Hillcrest Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lower Burrell, Pennsylvania.
- Location
- 100 Little Drive, Lower Burrell, Pennsylvania 15068
- CMS Provider Number
- 395208
- Inspections on file
- 45
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Hillcrest Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with malnutrition, non-Alzheimer’s dementia, and adult failure to thrive experienced an unwitnessed fall and was found on the floor with bleeding from a frontal head area previously injured in a prior fall. Facility policy and the neuro check flowsheet required neurological assessments and documentation after unwitnessed falls or suspected head injuries, at specified time intervals. Although the area was cleansed, the NP assessed the resident, family and hospice were notified, and the hospice physician ordered transfer to the hospital for further head injury evaluation, record review showed no evidence that any neurological checks were initiated or documented. The DON and the Nursing Home Administrator confirmed that required neurological checks were not performed, resulting in a failure to provide necessary care and services.
A resident with diabetes, anemia, and hypertension was given 30 units of rapid-acting insulin (Humalog) instead of the prescribed long-acting insulin (Lantus) at bedtime. The LPN who administered the medication recognized the error, documented it, and notified the RN supervisor and physician. The facility's policy requiring verification of the correct medication before administration was not followed, resulting in a significant medication error.
The facility did not provide the required minimum number of nurse aides per resident on multiple day and evening shifts, as confirmed by census and staffing records. The Nursing Home Administrator acknowledged that the facility failed to meet the mandated NA staffing ratios, and there was no evidence of additional higher-level staff compensating for these shortages.
A resident with multiple medical conditions was found with an undated dressing on a forearm wound that had not been changed for two days. Review of the clinical record showed there was no physician order for wound care, and staff confirmed the lack of documentation and orders for the wound treatment.
Three residents with significant medical needs did not receive scheduled bathing assistance as required, with facility records showing multiple missed baths or showers and no documentation that services were provided, offered, or refused. The DON was unable to produce evidence that these ADL services were delivered as scheduled.
Facility staff did not meet required NA staffing ratios for multiple day, evening, and night shifts, with NA FTEs falling below mandated levels for the facility census. Additionally, the required LPN-to-resident ratio was not met on one evening shift, with insufficient LPN FTEs present. The DON confirmed these staffing shortages and the absence of compensating higher-level staff.
Administrative staff did not ensure the required 3.2 hours of direct nursing care per resident per day on multiple days, as confirmed by review of schedules and census data and acknowledged by the DON.
A resident with multiple medical conditions who required extensive two-person assistance for bed mobility suffered a left hip fracture after falling from bed when a nurse aide provided care alone, failed to use required fall mats, and did not follow standard safety procedures. Staff interviews and documentation confirmed that the care plan and physician orders were not followed, resulting in actual harm.
A resident with dementia and mobility needs sustained a left hip fracture after falling from bed when a NA left the resident's side during care. Required fall mats were not in place, and the care plan did not specify the needed assistance for bed mobility. Staff witness statements and documentation confirmed that supervision and accident prevention measures were not followed.
A resident alleged that staff left her on the floor for an hour after a fall, but the facility failed to document the grievance, investigate the allegation, or record findings and actions in the grievance log as required by policy.
A resident reported being left on the floor for an extended period after a fall, and the facility did not obtain required written witness statements from the resident or her roommate, resulting in an incomplete investigation and failure to follow the abuse/neglect policy.
A resident reported being left on the floor for an hour after a fall, but the facility failed to document the grievance, interview the resident and her roommate, or identify the staff involved, resulting in an incomplete investigation and lack of required reporting to the state agency.
The facility failed to properly date and store food products in the main kitchen, as observed during an inspection. Opened packages of dried pasta were found undated in the dry storage room, and in the walk-in cooler, cooked ground meat was placed next to an open and undated bag of raw chicken. These issues were confirmed by the Dietary Manager, highlighting a breach in safe food handling practices.
The facility failed to conduct care plan conferences and notify residents or their representatives in advance, as required by policy. Residents with various medical conditions, including depression, renal insufficiency, and COPD, were unaware of or had not participated in care plan meetings. The RNAC, an interim per diem employee, did not run these meetings, indicating a gap in responsibility.
The facility did not conduct or document resident council meetings for four months, failing to uphold residents' rights to organize and participate in such groups. Staff conducted room-to-room visits instead of group meetings, and residents reported not receiving feedback on their concerns. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to conduct initial and ongoing assessments for the use of enabler bars for three residents, as required by their policy. The residents, with various medical conditions such as hypertension, hemiplegia, and diabetes, had enabler bars on their beds, but necessary evaluations were either outdated or missing, leading to a deficiency in care.
A facility failed to investigate and report an allegation of neglect involving a resident with atrial fibrillation and CHF. The resident was found with a bump on the shin and expressed fear during Hoyer lift use. Despite facility policy requiring investigation of such incidents, no investigation or report was made. The DON confirmed this oversight.
A facility failed to develop a baseline care plan for pain management for a resident admitted with multiple diagnoses, including fractures and neuropathy. Despite having physician orders for pain medication and a requirement to record pain scores, the resident's care plan lacked interventions for pain management, as confirmed by the Nursing Home Administrator.
The facility failed to meet professional standards in nutritional services due to the absence of an on-site Registered Dietitian (RD) over a six-month period. The RD worked remotely for eight hours a week and did not participate in care plan meetings or monitor food service operations as required. Interviews with staff revealed that the RD's absence affected the nutritional assessment process, leading to a deficiency in meeting residents' nutritional needs.
A resident with high blood pressure, heart failure, and dementia did not receive adequate assistance with ADLs, including scheduled showers and regular changing, as required by facility policy. The resident's family raised concerns about the lack of care, and the Nursing Home Administrator confirmed the deficiency.
A resident with dementia and multiple pressure ulcers did not receive necessary wound care services as per professional standards. The facility failed to document the stage of certain ulcers and did not follow the wound care provider's orders, including the use of Santyl and a wedge for repositioning. The Director of Nursing confirmed these deficiencies.
A facility failed to provide a resident with the necessary TLSO brace to maintain mobility, despite the resident's medical conditions requiring it. The resident's clinical record lacked an order or care plan for the brace, and staff confirmed its unavailability, leading to a deficiency in care.
A facility failed to timely assess the nutritional status of a resident, as required by their policy. The resident, with conditions including epilepsy and dysphagia, experienced an 11.8% weight loss over a short period, yet the first dietitian assessment occurred 40 days post-admission. Staff interviews revealed that assessments were not completed within the required timeframe, contributing to the deficiency.
The facility failed to provide appropriate respiratory care for two residents. One resident's oxygen tubing was not labeled with a date, contrary to physician orders, while another resident's nebulizer was neither labeled nor stored properly. These deficiencies were confirmed by nursing staff.
The facility failed to maintain consistent dialysis communication and care planning for a resident with renal insufficiency and diabetes. Despite physician orders for thrice-weekly dialysis, the resident's clinical record lacked a dialysis care plan and had incomplete communication forms for several dates. Interviews with an LPN and the DON confirmed these deficiencies.
