Hilltop Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Altoona, Pennsylvania.
- Location
- 700 S. Cayuga Avenue, Altoona, Pennsylvania 16602
- CMS Provider Number
- 395241
- Inspections on file
- 31
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Hilltop Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide meals at scheduled times, with lunch and dinner trays arriving 30–100+ minutes late to multiple wings and the main dining room, contrary to its own meal distribution policy and tray delivery logs. Staff reported that meals were routinely late and cited ongoing problems related to new dietary management and staff. A cognitively intact resident who was independent with eating became visibly upset and complained of waiting nearly an hour for lunch, while another cognitively intact resident who required only set-up for eating reported late dinners, including one evening when trays arrived very late. The NHA confirmed that meals were not served at the scheduled mealtimes for residents throughout the facility.
The facility failed to follow its menu and standardized recipes for entrée portion sizes when serving ham at lunch. Two cognitively intact residents, one independent with eating and one requiring set up, were observed receiving only a thin half slice of ham, which they described as too small, cold, or unpalatable, and one refused to eat more after one bite. Observation of the tray line showed staff serving only a small, thin crescent-shaped slice of ham to each resident, and a weighed sample showed the portion was 1 oz instead of the planned 3 oz. The Regional Dining and Nutrition Director confirmed that the recipe required a 3 oz portion and that the prep cook had prepared breakfast-size rather than entrée-size portions, resulting in most residents not receiving the appropriate serving size.
The facility failed to follow its dietary policies requiring hot foods to be held above 135°F and cold foods below 41°F, and to ensure meals were palatable and served at safe, appetizing temperatures. During a lunch test tray, hot items such as chicken, broccoli, and mashed potatoes were found to be lukewarm and below required temperatures, while milk was only slightly above the cold-holding threshold. At a separate dinner meal, a cognitively intact, self-feeding resident received chocolate ice cream that had fully melted to liquid before she began eating and refused it, and additional trays on a unit cart contained single-serve ice creams that were soft, leaking, and not frozen. Staff, including a nurse aide and the NHA, confirmed that the food and ice cream temperatures and consistencies were not appropriate, in violation of facility policy and state dietary regulations.
The facility failed to provide adequate dietary staffing to ensure meals were delivered on time and at proper temperatures and consistencies. On the survey day, lunch and dinner trays to all wings and the main dining room were consistently late, sometimes by more than an hour, with residents waiting in dining areas and a cognitively intact resident expressing hunger and frustration after a prolonged delay. A test tray showed hot foods below required hot-holding temperatures and milk above cold-holding standards, and multiple residents received melted ice cream that had lost its intended consistency, which some refused. Staff interviews indicated that late meals were a common occurrence and that several dietary staff had called off, with the Nursing Home Administrator observed working in the kitchen to cover basic duties.
A resident who was cognitively intact and required assistance with daily care had a physician-signed order to discontinue aspirin and famotidine following a pharmacist's recommendation. However, there was no documentation that these medications were discontinued, and the DON confirmed the orders were not followed.
A large, dirty fan with visible debris was observed blowing directly onto a dish dry rack containing clean pots, pans, and dishes. Both the Dietary Manager and the Administrator confirmed the fan's presence and its improper use, which did not comply with the facility's policy for maintaining sanitary dish cleaning areas.
The facility failed to ensure that residents and/or their representatives were given the opportunity to formulate an advance directive or were offered assistance in doing so. This deficiency was identified for six residents, who had varying degrees of cognitive impairment and required different levels of assistance with care needs. Despite these conditions, the facility did not document any efforts to discuss or assist with advance directives, as confirmed by the DON.
The facility did not adhere to its planned menu, resulting in incomplete meal trays for residents. A resident reported missing margarine, sugar packets, condiments, napkins, and flatware on her meal trays. Interviews with other residents confirmed similar issues with missing menu items. The dietary manager acknowledged that while margarine was available, it was not included on the trays as required.
The facility failed to serve food at appropriate temperatures, as per policy. Residents reported receiving cold, overcooked, and unpalatable meals, with missing items like condiments and flatware. Observations confirmed that hot foods were served below the required temperature, and cold foods were above the required temperature. The Dietary Manager acknowledged the issue.
The facility failed to maintain sanitary conditions in food storage and preparation, with unlabeled pizza crusts, ice build-up on the freezer condenser, and a dirty ceiling vent. The ice machine had a pink build-up and was dripping water onto the ice. The sanitizer log lacked documentation of sanitizer strength for meals, as confirmed by the Dietary Manager.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or chronic wounds, leading to infection control deficiencies. Observations revealed lapses in hand hygiene and PPE availability, affecting residents with conditions like MRSA and pressure ulcers. The infection preventionist and DON confirmed these issues, indicating systemic non-compliance with infection control guidelines.
A resident's room in the facility was found to have broken drywall caused by the footrest of the resident's electric wheelchair. The damage was not repaired due to a lack of a work order and the recent resignation of the maintenance director. The resident, who is cognitively intact and dependent on staff for care due to quadriplegia and depression, experienced a non-homelike environment as a result.
