to changes in their conditions. The clinical records for these residents did not contain documentation of written notifications that included necessary information such as the reason for transfer, effective date, location, appeal rights, and contact information for the State Ombudsman and advocacy agencies. The Nursing Home Administrator confirmed that the facility did not provide the required written notices and had not submitted any transfer notices to the State Ombudsman for several months until after the survey process highlighted the issue. Specific cases included Resident 59, who was transferred on December 1, 2024, without the required written notification. Resident 91 and Resident 98 were also transferred without proper notification, and the State Ombudsman was not informed in a timely manner. Resident 63 experienced two hospitalizations, and in both instances, neither the resident nor the resident's representative received the required written notices. The facility was unable to provide evidence of compliance with notification requirements during interviews with the surveyor, indicating a systemic issue in adhering to regulatory standards for resident transfers.
Plan Of Correction
1. Facility cannot retroactively correct transfer notification to residents 59, 63, 91, 18, and 98. 2. Business office manager/designee completed an audit of the last month of discharges and any missed transfer notifications were addressed. 3. Nursing staff will be re-educated on providing notification to residents and resident representatives upon transfer out of the facility. 4. DON/designee will conduct random audits of transfers to verify proper notification weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Failure to Complete Discharge Summary Within 30 Days
Penalty
Summary
The facility failed to complete a discharge summary within 30 days of a resident's death, as required by regulation. A closed clinical record review for a resident revealed that nursing documentation noted the resident was without pulse or respirations and was pronounced deceased. However, the review also showed that no discharge summary, including the final diagnosis and cause of death, was completed within the required timeframe. This deficiency was identified during a closed clinical record review and confirmed through staff interviews.
Plan Of Correction
1. Facility cannot retroactively provide resident 100's discharge summary. 2. Medical records director/designee conducted an audit of the last 2 weeks of discharges to verify discharge summaries have been completed. 3. Providers will be re-educated on providing discharge summaries. 4. DON/designee will audit discharges to verify they have completed discharge summaries weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Deficiency in Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels during the evening and overnight shifts for specific days reviewed. Specifically, the facility did not ensure a minimum of one nurse aide per 11 residents during the evening shift on two occasions and one nurse aide per 15 residents during the overnight shift on three occasions. This deficiency was identified through a review of nursing staffing hours and staff interviews conducted during an onsite survey. The survey revealed discrepancies in the staffing calculations, as staff were recorded as providing more hours of care than their scheduled shifts, leading to incorrect staffing data. Despite multiple requests from the surveyor, the facility was unable to provide accurate nurse staffing information. The review of nursing care hours for specific dates confirmed the shortfall in nurse aide staffing, which was discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
1. Facility cannot retroactively correct nurse aide staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
LPN Staffing Deficiency on Day and Overnight Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during specific shifts on three separate days. On two occasions during the day shift, the facility did not provide the minimum required number of LPNs per resident. Specifically, on October 6, 2024, and November 24, 2024, the facility had 4.03 and 4.0 LPNs respectively for a census of 103 residents, whereas 4.12 LPNs were required. Additionally, on October 12, 2024, during the overnight shift, the facility provided 2.06 LPNs for a census of 104 residents, falling short of the required 2.60 LPNs. These deficiencies were identified through a review of nursing care hours and were discussed with the Nursing Home Administrator and the Director of Nursing on January 16, 2025.
Plan Of Correction
1. Facility cannot retroactively correct LPN staffing ratio. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks schedule to determine if LPN ratio is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. 4. Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Deficiency in Meeting Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient per day (PPD) for four specific days across three different periods. The review of nursing staff care hours revealed deficiencies on October 6, 11, and 12, 2024, and November 24, 2024, with PPD hours recorded as 3.17, 3.08, 3.14, and 3.18, respectively. This shortfall was identified during a review of nursing staffing hours and confirmed through staff interviews. The findings were discussed with the Nursing Home Administrator and the Director of Nursing on January 16, 2025.
Plan Of Correction
1. Facility cannot retroactively correct staffing PPD. 2. Director of Nursing/Designee will conduct an initial audit of the past two weeks' schedule to determine if PPD is in compliance. 3. Director of Nursing/Designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made. 4. Director of Nursing/Designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
Resident-to-Resident Abuse Incident
Penalty
Summary
Highlands Rehabilitation And Healthcare Center was found to be non-compliant with the requirement to protect residents from abuse, as evidenced by an incident involving two residents. Resident 1, who was admitted with unspecified dementia, was found on the floor with a fracture to her right arm after reportedly being pushed out of bed by her roommate, Resident 2. Resident 1 expressed fear and pain following the incident, which was unwitnessed by staff. The facility's documentation confirmed the injury and Resident 1's statement about being pushed. Resident 2, who has a diagnosis of bipolar disorder and was assessed with intact cognition, initially denied involvement but later admitted to pushing Resident 1. The incident occurred after Resident 2 was observed leaving the room and later admitted to the police and staff that she had pushed her roommate. The facility responded by moving Resident 2 to a different room and placing her on 15-minute checks for safety. Despite these measures, the facility failed to prevent the abuse from occurring. Interviews with staff revealed that Resident 2 had been acting differently due to the recent death of another resident she was close to. The Director of Nursing noted that Resident 2 was attention-seeking and initially denied the incident. The facility's investigation included witness statements from staff who confirmed Resident 2's admission of pushing Resident 1. The report highlights the facility's failure to protect Resident 1 from physical abuse by another resident, as required by federal and state regulations.