The facility failed to ensure that pharmacy recommendations for a resident's medication regimen were reviewed by a physician. The resident had duplicate orders for Lidocaine gel and an order for oxycodone without non-pharmacological interventions. Recommendations were signed off by nursing staff instead of a physician.
A resident experienced significant medication errors due to incorrect dosages of Divalproex Sodium and Levetiracetam being administered, exceeding recommended limits. The error was identified after the resident's family reported increased lethargy, leading to a review of medication orders. Staff interviews revealed a lack of proper verification and clarification of orders upon admission, contributing to the error.
The facility failed to properly label and store medications, with opened and undated medications found on a medication cart and non-medical items improperly stored in a medication room. Additionally, a resident had unsecured vitamins and supplements at her bedside. An LPN and RN confirmed these deficiencies, indicating non-compliance with medication storage policies.
A facility failed to implement hospital dietary instructions for a resident with COPD and dementia. After being discharged from the hospital with specific dietary and speech therapy instructions, the resident's clinical record did not reflect these changes. The Director of Rehabilitation confirmed that the resident was not seen by speech therapy due to unawareness of the hospital's instructions.
The facility did not conduct the required quarterly Quality Assessment and Assurance (QAA) meetings from June to September 2024. Despite a plan for monthly QAPI meetings, attendance records showed no meetings occurred between May and October 2024. The Nursing Home Administrator confirmed this deficiency.
The facility failed to implement proper infection control measures during a COVID-19 outbreak, as residents were not tested on the required days and negative results were not tracked. Additionally, a nurse did not follow infection control practices during medication administration by using a dropped lancet without proper hygiene.
A resident with coronary artery disease did not receive a scheduled cardiology follow-up after a stent placement, as required by physician orders. The facility's failure to schedule the appointment was confirmed by staff interviews, indicating non-compliance with treatment orders and resident care policies.
The facility did not meet the requirement to review and update resident care policies annually. A review of facility documents showed no evidence of such a review, and the NHA confirmed the oversight during an interview, providing only a sign-in sheet from a Quality Assessment meeting as documentation.
The facility did not meet the required nurse aide staffing levels, failing to provide the minimum number of nurse aides per residents during various shifts over a 21-day period. The Nursing Home Administrator confirmed the staffing shortages, with no additional higher-level staff to compensate for the deficiency.
The facility did not meet the required LPN staffing levels during the day shift on six occasions. A review of nursing schedules and interviews revealed that the number of LPNs present was insufficient based on the resident census. For example, with 63 residents, only 2.44 LPN FTEs were present when 2.52 were required. The Nursing Home Administrator confirmed these shortages.
The facility did not notify the Department of Health about a significant disruption in service due to the therapy gym's heating system failure. The system was not operational, leading to therapy sessions being moved when temperatures dropped. The heating system was replaced, but the facility failed to report the disruption as required.
A facility failed to inform a resident's representative about a new medication, Haloperidol, prescribed for agitation. The resident, with severe cognitive impairment and multiple chronic conditions, had no documentation indicating that their representative was notified about the medication's risks, benefits, or alternatives. The Director of Nursing confirmed this oversight, violating resident rights.
A facility failed to maintain proper admission documentation for a resident with chronic kidney disease, dementia, and diabetes mellitus. The resident's MDS assessment showed a BIMS score of 4, indicating severe cognitive impairment. The Director of Nursing confirmed the absence of the required admission paperwork, violating the facility's admission policy and residents' rights.
The facility failed to employ a qualified Food Service Director for six months. Employee E9, who started in November 2023, lacked the necessary qualifications as outlined in the facility's job description, which requires a reputable course in food service operation or a degree in culinary arts management. This deficiency was confirmed by the NHA.
The facility failed to properly date and store food products and maintain clean equipment, as observed during an inspection. Opened packages of macaroni, spaghetti, and egg noodles were not dated, and a fan directed towards the tray line was covered in a gray, fuzzy substance. These deficiencies were confirmed by the FSD, highlighting lapses in food safety protocols.
The facility failed to communicate necessary information to receiving health care providers for three residents transferred to the hospital. This included care plan goals, advanced directives, and specific care instructions. The DON confirmed the lack of documentation for these communications.
The facility failed to notify the LTC Ombudsman of hospital transfers for three residents, despite policy requirements. The residents had various medical conditions, including COPD, heart failure, diabetes, and pneumonia. The DON confirmed the oversight during an interview.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy. This deficiency was identified for three residents who were transferred to the hospital. The clinical records lacked documented evidence of such notifications, and the DON confirmed this oversight.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in meeting their care needs. A resident with depression and dysphasia was not monitored for medication side effects, another resident's combative behavior was not addressed in their care plan, and a third resident with PTSD did not have identified triggers or coping methods in their care plan. Staff interviews confirmed these deficiencies.
A resident received an inaccurate Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS-10055) that misstated the cost of skilled nursing services. The form listed the cost as $361.00 per day, while the actual charge was $379.00 per day. This error was confirmed by facility staff.
A resident with dementia and other health issues experienced neglect in wound care management when a dressing on their right hand was not changed as required. Despite physician orders for regular dressing changes, an observation revealed the dressing was outdated, which was confirmed by an LPN and the DON. This discrepancy highlighted a failure in the facility's adherence to treatment protocols.
A resident's medications, including Morphine and Lorazepam, were misappropriated in an LTC facility. The medications were signed in by an RN and placed in the fridge, but later found missing. The facility's policy on controlled substances was not followed, as the required Controlled Drug Receipt/Record/Disposition form was not completed. The Assistant Director of Nursing confirmed the facility's failure to prevent the incident, and the alleged perpetrator was barred from returning.
The facility failed to conduct a required FBI background check for a newly hired LPN before her start date, as per their policy. This oversight was confirmed by the HR staff and the DON, revealing a lapse in adherence to procedures designed to protect resident safety and rights.
A facility failed to ensure accurate MDS assessments for a resident with high blood pressure, altered mental status, and a UTI. Despite progress notes indicating combative behavior, the MDS did not reflect physical behavioral symptoms. The DON confirmed the inaccuracy, highlighting a failure to adhere to RAI User's Manual guidelines.
Failure to Perform Neurological Checks After Unwitnessed Fall With Suspected Head Injury
Penalty
Summary
The facility failed to follow its neurological assessment policy and provide ordered care and services after an unwitnessed fall with suspected head injury for one of three reviewed residents. The facility’s policy, last reviewed on 2/20/25, required neurological checks following an unwitnessed fall or a fall with suspected head injury, with documentation of the date and time of each check, the person performing the assessment, and all assessment data. The facility’s neurological check flowsheet specified a standard frequency of every 15 minutes four times, every hour two times, and every four hours four times unless otherwise ordered by a physician. The resident involved was admitted on an unspecified date and had diagnoses including malnutrition, non-Alzheimer’s dementia, and adult failure to thrive, as documented on an MDS dated 12/9/25. On 12/12/25 at 11:20 a.m., the resident was found lying on the right side in front of a door with bleeding noted to the right frontal area at a site of a prior fall. The area was cleansed and bleeding stopped without difficulty, and the resident was assessed by a nurse practitioner; the family and hospice were notified, and the hospice physician ordered transfer to the hospital for further evaluation of a head injury. Review of the clinical record for that date showed no evidence that neurological checks were initiated or documented after this unwitnessed fall. In interviews, the DON and the Nursing Home Administrator confirmed that neurological checks were not performed and that the facility failed to provide the care and services needed for the resident to attain or maintain the highest practicable well-being.
Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anemia, hypertension, and diabetes mellitus was administered the wrong type of insulin. According to the physician's order, the resident was to receive 30 units of insulin glargine (Lantus), a long-acting insulin, subcutaneously at bedtime. However, during a night medication pass, an LPN administered 30 units of insulin lispro (Humalog), a rapid-acting insulin, instead of the prescribed Lantus. The error was identified by the LPN, who documented the incident and notified the RN supervisor and physician. At the time of the incident, the resident's blood glucose was 170, blood pressure was 134/76, temperature was 97.5°F, heart rate was 74, and oxygen saturation was 98% on room air. The facility's medication administration policy requires staff to verify the right resident, medication, dosage, time, and route before administration, but this protocol was not followed, resulting in a significant medication error for the resident.
Plan Of Correction
Resident R1's orders were clarified, and the order was correct and in place at the time of survey. The residents had no negative outcome from receiving the incorrect insulin. Current residents' insulin orders were audited to ensure that the insulin order for each resident is correct. The DON, or designee, will inservice licensed staff on administering medications policy and administering insulin medication orders policy. The DON, or designee, will conduct an audit on diabetic insulin administration for accuracy of medication orders to ensure that they are given as ordered and documented in the administration record. Audits will be completed weekly for 2 weeks, then monthly for 2 months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios as mandated by regulation. Specifically, for 14 out of 21 days reviewed, the facility did not provide at least one NA per 10 residents during the day shift. Additionally, on two days, the evening shift did not meet the minimum requirement of one NA per 11 residents. This was determined through a review of facility census data and nursing time schedules, which showed that the number of NA full-time equivalents (FTEs) present was consistently below the required levels for the census on those days. During an interview, the Nursing Home Administrator confirmed that the facility did not meet the minimum NA staffing requirements for the day and evening shifts as specified. There was no indication that additional higher-level staff were present to compensate for these staffing shortages. The deficiency was identified based on direct review of staffing records and census data, with no mention of specific residents or their conditions in the report.
Plan Of Correction
The residents had no negative outcome for not meeting the minimum of one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and has agency contracts to utilize for staffing needs. The Director of Nursing or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. The Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month.
Failure to Provide Physician-Ordered Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and treatment for a wound for one resident. According to the facility's policy, wound care must be performed with a physician's order, and all dressing changes must be documented with the date, time, staff involved, and type of dressing used. However, review of the clinical record for a resident admitted with diagnoses including high blood pressure, diabetes, and anxiety revealed no physician order for wound care from 9/26/25 to 10/6/25. During observation, the resident was found with an undated dressing on the left forearm, which the resident reported had not been changed since it was applied two days prior. Staff interviews confirmed the presence of the undated dressing and the absence of a physician order for wound care. The Nursing Home Administrator acknowledged that the facility did not provide appropriate care and treatment for the resident's wound.
Failure to Provide Scheduled Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and showering, for three residents who were dependent or required assistance. According to facility policy, residents unable to perform ADLs independently should receive services to maintain good nutrition, grooming, and personal and oral hygiene. Clinical records showed that these residents had significant medical conditions such as cerebral palsy, hemiplegia, dementia, anxiety, and depression, and were assessed as needing supervision, touching assistance, or being fully dependent for bathing. Each resident was scheduled for regular baths or showers twice weekly with staff assistance as indicated in their care plans. Documentation for the month reviewed revealed multiple missed scheduled baths or showers for all three residents, with no evidence that the services were provided, offered, or refused on those dates. In one instance, a nursing note indicated a resident was denied a shower after initially refusing and then requesting it later, citing lack of time. The Director of Nursing was unable to provide additional documentation to show that the residents were offered or received bathing assistance on the missed dates, confirming the failure to provide required ADL care.
Plan Of Correction
IA: Residents R1, R2, and R3 were reviewed for their shower/bath schedule and received a shower per schedule. Whole house audit was completed to ensure all residents' shower schedules are correct and meet the needs of the residents. Education: DON or designee will educate CNAs and licensed staff on the timely provision of activities of daily living (ADL) assistance and following assigned shower/bathing schedules. Audits: Showers will be audited 3 times weekly for 2 weeks and monthly times 1 month to ensure residents are receiving showers as assigned. F 0677
Failure to Meet Minimum Nurse Aide and LPN Staffing Ratios
Penalty
Summary
Facility administrative staff failed to meet required nurse aide (NA) staffing ratios on multiple occasions. Specifically, the facility did not provide the minimum of one NA per 10 residents during the day shift for 17 out of 21 days, one NA per 11 residents during the evening shift for 9 days, and one NA per 15 residents during the night shift for 5 days within the reviewed periods. Review of census data and nursing time schedules showed that the number of NA full-time equivalents (FTEs) present was consistently below the required levels for the respective shifts and census counts. The Director of Nursing confirmed these staffing shortages and acknowledged that there were no additional higher-level staff present to compensate for the deficiency. Additionally, the facility failed to provide the required minimum of one Licensed Practical Nurse (LPN) per 30 residents during the evening shift on one occasion. On that day, the number of LPN FTEs present was below the required amount based on the facility census. The Director of Nursing confirmed this LPN staffing shortage and also noted that there were no excess higher-level staff to offset the deficiency.
Plan Of Correction
The residents had no negative outcome for not meeting the minimum of one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evening shift, and one nurse aide per 15 residents on night shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month. --- The residents had no negative outcome for not meeting the minimum of one LPN per 30 residents on evening shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator or designee will audit the staffing ratios 3 times weekly for 2 weeks and monthly times 1 month.
Penalty
Summary
this deficiency..
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
Facility administrative staff failed to provide the minimum required 3.2 hours of direct general nursing care per resident per day on seven out of twenty-one reviewed days. Review of nursing time schedules and facility census data revealed that on these specific dates, the provided nursing care hours per patient day (PPD) fell below the regulatory minimum, with PPDs ranging from 2.91 to 3.16. The Director of Nursing confirmed during an interview that the facility did not meet the mandated nursing care hours on these days. No specific resident medical histories or conditions were mentioned in relation to the deficiency.
Plan Of Correction
IA: The residents had no negative outcome for not meeting the minimum 3.2 number of general nursing hours to each resident in a 24-hour period. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON or designee will provide the staffing coordinator and HR with education on the Pennsylvania staffing requirements for the 3.2 number of general nursing hours to each resident in a 24-hour time period. Audits: Staffing coordinator or designee will audit PPD 3 times weekly for 2 weeks and monthly times 1 month.