A facility failed to complete a quarterly MDS assessment within the required time frame for a resident. The assessment reference date (ARD) was 116 days after the previous annual MDS assessment, exceeding the 92-day requirement. This was confirmed by the DON.
The facility did not update care plans for two residents, failing to reflect changes in anticoagulation therapy and catheter use for one resident, and inaccurately documenting surgical wounds as scars for another. These deficiencies were confirmed by the DON.
A resident, dependent on staff for bathing, did not receive scheduled showers as preferred, receiving bed baths instead. Despite being cognitively intact and having chronic conditions, the resident's preference for showers twice a week was not met due to staff excuses like lack of hot water. The facility lacked documentation of offering or refusal of showers on scheduled days.
A resident with Parkinson's Disease received Midodrine Hydrochloride despite physician's orders to hold the medication if systolic blood pressure (SBP) exceeded 120. The MAR showed multiple instances of administration with SBP readings above the threshold. The DON confirmed the medication was improperly given, violating care standards.
A facility failed to document gastric residual volumes (GRV) for a resident with an enteral feeding tube, as required by its policy. The resident, who was cognitively impaired, had physician's orders to check GRV every shift and take specific actions if GRV exceeded certain levels. However, from January 1 to January 17, 2025, there was no documented evidence of GRV checks, confirmed by the DON.
The facility's QAPI committee failed to correct recurring deficiencies in maintaining a homelike environment, accuracy of assessments, care plan updates, quality of care, and food service standards. Despite developing plans of correction, the committee did not successfully implement these plans, resulting in repeated citations under various F-tags.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in documenting medical conditions. A resident with an ostomy was inaccurately recorded as bowel continent, another resident's Stage 4 pressure ulcer was not reflected in the MDS, a resident receiving Trazadone was not recorded as taking antidepressants, and a resident on Seroquel had an inaccurate GDR documentation.
The facility failed to maintain documentation for the emergency generator's annual maintenance and testing for 2024, affecting the entire facility. An interview with the Facilities Administrator and Assistant Maintenance Director confirmed the absence of required documentation, indicating non-compliance with NFPA standards for emergency power systems.
The facility failed to maintain proper hazardous area enclosures, as the door to a storage closet in the Rehabilitation Room did not latch due to tape on the striker plate. This affected one of eight smoke compartments, confirmed by the Facility Administrator and Assistant Maintenance Director.
The facility failed to maintain cooking facilities according to NFPA 101 standards, affecting one smoke compartment. Documentation for semiannual kitchen fire suppression testing and hood/duct cleanings for the latter half of 2024 was missing. The Facility Administrator and Assistant Maintenance Director confirmed these deficiencies.
The facility failed to document the administration of controlled medications for two residents who were cognitively impaired and receiving opioids for pain. Doses of oxycodone were signed out for administration, but there was no evidence in the MAR or clinical records to confirm administration or proper disposal of unused medication. The Director of Nursing confirmed the lack of documentation.
The facility failed to complete accurate MDS assessments for a resident. The quarterly MDS assessment incorrectly indicated that the resident did not use a wander/elopement alarm, despite having a physician's order and care plan for the use of a Wanderguard. This discrepancy was confirmed by the DON.
A resident, who was cognitively intact, managed to leave the building without staff knowledge and was found outside. The incident was not documented in the resident's clinical record, nor was there any evidence of an assessment upon her return. Interviews with staff confirmed the incident and the lack of documentation.
Failure to Provide Timely Meal Service According to Scheduled Mealtimes
Penalty
Summary
The deficiency involves the facility’s failure to serve meals at the scheduled times established in its own meal distribution policy and tray delivery logs. The policy dated June 26, 2025, required timely delivery of meals to dining locations, but observations and records on March 18, 2026, showed significant delays for both lunch and dinner across all wings (A, B, C, D) and the main dining room. Lunch trays scheduled for delivery between 11:55 a.m. and 12:40 p.m. arrived between 12:45 p.m. and 2:22 p.m., with delays ranging from 50 minutes to 1 hour and 42 minutes. Dinner trays scheduled between 5:30 p.m. and 6:10 p.m. arrived between 6:04 p.m. and 7:17 p.m., with delays of 34 minutes to 1 hour and 7 minutes. Staff interviews indicated that meals were routinely late by 10–20 minutes and that breakfast and supper on the same day and the previous evening had also been significantly delayed. Residents were directly affected by these delays. A quarterly MDS for one cognitively intact resident who was independent with eating showed that this resident became visibly upset in the dining room, stating it had almost been an hour and expressing hunger while slapping the table. An admission MDS for another cognitively intact resident who required only set-up for eating showed that this resident reported dinner trays being late on the survey day and recalled a recent Sunday when dinner did not arrive until 8:45 p.m. Activity and nursing staff attributed the ongoing delays to new dietary management and staff. The Nursing Home Administrator confirmed that lunch and dinner meals were served late and not at the scheduled mealtimes for all residents in the affected wings and the main dining room, in violation of 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Failure to Provide Planned Entrée Portion Sizes at Lunch
Penalty
Summary
The facility failed to ensure that dietary staff served the appropriate planned portion sizes as required by facility policy and posted menus. The facility’s policy on food quality and palatability stated that menu items are to be prepared according to the menu, production guidelines, and standardized recipes. The posted lunch menu indicated residents had a choice of ham or chicken, and the dietary guide sheet specified that the honey glazed ham portion was to be 3 ounces. During the lunch meal, observations showed that residents were being served only one small, thin crescent-shaped slice of ham. When weighed on a food scale at the surveyor’s request, the ham portion was found to weigh only 1 ounce instead of the required 3 ounces. A quarterly MDS for one resident showed that she was cognitively intact, able to understand and be understood, and independent with eating. Observation of this resident during lunch revealed she had only one half slice of thinly sliced ham and she complained that the portion was small and cold. An admission MDS for another resident showed that she was cognitively intact, able to understand and be understood, and required set up for eating. Observation of this resident at lunch revealed she also had one half slice of thin, curled ham, which she described as very thin and tasting like leather; she took one bite and refused to eat more. The Regional Dining and Nutrition Director confirmed that the ham slice should have weighed 3 ounces per the recipe and later stated that the prep cook had prepared breakfast-size portions instead of entrée-size portions, resulting in most residents not receiving the planned 3-ounce serving of ham.