Plan Of Correction
1. R1 remains in the facility. Sling intact to right arm and pain controlled. She continues to have no recollection of the events and is happy in her new room. Social work visits completed. R2 remains in the facility. Medical follow up complete. ABT completed. Psych services continue to follow. Social work visits completed. She remains happy in her new room. 2. Residents on 3rd floor with a BIMS score of 8 or higher were interviewed/assessed for potential abuse. 3. DON/Designee reeducated abuse policies, investigation procedure and documentation process. Nurse aides and Licensed Nurses have been educated on documenting behaviors. 4. DON/SW/Designee will perform random audits of 5 resident's behaviors in nursing notes or EMAR/ETAR to ensure care plans updated weekly X 8, then monthly X 1. Results will be brought to QAPI.
Facility Fails to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels between 71 and 81 degrees Fahrenheit on both the second and third floors. Observations on October 19, 2024, revealed that temperatures in various resident rooms and medication rooms exceeded the recommended range, with readings as high as 88 degrees Fahrenheit. Interviews with multiple residents confirmed that the facility was too warm, with several residents expressing discomfort and a preference for cooler temperatures. Fans were provided to help alleviate the heat, but residents reported that they were not very effective. The Director of Nursing and the maintenance director confirmed the warm temperatures and attributed the issue to the need for a replacement of the chiller and control panel. While approval had been received to replace the chiller, there was no scheduled date for the repairs, and approval for the control panel replacement was still pending. This deficiency was previously cited on February 9, 2024, under the regulation 483.10(i)(1)-(7) for maintaining a safe, clean, comfortable, and homelike environment.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to ensure an effective infection control program for outbreak testing and transmission-based precautions on one of its nursing units. The policy for COVID-19 testing requires immediate testing and follow-up tests 48 hours apart until no new cases are detected for 14 days. Additionally, residents with COVID-19 should be on transmission-based precautions for at least 10 days. However, Resident 1, who tested positive and was symptomatic, had droplet precautions discontinued after only seven days. Resident 2, who also tested positive and was symptomatic, had no documented evidence of how long transmission-based precautions were maintained, nor was there a physician order to start or discontinue droplet precautions. The facility did not initiate either contact tracing or a broad-based testing approach after identifying symptomatic COVID-19 cases starting on March 26, 2024. The facility's infection control preventionist quit at the end of March 2024, and a new infection control preventionist did not initiate facility-wide COVID-19 testing until April 3, 2024. Between March 26, 2024, and April 20, 2024, the facility reported at least 55 resident and staff cases of COVID-19 to the Department of Health. Interviews with the Administrator and Director of Nursing confirmed these findings, indicating a significant lapse in the facility's infection control measures during this period.
Failure to Implement Abuse Policy and Investigate Allegation
Penalty
Summary
The facility failed to implement their abuse policy regarding investigating an allegation of abuse for two residents. According to the facility's Abuse Policy, allegations must be reported to the Administrator or other officials, and an investigation must be initiated immediately. However, the facility did not provide documented evidence that an investigation was started regarding a physical incident between two residents. Nursing documentation indicated that one resident struck another in the face, which was witnessed by a housekeeper and reported to the Director of Nursing. Despite this, there was no documented evidence that the injured resident was assessed for injuries or that an investigation was initiated. The surveyor observed the housekeeper writing a statement about the incident during the on-site visit, despite the statement being dated for a previous year. The housekeeper confirmed that she had initially written a statement when the incident occurred but was unsure what happened to it after submission. Interviews with the Administrator and Director of Nursing confirmed these findings, indicating a failure to follow the facility's abuse policy and properly document and investigate the incident.
Failure to Administer Correct Dosage of Pain Medication
Penalty
Summary
The facility failed to provide the highest practicable care regarding the administration of physician-ordered pain medications for one resident. A review of the resident's closed clinical record revealed a physician's order for Morphine Sulfate 20mg/ml, 0.75 ml to be administered every four hours around the clock for pain. However, the Medication Administration Record (MAR) for April 2024 showed that a registered nurse only administered 0.5 ml of Morphine Sulfate on two occasions, instead of the prescribed 0.75 ml. There was no documented evidence that any as-needed doses of Morphine Sulfate were administered during the nurse's shift. An interview with the Administrator confirmed that there were no reported medication errors for April 2024 and verified the findings for the resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