Failure to Follow Care Plan and Safety Protocols Results in Resident Hip Fracture
Penalty
Summary
A deficiency occurred when a resident with diagnoses including hypertension, heart failure, and dementia, who required extensive assistance of two staff for bed mobility, was not provided with the necessary goods and services as outlined in their care plan. The care plan specifically required the use of fall mats on both sides of the bed to minimize the risk of injury related to falls. However, during an episode of care, a nurse aide provided care alone and without the fall mats in place, despite physician orders and care plan directives. While the nurse aide was changing the resident, the bed was elevated to over two and a half feet, and the aide turned away from the resident to retrieve a brief. During this moment, the resident rolled out of bed and landed on the floor, resulting in an angulated left hip fracture. Multiple staff interviews confirmed that standard procedure is to roll residents toward the caregiver to prevent falls, and that the care plan requiring two-person assistance and fall mats was not followed at the time of the incident. Documentation and witness statements further indicated that the nurse aide did not maintain appropriate supervision and failed to follow established protocols for resident safety. The Director of Nursing and Nursing Home Administrator confirmed that the lack of adherence to the care plan and failure to provide required safety interventions constituted neglect, resulting in actual harm to the resident.
Failure to Provide Adequate Supervision and Accident Prevention During Bed Mobility
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents, resulting in actual harm. The resident, who had diagnoses including hypertension, heart failure, and dementia, required extensive assistance from two staff members for bed mobility, as documented in the Minimum Data Set. However, the care plan and physician orders did not clearly specify the required assistance for bed mobility, and fall mats, which were ordered to be placed bilaterally at the bedside, were not in place at the time of the incident. During care, a nurse aide was changing the resident and turned away to grab a brief, at which point the resident rolled out of bed and fell, sustaining a left hip fracture. The bed was elevated to over two and a half feet, and the fall mats were not present as required by the care plan and physician order. Witness statements from staff confirmed that the fall mats were not in place and that the nurse aide left the resident's side during care, contrary to facility policy and the resident's needs. The Director of Nursing also confirmed that the nurse aide's account of the incident was inconsistent with the physical evidence and that the aide failed to provide adequate supervision. The facility's policies on accident investigation and activities of daily living were not followed, contributing to the resident's fall and injury.
Failure to Document and Investigate Resident Grievance of Neglect
Penalty
Summary
The facility failed to properly document and process a resident grievance related to an allegation of neglect. Specifically, a resident reported that facility staff allowed her to remain on the floor for an hour after a fall. The facility's grievance log for the relevant month did not contain documentation of the date the grievance was received, a summary of the resident's allegation, steps taken to investigate, a summary of findings or conclusions, whether the grievance was substantiated, corrective actions implemented, or the date a written decision was issued. A review of the facility's grievance policy indicated that the Grievance Officer is required to submit a written report of findings to the Administrator upon receiving a grievance. However, interviews and document reviews confirmed that the facility did not follow this process for the resident's allegation. The Administrator in Training acknowledged that the required documentation and investigation steps were not completed or recorded in the grievance log.
Failure to Follow Abuse/Neglect Investigation Policy
Penalty
Summary
The facility failed to implement its Abuse Investigation and Reporting policy during an incident involving a resident who alleged neglect after a fall. According to the policy, all parties involved in an allegation are to be interviewed, and written, signed, and dated witness statements must be obtained. However, during the investigation of the incident where a resident reported being left on the floor for an hour after a fall, the facility did not obtain written witness statements from the resident or her roommate, resulting in an incomplete investigation. Facility documents submitted to the State Agency confirmed the lack of required documentation, and interviews with the Chief Nursing Officer and the resident identified specific staff members allegedly involved. The failure to follow established procedures meant that the investigation did not thoroughly identify or address the alleged perpetrators related to the neglect allegation.
Failure to Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of neglect involving a resident who reported being left on the floor for an hour after a fall. The facility did not complete documentation of the resident's grievance, nor did they interview the resident or her roommate, resulting in an incomplete and inaccurate investigation. Additionally, the facility did not identify the alleged perpetrators or submit the required PB22 documents to the state agency. The investigation was further compromised by the facility's failure to implement a previously issued plan of correction related to ensuring residents are free from abuse and neglect. During interviews, the resident identified the staff members involved, including the DON and two nurse assistants. The lack of a thorough investigation prevented the facility from properly addressing and correcting the alleged neglect.
Improper Food Storage and Dating in Kitchen
Penalty
Summary
The facility failed to adhere to safe food handling practices as outlined in their Food Receiving and Storage policy. During an inspection, it was observed that the dry storage room contained two opened packages of dried pasta that were not dated. Additionally, in the walk-in cooler, a meal cart was found holding a metal tray with cooked ground meat placed next to an open and undated bag of raw chicken. These observations were confirmed by the Dietary Manager, Employee E7, indicating a failure to properly date and store food products, which could potentially lead to foodborne illness.
Failure to Conduct and Notify Residents of Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences and ensure that residents or their representatives were notified in advance of these meetings for four residents. The facility's policy, dated 2/20/25, mandates that residents and their representatives be encouraged to participate in the development of the resident's care plan, with a seven-day notice provided for care plan conferences. However, interviews and record reviews revealed that residents R12, R36, and R39 were not aware of or had not participated in any care plan meetings. Resident R12, diagnosed with depression, renal insufficiency, and diabetes, had her care plans last revised on 2/14/25, but she stated she was unaware of any care plan meetings. Similarly, Resident R36, with high blood pressure, anxiety, and depression, and Resident R39, with hyperlipidemia, COPD, and major depressive disorder, also reported not attending or being aware of any care plan meetings. The Registered Nurse Assessment Coordinator (RNAC), who was an interim per diem employee, stated that she did not run the care plan meetings, indicating a possible gap in responsibility for organizing these conferences. The Nursing Home Administrator was informed of the facility's failure to conduct care plan conferences and notify residents or their representatives in advance. The deficiency was noted under 28 Pa. Code 201.29 (a) Resident rights and 28 Pa. Code 211.11 (e) Resident care plan.
Failure to Conduct and Document Resident Council Meetings
Penalty
Summary
The facility failed to uphold the residents' right to organize and participate in resident/family groups, as evidenced by the lack of documentation and follow-up from resident council meetings for four consecutive months. The facility's policy on grievances and complaints, dated February 20, 2025, mandates that all issues raised by resident or family groups be considered and responded to in writing. However, the review of resident council minutes for October and November 2024 revealed that staff conducted room-to-room visits instead of organizing a resident group meeting. Interviews with residents confirmed that no resident group meetings were held in October and November 2024, and they did not receive feedback or responses to their concerns. The Nursing Home Administrator acknowledged the failure to hold monthly resident council meetings and to document and follow up on resident concerns for the specified period.
Failure to Conduct and Document Enabler Bar Assessments
Penalty
Summary
The facility failed to conduct an initial Enabler/Assist Rail/Device Evaluation assessment for one resident and did not complete ongoing accurate assessments for three residents regarding the use of enabler/side rail assist bars. Specifically, Resident R30 did not have an initial assessment conducted, and Residents R7, R8, and R30 did not have ongoing assessments to ensure the enabler bars met their needs and addressed associated risks. Observations revealed that enabler bars were present on the beds of these residents, but the necessary evaluations were either outdated or missing. Resident R7, diagnosed with anemia, hypertension, and hemiplegia, had bilateral enabler bars on their bed, with the last evaluation completed nearly a year prior. Resident R8, with heart failure, hypertension, and diabetes, also had bilateral enabler bars, with the last assessment conducted over a year ago. Resident R30, diagnosed with hypertension, hyperlipidemia, and hemiplegia, had a right enabler bar without any recorded initial assessment. The facility's policy required assessments to determine the risks and benefits of using side rails, but these were not adequately performed or documented for the residents in question.