Failure to Serve Palatable Food at Safe Temperatures and Consistencies
Penalty
Summary
The facility failed to ensure that food and beverages were served at palatable and appropriate temperatures and consistencies, as required by its own policies and the FDA Food Code. The facility’s food preparation and food quality policies required hot foods to be held above 135°F, cold foods below 41°F, and all foods to be palatable, attractive, and served at safe and appetizing temperatures. During a test tray observation on the D nursing unit lunch meal, the meal cart left the kitchen at 2:01 p.m., arrived on the unit at 2:02 p.m., and the last resident was served at 2:15 p.m. When the test tray was checked at 2:17 p.m., the chicken breast with gravy measured 118°F, broccoli 116°F, mashed potatoes with gravy 125°F, and milk 45°F. The chicken and broccoli were described as lukewarm and not palatable at those temperatures. The Dining and Nutrition Director confirmed that the food should have been served at a higher temperature. The facility also failed to maintain appropriate temperature and consistency for frozen dessert items. A quarterly MDS for one cognitively intact resident showed that she was independent with eating. During a dinner meal observation in the main dining room, this resident received a serving of chocolate ice cream that, by the time she began eating, had completely melted to a liquid consistency; she refused it, stating she did not want it because it was no longer ice cream. Further observation of the B wing dinner cart revealed single-serving chocolate ice cream containers that were very soft, with lids popping off and liquid ice cream leaking out. A nurse aide confirmed that the ice creams on the B wing dinner trays were melted, and the Nursing Home Administrator agreed that the ice cream on another resident’s tray was not frozen or firm as it should have been. These findings occurred under the regulatory requirements of 28 Pa. Code 201.18(b)(1) Management and 28 Pa. Code 211.6(f) Dietary Services.
Insufficient Dietary Staffing Causing Late Meals and Improper Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient dietary staff to ensure meals were prepared, transported, and served at scheduled times and at appropriate temperatures and consistencies. Facility policies required timely meal distribution and proper temperature maintenance for hot and cold foods. Tray delivery logs showed scheduled lunch and dinner delivery times for each wing and the main dining room. On the identified survey date, lunch and dinner trays were repeatedly delivered significantly later than the scheduled times to all wings (A, B, C, D) and the main dining room. Staff interviews, including with an activity aide and nurse aides, indicated that late meals were a routine occurrence and that breakfast had also been delayed that morning. Multiple specific observations documented substantial delays in meal service. Lunch trays for B wing, C wing, the main dining room, D wing, and A wing were between 50 minutes and 1 hour and 42 minutes late. Dinner trays for the main dining room and all wings were between 34 minutes and 1 hour and 7 minutes late. Residents were observed waiting in the dining room for meals, with one cognitively intact resident, independent with eating, verbally expressing frustration and hunger after waiting nearly an hour for lunch and striking the table. Another cognitively intact resident, requiring only set-up for eating, reported that dinner trays were late that evening and recalled a recent Sunday when dinner did not arrive until 8:45 p.m. The facility also failed to maintain food at palatable and safe temperatures and appropriate consistencies, as required by its policies. A test tray on D wing showed hot foods (chicken breast with gravy, broccoli, mashed potatoes with gravy) below the required hot-holding temperature, and the chicken and broccoli were described as lukewarm and not palatable; the milk was above the cold-holding standard. During dinner service, a cognitively intact resident in the main dining room received chocolate ice cream that had completely melted to a liquid consistency and refused it. Additional observations of the B wing dinner cart showed single-serving ice cream containers so soft that lids popped off and liquid ice cream leaked out. Staff, including a nurse aide and the Nursing Home Administrator, confirmed that the ice cream was melted and not frozen or firm. The Dietary Director reported that three dietary staff members had called off that day, and the Nursing Home Administrator was observed working in the kitchen as a dishwasher.
Failure to Discontinue Medications as Ordered
Penalty
Summary
The facility failed to ensure that physician orders were written and followed for one resident. According to facility policy, verbal orders from a physician must be communicated to the nurse and followed through with appropriate documentation. For one resident, an admission MDS assessment indicated the resident was cognitively intact and required assistance with daily care. A pharmacist's recommendation to discontinue aspirin and famotidine was reviewed and signed by the physician, but there was no documentation in the clinical record that these medications were discontinued as ordered. The DON confirmed that the orders to discontinue the medications were not carried out as required.
Unsanitary Fan Blowing on Clean Dishes in Kitchen Dishroom
Penalty
Summary
Surveyors found that the facility failed to maintain a clean and sanitary environment in the main kitchen dishroom. During an observation, a large, upright fan with a heavy accumulation of visible dirt and debris on its blade cover was found blowing directly onto the dish dry rack, which held several clean pots, pans, and dishes. The fan was noted to have several half-inch tendrils of dirt and debris flowing from the cover as it operated, potentially contaminating the clean kitchenware. The Dietary Manager and the Nursing Home Administrator both confirmed the presence of the dirty fan blowing on the clean dishes and acknowledged that it should not have been there. The facility's policy required that dish cleaning areas be kept sanitary, but this was not followed in this instance.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to formulate an advance directive or were offered assistance in doing so. This deficiency was identified for six residents during a review of facility policies, clinical records, and staff interviews. The facility's policy, dated November 26, 2024, mandates that upon admission, the facility should determine if a resident has executed an advance directive and provide information about the right to refuse medical or surgical treatment and formulate an advance directive. However, there was no documented evidence in the medical records of the six residents reviewed that these steps were taken. The residents involved had varying degrees of cognitive impairment and required different levels of assistance with care needs. For instance, one resident had mild cognitive impairment and required supervision to moderate assistance, while others were cognitively impaired with diagnoses such as dementia and hemiplegia. Despite these conditions, the facility did not document any efforts to discuss or assist with advance directives, as confirmed by the Director of Nursing during an interview. This lack of documentation and action indicates a failure to comply with the regulatory requirements regarding advance directives.
Plan Of Correction
1. Assistance with completing advanced directives was offered to residents 37, 62, 81, 88, 90. Resident 100 has been discharged from the facility. 2. Audit of all residents in the facility was completed to ensure all residents had been offered the opportunity to formulate an advanced directive. All residents without a current advanced directive are offered the opportunity to complete one. 3. Education completed with the Interdisciplinary team to ensure the opportunity to formulate an advanced directive is being offered during the residents' initial care plan meeting and the opportunity to update/change at a minimum of each care plan meeting thereafter. 4. Audits will be completed on all new admissions weekly x 4 weeks and monthly x 2 months to ensure the opportunity to formulate an advanced directive is being completed. 5. Date of compliance 3/5/2025
Failure to Follow Planned Menu and Provide Complete Meal Trays
Penalty
Summary
The facility failed to follow their planned menu, as evidenced by observations and interviews with residents and staff. A facility policy dated November 25, 2024, required service staff to inspect food trays to ensure the correct meal was provided to each resident. However, on January 13, 2025, a resident's lunch tray was missing margarine for her roll, which she stated made her unwilling to eat it. The resident also reported that her meal trays routinely lacked sugar packets, condiments, napkins, or flatware. An interview with a nurse aide confirmed that no margarine was available on any trays in A wing, and the kitchen was contacted but had none available. Further interviews with a group of residents on January 14, 2025, revealed that they often did not receive the correct menu items or were missing items on their trays. The facility's written and printed menu for January 13, 2025, specified that residents were to receive beef meatloaf with glaze, green beans, scalloped potatoes, a buttered dinner roll, margarine, pound cake, and a choice of beverage. However, the dietary manager confirmed that while the kitchen had margarine available, it was not placed on the trays. The facility did not have individual packets but could provide small lidded cups of margarine, which were not utilized by the kitchen staff.
Plan Of Correction
1. The Dietary Manager immediately educated line staff on the importance of adding the condiments that are listed on the menu. 2. The dietary department will add an extra bowl of condiments to each tray cart sent to the units to ensure there is extra available. 3. The Dietary Manager or designee will review the Food Preparation and Service Policy and Menus. The Dietary Manager or designee will educate the Dietary staff on the importance of following the menus as listed to include condiments. 4. The Dietary Manager or designee will randomly audit daily for 4 weeks, then weekly for 3 months to ensure that the food delivered to residents matches the menu posted. The Dietary Manager or designee will report the results of this audit monthly to the Quality Assurance Performance Improvement (QAPI). 5. The completion date will be 03/5/202.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to meet the requirements for serving food at appropriate temperatures, as evidenced by multiple observations and interviews. The policy for food service temperatures, dated November 26, 2024, stated that hot foods should be served at 140 degrees Fahrenheit or above, and cold foods at 40 degrees Fahrenheit or below. However, interviews with residents revealed that meals served in their rooms were often cold, overcooked, and not palatable. Additionally, residents reported missing items such as sugar packets, condiments, napkins, or flatware on their meal trays. During an observation in the kitchen, a test tray was placed on a meal cart destined for the A wing. The cart arrived at the unit, and the last resident was served approximately 19 minutes later. At that time, the temperature of the mashed potatoes was recorded at 129 degrees Fahrenheit, and the mixed vegetables at 122 degrees Fahrenheit, both below the required temperature for hot foods. The milk was also found to be at 51 degrees Fahrenheit, above the required temperature for cold foods. The Dietary Manager confirmed that the foods were not served at the proper temperatures, corroborating the residents' complaints.