Failure to Investigate and Report Allegation of Neglect
Penalty
Summary
The facility failed to investigate and report an allegation of neglect involving a resident identified as R24. According to the facility's policy on identifying types of abuse, neglect is defined as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. Resident R24, who was admitted with diagnoses of atrial fibrillation and congestive heart failure, was found to have a 7 x 5 cm bump on the right shin during a dressing change. The resident was unable to describe the cause of the injury but expressed fear when using the Hoyer lift. Despite this, the facility did not conduct an investigation or report the incident to the state survey agency. The Director of Nursing confirmed the failure to investigate and report the potential neglect incident.
Failure to Develop Baseline Care Plan for Pain Management
Penalty
Summary
The facility failed to develop a baseline care plan for pain management for one of its residents, identified as Resident R223. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission to address their immediate needs. Resident R223 was admitted with several diagnoses, including a fracture of the right tibia and fibula, pain in the right ankle and joints of the right foot, and idiopathic progressive neuropathy. Despite these conditions and the resident's report of experiencing significant pain, the facility did not include a baseline care plan for pain management in the resident's care plan. The clinical records showed that Resident R223 had physician orders for pain management, including scheduled and as-needed doses of Acetaminophen and Oxycodone. The orders also required recording the resident's pain score every shift. However, during an interview, the Nursing Home Administrator confirmed that the baseline care plan for Resident R223 did not include interventions for pain management, indicating a failure to comply with the facility's policy and regulatory requirements.
Deficiency in Nutritional Services Due to Lack of On-Site Dietitian
Penalty
Summary
The facility failed to adhere to professional standards of quality in its nutritional services, as evidenced by the lack of a Registered Dietitian's (RD) active participation in essential duties over a six-month period. The RD, who began working remotely for the facility in late 2024, did not conduct in-person assessments, participate in care plan meetings, or monitor food service operations as required by the job description and state regulations. The RD worked only eight hours a week remotely and did not sign off on substitute menus or attend interdisciplinary meetings unless there was a specific concern. This lack of presence and involvement in the facility's operations led to a failure in meeting the nutritional needs of residents as per the facility's policies and state regulations. Interviews with facility staff, including the Dietary Manager and the Registered Nurse Assessment Coordinator, revealed that the RD's absence from the facility impacted the nutritional assessment process. The Dietary Manager indicated that resident meal preferences were managed by the Activities department, and the RNAC expressed uncertainty about the RD's presence in the building. The Nursing Home Administrator was informed of the deficiency, highlighting the facility's failure to have a Registered Dietitian on-site to fulfill the responsibilities outlined in the job description, which includes participating in interdisciplinary meetings and monitoring food service operations.
Failure to Provide ADL Assistance for a Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for Resident R33, who was dependent on staff for toileting and required substantial assistance for showering. According to the facility's policy, residents unable to perform ADLs independently should receive necessary services to maintain good personal hygiene. However, a review of Resident R33's February 2025 shower documentation revealed that the resident did not receive scheduled showers on two occasions, and the toilet use documentation indicated that the resident was not changed at least every shift for 12 out of 28 days. Resident R33, who was admitted to the facility in April 2024, has diagnoses of high blood pressure, heart failure, and dementia, which affect their ability to perform self-care. The resident's family representative expressed concerns about the lack of bathing and changing, noting that staff had been informed multiple times about the need to prevent the resident from sitting in feces or a soiled brief. The Nursing Home Administrator confirmed the facility's failure to provide the necessary ADL assistance for Resident R33.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards of practice for a resident with multiple pressure ulcers. Resident R27, who was admitted with diagnoses including dementia, morbid obesity, and muscle weakness, had several pressure ulcers upon admission. The facility did not document the stage of the sacrum and left rear thigh pressure ulcers. The care plan indicated a stage three pressure ulcer on the buttocks, and interventions included treatment per physician orders and repositioning assistance. However, the facility did not follow the wound care provider's orders, as the physician order did not include Santyl, which was necessary for the treatment. Additionally, the facility delayed implementing the wound care treatment ordered by the wound care provider for 29 days. The physician orders also failed to include an order for a wedge to assist with turning and repositioning, as recommended by the wound care provider. The Director of Nursing confirmed that the facility did not ensure residents received necessary services to promote healing and prevent infection, as required by professional standards of practice.
Failure to Provide Necessary Mobility Equipment
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received the necessary services, equipment, and assistance to maintain or improve mobility. Resident R223, who was admitted with diagnoses including a fracture of the right tibia and fibula, pain in the right ankle and joints of the right foot, and idiopathic progressive neuropathy, was ordered to wear a TLSO brace when upright or out of bed. However, the resident reported that the brace had been missing for a couple of days, and this was confirmed by a Licensed Practical Nurse who stated that there was no TLSO brace available for the resident. Further review of Resident R223's clinical record revealed that there was no order or care plan for the TLSO brace, which was confirmed by the Director of Nursing. This oversight resulted in the resident not receiving the appropriate equipment and assistance needed to maintain or improve mobility, as required by the facility's obligations under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Timely Assess Nutritional Status
Penalty
Summary
The facility failed to timely assess the nutritional status of Resident R23, as required by their own policy. According to the facility's Nutritional Assessment policy, a dietitian is supposed to conduct a nutritional assessment for each resident upon admission within the current baseline assessment time frames. However, for Resident R23, who was admitted with diagnoses including epilepsy, dysphagia, hypertension, and hyperlipidemia, the first dietitian assessment was not conducted until 40 days after admission. This delay occurred despite the resident's hospital discharge summary indicating the need for nutritional monitoring due to increased nutritional demands. During the period from July 13 to July 30, Resident R23 experienced a significant weight loss of 11.8 percent, dropping from 242.2 lbs to 213.4 lbs. Despite this notable weight loss, there was no dietitian assessment related to this issue until August 22. Interviews with facility staff revealed that the dietitian assessments were not completed within the required 14-day timeframe, and there was uncertainty about the dietitian's presence in the facility on a daily basis. This lack of timely assessment and monitoring contributed to the deficiency identified by the surveyors.
Failure in Respiratory Care Management
Penalty
Summary
The facility failed to provide appropriate respiratory care related to oxygen management for two residents. Resident R41, who has a medical history of hypertension, respiratory failure, and coronary artery disease, was observed with oxygen administered via a nasal cannula. However, the oxygen tubing was not labeled with a date, which was confirmed by a registered nurse. This oversight was contrary to the physician's orders that required the oxygen tubing and canister to be changed every Saturday night shift. Similarly, Resident R274, diagnosed with diabetes, heart failure, and hypertension, was observed with a nebulizer that was not labeled with a date or stored in a bag. This was also confirmed by a registered nurse. The physician's orders for this resident included the administration of Ipratropium-Albuterol Inhalation Solution every six hours, but the lack of proper labeling and storage of the nebulizer indicated a failure in providing appropriate respiratory care.