Plan Of Correction
The policy on palatable food temperatures was reviewed with all members of the dietary department by the Registered Dietician and/or designee. All nursing staff re-educated on serving meal trays timely to residents eating in their rooms. Test trays will be completed by the Registered Dietician dietary manager twice weekly x 4 weeks, then monthly x 2 months, and at random afterwards to ensure that served foods are within facility policy temperatures and palatable. Results for test trays will be reviewed during facilities Quality Assurance committee meetings. Date of compliance 3/5/2025
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage and sanitation practices. Observations in the walk-in freezer revealed a plastic bag of pizza crusts that were not labeled or dated, contrary to the facility's policy requiring all items to have a received date and an expiration date. Additionally, there was a significant build-up of ice on the freezer's condenser, and a ceiling vent above the tray line in the kitchen was covered with a large accumulation of black debris and dust. The ice machine was found to have a pink, removable build-up on the top plastic piece and was dripping water onto the ice, indicating unsanitary conditions. Further observations in the kitchen showed that the ceiling vent above the tray line remained uncleaned, and the three-compartment sink contained water with utensils and pans drying on the counter. The facility's sanitizer log for January 2025 lacked documentation of the sanitizer strength for each meal from January 1 through January 17, 2025, which was confirmed by the Dietary Manager. These findings highlight the facility's failure to maintain sanitary conditions in food storage and preparation areas, as well as a lack of adherence to their own policies regarding food labeling and sanitation practices.
Plan Of Correction
Dietary manager immediately verified no other items in the walk-in freezer was not labeled and completed on the spot education to the dietary staff on recording chemical sanitizer strength. Both the ice storage machine and the kitchen vents were cleaned and the buildup of ice on the freezer condenser was removed. Administrator or designee educated all dietary staff on the policy for food storage and record keeping for the strength of chemical sanitizers. Administrator or designee educated both dietary staff and maintenance on cleaning of kitchen equipment and vents. Audits will be completed by dietary manager or designee 2 x week for 2 weeks and monthly for 2 months for food labeling and buildup of ice in the walk-in freezer. Audits of the record sheets for chemical sanitizer strength will be completed 2 x week for 2 weeks and monthly for 2 months to ensure documentation is accurate and available. Audits for the ice machine and kitchen ceiling vents will be completed weekly for 4 weeks then monthly for 2 months. All results of findings will be reported and trended through the facilities Quality Assurance Committee. Date of compliance 3/5/2025.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC), resulting in deficiencies in the implementation of Enhanced Barrier Precautions (EBP) for several residents. The report highlights that the facility did not implement EBP for residents with indwelling medical devices or chronic wounds until November 27, 2024, despite having residents with conditions that warranted such precautions. This oversight affected multiple residents, including those with indwelling catheters, pressure ulcers, and infections with multidrug-resistant organisms (MDROs). Observations and staff interviews revealed specific instances of non-compliance with infection control practices. For example, a Licensed Practical Nurse (LPN) failed to perform hand hygiene between glove changes during wound care for a resident with pressure ulcers, which is a critical step in preventing cross-contamination. Additionally, there was a lack of proper signage and personal protective equipment (PPE) availability for residents on transmission-based precautions, as evidenced by the case of a resident with a methicillin-resistant Staphylococcus aureus (MRSA) infection. The facility's infection preventionist and Director of Nursing confirmed the lapses in implementing EBP and maintaining proper infection control measures. These deficiencies were identified through a review of clinical records, facility policies, and direct observations, indicating a systemic issue in the facility's infection prevention and control program. The report underscores the need for adherence to established guidelines to prevent the spread of infections and protect both residents and staff.
Plan Of Correction
1. Residents 7, 8, 11, 12, 34, 63, 70, and 80 suffered no ill effects. EBP for residents 7, 11, 12, 63, 70, and 80 was implemented on 11.27.2024. Signage for Enhanced Barrier Precautions was replaced for resident 34. 2. Baseline audit done on all residents needing Enhanced Barrier Precautions to ensure all needed signage is posted. 3. Education completed with all nursing staff on hand hygiene to include demonstration and with housekeeping and nursing to ensure EBP signage stays in place at all times. Nursing staff reeducated on residents that require the need for enhanced barrier precautions. 4. Audits will be completed 2 x week for 2 weeks and monthly for 2 months to ensure all residents' doors that require EBP signage is up and current. Audit on staff hand hygiene will be done 5 x a week for 2 weeks. 5. Date of compliance 3/5/2025.