Inconsistent Dialysis Communication and Care Planning
Penalty
Summary
The facility failed to ensure consistent dialysis communication and care planning for a resident requiring dialysis services. The resident, who was admitted with diagnoses of depression, renal insufficiency, and diabetes, had physician orders to attend dialysis three times a week. However, the clinical record review revealed the absence of a care plan for dialysis and incomplete communication forms for several dates in February and March. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed these deficiencies, indicating a lack of consistent communication and care planning for the resident's dialysis needs.
Failure to Ensure Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified in the Medication Regimen Reviews (MRR) by the pharmacy were reviewed by a physician for one of the residents. The facility's policy requires that a licensed pharmacist perform a monthly drug regimen review, and any irregularities should be reviewed by a physician who either accepts and acts upon the suggestions or provides an explanation for disagreeing. However, for Resident R12, this process was not followed. The resident had duplicate orders for Lidocaine gel, and the recommendation to discontinue one of the orders was signed off by the Director of Nursing instead of a physician. Additionally, another pharmacy review for the same resident indicated that there were no non-pharmacological interventions listed with an order for oxycodone, and it was recommended to consider adding such interventions. This recommendation was signed off by a Registered Nurse, who indicated the order was discontinued, but again, there was no physician review. The Nursing Home Administrator confirmed that the facility failed to ensure physician review of pharmacy recommendations for this resident.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was admitted with diagnoses including dementia, morbid obesity, and muscle weakness, was prescribed Divalproex Sodium and Levetiracetam for seizures. However, the dosages administered exceeded the recommended maximums. Specifically, the resident received 875 mg of Divalproex and 1750 mg of Levetiracetam, which were not aligned with the hospital's discharge orders. The error was identified when the resident's family reported increased lethargy, prompting a review of the medication orders. It was discovered that the orders entered by the Director of Nursing did not match the hospital's discharge instructions. The Licensed Practical Nurse had questioned the high dosages from the start, but the orders were not clarified until after the family raised concerns. The resident's condition was monitored, and medications were held due to the lethargy caused by the incorrect dosages. Interviews with staff revealed that there was a lack of proper verification and clarification of medication orders upon the resident's admission. The RN Supervisor confirmed that the facility failed to ensure the resident was free from significant medication errors. The Pharmacy Consultant Manager also noted that clarification was needed when multiple orders with different dosages were present, indicating a breakdown in communication and verification processes within the facility.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage and labeling policies, resulting in several deficiencies. During an observation of a medication cart on the East Hall, multiple medications were found opened and undated, including inhalers and ointments. Additionally, various treatment supplies and personal items were improperly stored on the cart. An LPN confirmed these findings, noting that certain supplies were kept on the cart to restrict access by nurse aides. Furthermore, the medication room contained non-medical items stored under the sink and an undated open vial of tubersol solution in the refrigerator. In another instance, a resident was found with unsecured bottles of vitamins and supplements at her bedside, which she claimed were given to her by her daughter. A registered nurse confirmed the unsecured medications, indicating a failure to secure medications at a resident's bedside. These observations highlight the facility's non-compliance with its policies on medication storage and labeling, as well as the need for secure storage of medications at residents' bedsides.
Failure to Implement Hospital Dietary Instructions for Resident
Penalty
Summary
The facility failed to identify and review a change in dietary recommendations for a resident, referred to as Resident R17. The resident was admitted with diagnoses of COPD and unspecified dementia. During the resident's stay, several nursing notes documented symptoms such as abdominal tenderness, confusion, hallucinations, and shortness of breath. The resident was eventually sent to the emergency room, where hospital discharge instructions included a specific dysphagia diet and follow-up with speech therapy. Upon returning to the facility, the hospital's dietary instructions were not addressed in the resident's clinical record, physician orders, or speech therapy notes. The Director of Rehabilitation confirmed that Resident R17 was not seen by speech therapy after returning to the facility, as the therapy team was unaware of the hospital instructions. This oversight led to the facility's failure to implement the necessary dietary and therapeutic interventions for the resident.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly, as required by regulations, for the period from June 2024 through September 2024. The facility's Quality Assurance Performance Improvement (QAPI) plan, last reviewed on February 20, 2025, indicated that monthly QAPI meetings were scheduled to ensure compliance with the quarterly meeting requirement. However, a review of the Quality Assurance attendance records for 2024 revealed that there were no sign-in documents for the period from May 13, 2024, to October 24, 2024. During an interview on March 7, 2025, the Nursing Home Administrator confirmed the failure to conduct the required quarterly QAA meetings with all necessary committee members.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control monitoring and management during a COVID-19 outbreak for three residents. The facility's policy required testing on Days 1, 3, and 5 after exposure, but residents were not tested on Days 3 and 5. Additionally, the facility did not track the results of residents who tested negative for COVID-19 on the outbreak case-patient line listing report. This deficiency was confirmed by the Infection Preventionist and the Director of Nursing during interviews. Furthermore, the facility failed to follow proper infection control practices during medication administration for one resident. A registered nurse dropped a lancet on the floor, picked it up, and continued to use it without disposing of it or performing hand hygiene. This incident was confirmed by the registered nurse involved, highlighting a lapse in adherence to the facility's infection control procedures during medication administration.
Failure to Schedule Cardiology Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care as per physician orders. The deficiency was identified through a review of facility policies, clinical records, and staff interviews. The facility's policy on 'Resident Rights' mandates that residents be informed of their medical conditions and participate in their care planning and treatment. Additionally, the 'Medication and Treatment Orders' policy requires that treatment orders be consistent with safe and effective practices. However, the facility did not adhere to these policies for one resident. The resident in question was admitted with diagnoses including high blood pressure, arthritis, and coronary artery disease. A physician's order dated shortly after admission required a follow-up appointment with cardiology one month after a stent placement. Upon review of the resident's clinical record, it was found that no cardiology follow-up appointment had been scheduled or attended. Interviews with the scheduler and the Director of Nursing confirmed that the appointment had not been made, indicating a failure to comply with the physician's order and facility policies.
Plan Of Correction
Immediate Action: On 2/5/2025 while the DOH surveyors were present, the appointment with cardio for resident R1 was scheduled for 2/6/2025 and transport was arranged. Resident R1 had no ill effects from the appointment being after the date it was to be scheduled. Education: Education was provided to all licensed nursing staff on the process for making appointments listed on the hospital discharge orders. Audits: All admission charts are reviewed during the AM clinical meeting. During review appointments will be audited to ensure they are made timely in accordance with the discharge orders. Audits will be completed weekly times 2 weeks and monthly times 1 month.
Failure to Annually Review Resident Care Policies
Penalty
Summary
The facility failed to comply with the regulation requiring annual review and updating of resident care policies. This deficiency was identified through a review of facility policies and procedures, which lacked documented evidence of an annual review. During an interview, the Nursing Home Administrator (NHA) provided a sign-in sheet from a Quality Assessment and Performance Improvement meeting but admitted to not having a policy review date signature sheet. The NHA confirmed that the facility did not conduct the required annual review and update of policies and procedures.