Failure to Maintain a Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a clean and homelike environment for one resident, identified as Resident 8, who was cognitively intact and dependent on staff for all care needs due to quadriplegia and depression. During an observation, it was noted that Resident 8's room had areas of broken drywall near the closet and bathroom entrance. The damage was reportedly caused by the footrest of the resident's electric wheelchair scraping the wall when staff forgot to put the footrest up while parking the wheelchair. Interviews with staff revealed that the damage had been reported to the maintenance department, but no work order was found in the system, and the former maintenance director had recently resigned. Maintenance Employee 2 confirmed the need for repairs and acknowledged that the room was not homelike. The deficiency was noted as a failure to maintain a safe, clean, and homelike environment as required by regulations.
Plan Of Correction
1. Repair of both areas of the drywall in resident 8's room was completed. 2. Audit of all resident rooms was done and any other holes found were repaired. 3. Education with all staff completed on completing a work order on any holes observed. 4. Weekly audits x 4 weeks and monthly times 2 months will be completed to check and repair any holes observed in resident rooms. 5. Date of compliance 3/5/2025
Quarterly MDS Assessment Not Completed Timely
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments within the required time frame for one resident. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type. However, for Resident 81, the quarterly MDS assessment had an ARD of December 13, 2024, which was 116 days after the previous annual MDS assessment with an ARD of August 19, 2024. This discrepancy was confirmed during an interview with the Director of Nursing on January 17, 2025.
Plan Of Correction
1. Resident 81 suffered no ill effects. 2. Baseline audit completed to ensure all other Minimum Data Sets were completed timely by the registered nurse assessment coordinator/designee. 3. Review of the Resident Assessment Instrument manual was completed with Registered Nurse Assessment Coordinator to ensure understanding of the completion dates. 4. Audits will be completed by RNAC weekly x 2 weeks and monthly x 2 months checking for timeliness of assessments. 5. Date of compliance 3/5/2025.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise the care plans for two residents to reflect their current care needs. For one resident, the care plan was not updated to indicate the discontinuation of Coumadin and the initiation of Apixaban for anticoagulation therapy. Additionally, the care plan did not document the resident's use of a foley catheter leg bag, which was preferred for dignity. These omissions were confirmed by the Director of Nursing during interviews. For another resident, the care plan inaccurately documented surgical wounds on the palms, which were actually scars from previous surgeries. This error was identified during a skin and wound assessment shortly after the resident's admission, but the care plan was not revised to reflect the correct information. The Director of Nursing confirmed that the care plan should have been updated to remove the incorrect information about surgical wounds.
Plan Of Correction
1. Care plan for resident 7 and resident 11 were reviewed and updated by the Director of Nursing. Neither resident suffered any adverse effects. 2. The Director of Nursing or designee will review the care plans for all current residents with catheters, have wounds or on anticoagulation medication for accuracy in anticoagulation medication, for residents with catheters who preference leg bags along with correct wound documentation. Any identified care plans will be updated upon discovery. 3. The Director of Nursing or designee will educate all staff who are responsible for completing and updating the care plan so that to reflect a resident's new orders, treatments, and interventions. 4. The Director of Nursing or designee will audit any changes to resident preferences to ensure comprehensive care plans are updated to reflect changes 2 times a week for 2 weeks then monthly for 2 months to assure the resident's anticoagulant therapy/catheter bag preferences wound changes are reflected. The Director of Nursing or designee will report on the results of the audit to the facility's Quality Assurance Committee. 5. Date of compliance 3/5/2025.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that Resident 24, who was dependent on staff for bathing and showering, received showers as per her preference and schedule. The resident, who was cognitively intact and had chronic congestive heart failure and diabetes, had a documented preference for showers twice a week on Wednesdays and Sundays during the day shift. However, a review of the Bath/Shower record from October to December 2024 revealed that the resident was consistently provided with bed baths instead of showers on multiple occasions, including all of November and specific dates in October and December. Interviews with Resident 24 and the Director of Nursing highlighted that the resident was not receiving her preferred showers due to various excuses provided by the staff, such as the lack of hot water or the shower room being too cold. Furthermore, there was no documented evidence that the resident was offered or refused a shower on her scheduled days when bed baths were given instead. This lack of adherence to the resident's bathing preferences and schedule constitutes a failure to meet the requirement of providing necessary services to maintain good personal hygiene.