Plan Of Correction
Immediate Action: Policy and Procedures were reviewed, and the signature sheet was updated. Education: The NHA and DON were educated by the chief nursing officer on the regulations for annual review of policies and procedures. Audits: Audits will be completed through the QA/QI process monthly times 2 months to ensure the signature sheet is complete.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum of one nurse aide per 10 residents during the day shift for 16 out of 21 days, one nurse aide per 11 residents during the evening shift for two days, and one nurse aide per 15 residents during the night shift for one day. This deficiency was identified through a review of nursing time schedules and staff interviews. The Nursing Home Administrator confirmed the staffing shortages, acknowledging that there were no additional higher-level staff to compensate for the deficiency. The census data and nursing time schedules revealed specific dates where the full-time equivalents (FTE) present were below the required FTE, leading to the staffing shortfall.
Plan Of Correction
Immediate Action: The residents had no negative outcome for not meeting the minimum of one nurse aide per 10 residents on day shift, one nurse aide per 11 residents on evenings, and one nurse aide per 15 on the night shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON/designee will provide the Staffing Coordinator/HR with re-education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator/designee will audit the ratios 3 times weekly for 2 weeks and monthly x1 month.
LPN Staffing Shortages During Day Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift on six specific days. This deficiency was identified through a review of nursing time schedules and staff interviews. The facility's census data and nursing time schedules from January 12, 2025, to February 1, 2025, revealed LPN staffing shortages on January 16, 18, 19, 24, 26, and February 1, 2025. On these dates, the number of LPN Full Time Equivalents (FTE) present was below the required number based on the resident census. For instance, on January 16, 2025, with a census of 63 residents, only 2.44 FTEs were present when 2.52 were required. The Nursing Home Administrator confirmed these staffing shortages during an interview on February 5, 2025, acknowledging the facility's failure to meet the staffing requirement without additional higher-level staff to compensate for the deficiency.
Plan Of Correction
Immediate Action: The residents had no negative outcome for not meeting the minimum of one LPN per 25 residents on day shift. The facility has hired additional staff, holds daily staffing meetings to track staffing, and added additional agencies to utilize for staffing needs. Education: DON/designee will provide the Staffing Coordinator/HR with re-education on the Pennsylvania staffing requirements for ratios. Audits: Staffing coordinator/designee will audit the ratios 3 times weekly for 2 weeks and monthly x1 month.
Failure to Notify Health Department of Heating System Disruption
Penalty
Summary
The facility failed to notify the Department of Health about a significant disruption of service due to a disaster, specifically the malfunction of the therapy gym's heating system. The documentation reviewed on December 12, 2024, revealed that the heating system was not operational, and the facility had to monitor temperatures in the therapy gym. When temperatures fell below 71 degrees, therapy sessions for residents were relocated to alternative locations. The heating system was eventually replaced on December 9, 2024. During an interview on December 12, 2024, the Nursing Home Administrator (NHA) confirmed that a purchase order for a new heating system was made in November, and the replacement occurred in the week of the interview. However, the NHA acknowledged that the facility did not notify the Department of Health about the significant disruption of service caused by the heating system failure, which is a requirement under the regulation.
Plan Of Correction
Immediate Action: The report was placed to the DOH ERS during the survey with the surveyor on 12/12/2024. Education: The NHA and Maintenance Director were educated on the DOH reporting guidelines. Audits: Walking rounds will be completed 3 times weekly for 3 weeks and monthly times 1 month to ensure all utilities are in good working order.
Failure to Inform Resident's Representative of New Medication
Penalty
Summary
The facility failed to inform a resident's representative in advance of the proposed care, specifically regarding the risks and benefits of a newly prescribed medication. This deficiency was identified for one of the three sampled residents, who had a history of chronic kidney disease, dementia, and diabetes mellitus. The resident's Minimum Data Set (MDS) assessment indicated a severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4. Despite the resident's condition, there was no documentation in the nurse progress notes from August to October 2024 indicating that the resident's representative was notified about the new medication order for Haloperidol, prescribed for agitation. The physician's order for Haloperidol was dated October 22, 2024, but there was no evidence that the resident's daughter or other representatives were informed about the new medication, its advantages, disadvantages, or alternative options. An interview with the Director of Nursing confirmed that the facility did not fulfill the requirement to inform the resident's representative about the proposed care. This failure was a violation of the resident's rights as outlined in the relevant Pennsylvania Code sections.
Failure to Maintain Admission Documentation
Penalty
Summary
The facility failed to maintain proper admission documentation for one of its residents, identified as Resident R1. Upon review of Resident R1's records, it was found that there was no admission packet available. Resident R1 had a Minimum Data Set (MDS) assessment dated 9/24/24, which indicated diagnoses of chronic kidney disease, dementia, and diabetes mellitus. The assessment also revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. During an interview, the Director of Nursing confirmed that the admission paperwork for Resident R1 was not completed as required, which is a violation of the facility's admission policy and residents' rights as per the cited Pennsylvania Code regulations.
Inadequate Staffing in Dietary Department
Penalty
Summary
The facility failed to employ staff with the necessary skills and competencies in the Dietary Department for six out of twelve months. Specifically, the Food Service Director, Employee E9, who began working at the facility in November 2023, did not possess the qualifications required for the position. According to the facility's Dietary Supervisor Job Description, a qualified candidate must have completed a reputable course in food service operation or hold a college degree in culinary arts management. However, during an interview, Employee E9 admitted to lacking the qualifications of a certified dietary manager or any related degrees. This deficiency was confirmed by the Nursing Home Administrator during an interview, acknowledging that Employee E9 did not meet the state agency requirements for a food service director.