Plan Of Correction
1. Resident 24 suffered no adverse effects. Education was provided to all nursing staff on following resident preferences. 2. The Director of Nursing or designee will review residents' tasks to ensure preferences on bathing/showering are being met or documented as completed. 3. The Director of Nursing or designee will educate all staff on documentation of tasks and refusals, making sure resident preferences are followed. 4. The Director of Nursing or designee will do random audits on bathing preferences for a minimum of 10% of the population 2 times a week for 4 weeks, monthly for 2 months to ensure showers/bathing preferences are followed. The Director of Nursing or designee will report the results of the audit to the facility's Quality Assurance Committee. 5. Date of Compliance: 3/5/2025
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of Midodrine Hydrochloride for a resident diagnosed with Parkinson's Disease. The resident, who was cognitively intact and required assistance with personal care, had a physician's order to receive 2.5 mg of Midodrine Hydrochloride twice daily, with the stipulation to hold the medication if the resident's systolic blood pressure (SBP) exceeded 120. However, the medication was administered multiple times over several months when the resident's SBP was above the specified threshold. The Medication Administration Record (MAR) for the resident showed instances in October, November, December, and January where the medication was given despite the SBP readings being higher than 120, with values ranging from 122 to 150. An interview with the Director of Nursing confirmed that the medication was improperly administered on these occasions, contrary to the physician's orders. This oversight indicates a failure in following professional standards of practice and the resident's care plan, as required by the quality of care regulations.
Plan Of Correction
1. Resident 9 suffered no ill effects. The Medical Director was notified of resident 9 receiving medication outside of parameters. No new orders given. 2. A baseline audit was completed on all residents currently receiving the medication Midodrine to check for error in documentation. 3. All licensed nursing staff were educated on the process of documenting medications not given due resident being outside of parameters. 4. Audits on residents receiving medications with parameters will be completed weekly x4 weeks and monthly x 2 months to ensure compliance. Results will be reported and trended through the facility's Quality Assurance Committee. 5. Date of compliance 4/5/2024
Failure to Document Gastric Residual Volumes for Enteral Feeding
Penalty
Summary
The facility failed to adhere to its policy regarding the documentation of gastric residual volumes (GRV) for a resident with an enteral feeding tube. According to the facility's policy, staff were required to check and document the GRV every shift to assess the resident's tolerance to enteral feeding and minimize the risk of aspiration. If the GRV exceeded 250 mL, the physician was to be notified, and the resident was to be assessed for feeding intolerance. However, a review of the clinical records for Resident 70, who was cognitively impaired and had an enteral feeding tube, revealed that there was no documented evidence of GRV checks from January 1 to January 17, 2025. Physician's orders for Resident 70 specified that the GRV should be checked every shift, and specific actions were to be taken if the GRV exceeded certain thresholds. Despite these orders, the facility did not document the GRV checks as required. An interview with the Director of Nursing confirmed the absence of documentation for the GRV checks in the resident's clinical record, indicating a failure to comply with the facility's policy and the physician's orders.
Plan Of Correction
1. Medical Director was immediately notified of staff not documenting residuals. Electronic Medication Administration Record updated to reflect spot for documentation of residual amount. Resident 70 suffered no ill effects. 2. Audit completed for all residents receiving feedings completed to ensure that residual is being documented. 3. Director of nursing/designee completed Education with licensed nursing staff on the facility policy for checking residual every shift. 4. Director of nursing or designee will audit Electronic Medication Administration Record for all residents receiving feedings 2 x week for 4 weeks and monthly for 2 months to ensure residual is being documented. 5. Date of compliance 3/5/2025
Repeated Deficiencies in QAPI Implementation
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The survey ending January 17, 2025, identified repeated deficiencies related to maintaining a homelike environment, accuracy of assessments, updating/revising care plans, quality of care, and food service standards. These deficiencies were previously cited in a survey ending February 1, 2024, indicating a lack of effective implementation of corrective actions. The facility's plan of correction for maintaining a homelike environment included completing audits and reporting results to the QAPI committee. However, the current survey revealed that the QAPI committee failed to implement the plan successfully, resulting in ongoing non-compliance with regulations. Similarly, deficiencies in the accuracy of assessments and updating/revising residents' care plans were not addressed effectively, as the QAPI committee did not ensure compliance with the established corrective plans. Additionally, the facility's plans to address quality of care and food service issues, such as ensuring food was palatable and served at proper temperatures, were not successfully implemented. The QAPI committee's failure to ensure compliance with these plans resulted in repeated citations under various F-tags, including F584, F641, F657, F684, F804, and F812. This indicates a systemic issue in the facility's ability to sustain improvements and adhere to regulatory standards.
Plan Of Correction
The facility Quality Assurance Performance Improvement committee will continue to be held on a monthly basis and meet the expectations as outlined in the facilities policy. The Quality Assurance Performance Improvement committee has not been following the appropriate policy guidelines as outlined in the policy and therefore, the Administrator will provide re-education on the Quality Assurance Performance Improvement committee process and the expectations to active committee participants as outlined in the above-mentioned policy. The committee failed to successfully implement plan of corrections for previously identified areas by not reviewing audit findings and making any corrective recommendations. To assure compliance of the plan of correction, participating members (department heads) of the committee will present their specified areas at the committee meetings for discussion, committee recommendations, effectiveness and implementation of corrective actions. These presentations will include audit tools utilized to address areas of the plan of correction and will be reported on a monthly basis. Committee members will implement recommendations as discussed and detailed by the committee. Participating committee members will follow up on recommendations to assure continued compliance. Any outlying findings will be corrected and reported back to the committee for further discussion/recommendations. Monthly minutes from the Quality Assurance Performance Improvement committee will be forwarded to the Director of Clinical Operations for review and recommendations. Date of compliance 3/5/2025
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of their medical conditions. For one resident with an ostomy, the MDS inaccurately indicated bowel continence, despite physician orders confirming the presence of an ostomy. Another resident's MDS failed to reflect a Stage 4 pressure ulcer, as documented in a skin and wound note, leading to an inaccurate assessment of the resident's skin condition. Additionally, the MDS for a resident receiving Trazadone, an antidepressant, did not record the medication during the assessment period, despite physician orders and the Medication Administration Record confirming its administration. Furthermore, a resident receiving Seroquel for dementia with agitation had an MDS that inaccurately indicated no physician-documented Gradual Dose Reduction (GDR) as clinically contraindicated, despite a pharmacy recommendation and physician's decision against a GDR.