Improper Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to proper food storage and equipment maintenance protocols, which are essential to prevent foodborne illness. During an inspection, it was observed that opened packages of macaroni, spaghetti, and egg noodles in the dry storage room were not dated, indicating a failure to properly label and date opened food packages. This was confirmed by the Food Service Director (FSD), Employee E9. Additionally, a fan directed towards the tray line was found to be covered in a gray, fuzzy substance, suggesting inadequate cleaning practices. The FSD also confirmed the failure to maintain clean equipment, which is crucial for preventing foodborne illness.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for three residents who were transferred to the hospital and expected to return. For Resident R16, who had diagnoses of COPD, high blood pressure, and heart failure, there was no documented evidence that the facility communicated the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Similarly, Resident R24, with diagnoses of heart failure, diabetes, and multiple sclerosis, was transferred without the required documentation being communicated to the hospital. Resident R212, who had high blood pressure, a seizure disorder, and pneumonia, was transferred to the hospital without a physician order, and there was no documented evidence of communication of necessary information to the receiving health care provider. The Director of Nursing confirmed that the facility failed to document the communication of necessary information for these residents. The deficiency was identified during a clinical record review and staff interviews, highlighting a failure in the facility's process for handling resident transfers.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of three residents to the hospital. The facility's policy, reviewed on March 4, 2024, mandates that a copy of the transfer and discharge notice be sent to the Ombudsman. However, upon reviewing the clinical records of three residents, it was found that the facility did not document evidence of sending the required notifications for hospitalizations that occurred on specific dates. Resident R16, who was admitted with diagnoses including COPD, high blood pressure, and heart failure, was transferred to the hospital on October 11, 2023, without the required notification. Similarly, Resident R24, with conditions such as heart failure, diabetes, and multiple sclerosis, was transferred on March 22, 2024, without notification. Resident R212, diagnosed with high blood pressure, seizure disorder, and pneumonia, was also transferred on April 22, 2024, without the necessary notification. The Director of Nursing confirmed during an interview that the facility did not send any notifications to the Ombudsman's Office.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their own policy. This deficiency was identified for three out of four residents who were transferred to the hospital. The facility's policy, dated 3/4/24, mandates that residents or their responsible parties be informed of bed-hold options, potential financial obligations, and the processes to ensure a bed is available upon their return. However, the clinical records for Residents R16, R24, and R212 lacked documented evidence of such notifications at the time of their respective hospital transfers. Resident R16, who had diagnoses of COPD, high blood pressure, and heart failure, was transferred to the hospital on 10/11/23. Resident R24, with heart failure, diabetes, and multiple sclerosis, was transferred on 3/22/24. Resident R212, diagnosed with high blood pressure, seizure disorder, and pneumonia, was transferred on 4/22/24. In each case, there was no documentation that the residents or their representatives were informed about the bed-hold policy. The Director of Nursing confirmed this oversight during an interview.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in meeting their care needs. For Resident R21, the care plan included evaluating the effectiveness and side effects of psychotropic medications, but the facility did not monitor medication side effects and resident behaviors as required. Resident R21 had diagnoses of depression, dysphasia, and a thyroid disorder, which necessitated careful monitoring and management. Resident R25 exhibited combative behavior during care, as noted in progress notes, but the care plan was not updated to include interventions to address these behaviors. Additionally, Resident R34, who had high blood pressure, anxiety, and PTSD, had a care plan that mentioned assisting with coping methods and discussing triggers. However, the facility failed to identify specific triggers and appropriate coping methods for PTSD. Interviews with staff confirmed these deficiencies, highlighting the facility's failure to implement comprehensive care plans for these residents.
Inaccurate SNF ABN Issued to Resident
Penalty
Summary
The facility failed to issue an accurate Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS-10055) for a resident, identified as Resident R163. The SNF ABN form is intended to inform residents or their representatives that skilled nursing services may not be covered by Medicare, allowing them to decide whether to continue receiving services and assume financial responsibility. Resident R163 was admitted and readmitted to the facility, with the last covered day under Medicare Part A being 2/29/24. However, the SNF ABN form signed on 2/27/24 inaccurately listed the cost for skilled nursing services as $361.00 per day, excluding ancillary charges, while the actual room and board charge was $379.00 per day, as indicated in a statement dated 3/1/24. This discrepancy was confirmed by both a social worker and the Nursing Home Administrator during interviews.
Neglect in Wound Care Management
Penalty
Summary
The facility failed to ensure that Resident R49 was free from neglect, as evidenced by the improper management of a skin tear on the resident's right hand. Resident R49, who has a history of dementia, high blood pressure, and anxiety, was admitted to the facility with a care plan indicating a risk for alteration in skin integrity. The care plan required staff to observe and report changes in skin condition and administer treatment as per physician orders. On 5/12/24, a physician ordered the cleansing of the resident's right hand with normal saline, application of Triple Antibiotic Ointment, and covering with bordered gauze every shift for a skin tear. However, during an observation on 5/13/24, it was found that the dressing on Resident R49's right hand was dated 5/11/24, indicating that the dressing had not been changed as required. This was confirmed by LPN Employee E6 and the Director of Nursing, who acknowledged the facility's failure to protect the resident from neglect. The Treatment Administration Record (TAR) showed that the dressing was changed on 5/12/24 for both day and night shifts, but the observation contradicted this documentation. LPN Employee E6 stated that treatments are not signed off in the TAR until completed, highlighting a discrepancy in the facility's adherence to treatment protocols.
Misappropriation of Resident Medications
Penalty
Summary
The facility failed to prevent the misappropriation of medications for a resident, identified as R112, who was admitted with diagnoses including depression, anxiety, anorexia, hypertension, and Alzheimer's Disease. The resident's physician orders included several medications such as Morphine Sulfate, Acetaminophen Suppository, Atropine Sulfate Ophthalmic Solution, Lasix, Lorazepam Concentrate, and Zofran. On a specific date, a comfort kit containing these medications was delivered and signed in by RN Employee E16, and placed in the fridge by RN Employee E17. However, when RN Employee E18 checked for the medications, they found an empty bag without any medications, indicating the medications were missing. The investigation into the incident revealed that the Controlled Drug Receipt/Record/Disposition form for the resident's comfort kit was not included, which is a breach of the facility's policy on controlled substances. The policy requires that controlled substances be counted upon delivery and reconciled at the end of each shift by two nurses. During interviews, RN Employee E16 confirmed the misappropriation of the medications, and the Assistant Director of Nursing, Employee E11, acknowledged the facility's failure to prevent this incident. The alleged perpetrator, RN Employee E18, was not allowed back into the facility following the incident.
Failure to Conduct FBI Background Check for New Hire
Penalty
Summary
The facility failed to conduct a current FBI background check on a newly hired Licensed Practical Nurse (LPN), identified as Employee E3, prior to her date of hire. This oversight was discovered during a review of personnel records and staff interviews. The facility's Background Check Procedures policy, dated 3/4/24, mandates that all employment offers are contingent upon the completion and review of a thorough criminal background check, with results received before employment begins. However, Employee E3, who had not lived in Pennsylvania for two consecutive years and had an out-of-state home address, was hired on 5/3/24 without the required FBI background check being completed. During interviews, Human Resource Employee E4 admitted that the failure to conduct the background check was an oversight on their part. The Director of Nursing confirmed this lapse, acknowledging that the facility did not adhere to its policy of conducting a current FBI background check before the employee's start date. This deficiency was identified in one out of five personnel records reviewed, highlighting a breach in the facility's procedures to ensure the safety and rights of residents, as outlined in their Abuse Prevention Program policy.
Inaccurate MDS Assessment of Resident Behavior
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the resident's status for one of six residents. Specifically, the MDS for a resident, who was admitted with diagnoses including high blood pressure, altered mental status, and a urinary tract infection, did not accurately capture the resident's physical behavioral symptoms. The resident's progress notes indicated episodes of combative behavior, including attempts to physically swing at nurse aides during care, on consecutive days. However, the MDS assessment for this resident did not report any physical behavioral symptoms directed toward others. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to accurately reflect the resident's status in the MDS assessment. The RAI User's Manual outlines the requirements for completing MDS assessments, including the observation period necessary to capture the resident's condition accurately. The failure to adhere to these guidelines resulted in an inaccurate assessment of the resident's behavior, as documented in the MDS.
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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