Plan Of Correction
Plan of Correction: 1. The Minimum Data Set assessments for residents 7, 63, 75, and 85 have been reviewed and modified to correctly reflect the residents' condition at the time of the assessment periods. Modifications have been completed and submitted to MDS. 2. Sections H, M, and N were reviewed for accuracy on current residents' most recent Minimum Data Set based on his/her most recent Assessment Reference Date (ARD) and corrected where applicable. 3. The Registered Nurse Assessment Coordinator was educated by the Director of Nursing on assessment accuracy. 4. Registered Nurse Assessment Coordinator(s) and/or designee will audit 10% or a minimum of 5 completed Minimum Data Set(s) section H, M, and N weekly for 2 weeks and then monthly for 2 months. The results of the audits will be addressed at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions. 5. Date of compliance: 3/5/2025.
Deficiency in Emergency Generator Maintenance Documentation
Penalty
Summary
The facility was found to be deficient in maintaining proper documentation for the emergency generator's annual preventative maintenance and testing for the year 2024. During a document review conducted on January 15, 2025, it was revealed that the facility could not provide the necessary documentation to confirm that the required maintenance and testing had been performed. This deficiency affects the entire facility as the emergency generator is a critical component of the essential electrical system, which is required to supply power within 10 seconds in the event of an outage. An interview with the Facilities Administrator and Assistant Maintenance Director on the same day confirmed the absence of documentation for the emergency generator's maintenance and testing. This lack of documentation indicates a failure to comply with the standards set forth by NFPA 101, NFPA 110, and NFPA 111, which require regular inspection, testing, and maintenance of emergency power systems to ensure their reliability and functionality in emergencies.
Plan Of Correction
1. Documentation for the emergency generator annual preventive maintenance was found and added to the life safety binder. 2. Review of life safety binder will be completed monthly by maintenance director/designee to ensure all needed paperwork is available. 3. Maintenance Director will bring results of monthly audit to the facility's Quality Assurance Committee for review.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, as evidenced by an observation on January 15, 2025. During the inspection, it was noted that the door to the storage closet in the Rehabilitation Room did not latch properly because tape was placed on the striker plate. This deficiency affected one of the eight smoke compartments in the facility. The issue was confirmed through an interview with the Facility Administrator and Assistant Maintenance Director on the same day, who acknowledged the hazardous area enclosure deficiencies.
Plan Of Correction
Tape was removed from the striker plate on the storage room doors in the rehab department. Maintenance director/designee educated rehab staff on not attaching foreign objects that would obstruct closing of any doors. Audit will be completed by maintenance director/designee weekly x 2 months and then randomly thereafter to ensure nothing is obstructing closet door from latching. Date of compliance 2/28/2025.
Deficiency in Kitchen Fire Safety Maintenance
Penalty
Summary
The facility failed to maintain cooking facilities in compliance with NFPA 101 standards, specifically affecting one of eight smoke compartments. During a review of documentation and observation on January 15, 2025, it was found that the facility lacked necessary documentation for semiannual kitchen fire suppression testing and maintenance for the second half of 2024. Additionally, there was no record of semiannual kitchen exhaust hood and duct cleanings for the same period. An interview with the Facility Administrator and Assistant Maintenance Director confirmed these deficiencies in the kitchen fire suppression system and hood maintenance.
Plan Of Correction
Semiannual kitchen fire suppression testing was located and added to the life safety binder. The cleaning of the kitchen exhaust hood/duct was scheduled for completion on 1/27/2025. Review of the life safety binder will be completed monthly by the maintenance director/designee to ensure all needed paperwork is easily accessible. The facility obtained contracted services to ensure kitchen exhaust hood/duct cleaning is completed as required. Semiannual cleaning will be monitored by the facility maintenance director/designee to ensure completion and brought to the facility's Quality Assurance Committee meeting for confirmation and review. Date of compliance: 2/28/2025.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for two residents, both of whom were cognitively impaired and receiving opioids for pain management. For one resident, the controlled drug record indicated that doses of oxycodone were signed out for administration on specific dates and times, but there was no documented evidence in the Medication Administration Record (MAR) or clinical record to confirm that the medication was administered. Similarly, for the second resident, doses of oxycodone were signed out, but there was no documentation to show that the medication was administered as ordered, nor was there evidence that the remaining medication was properly wasted by two licensed nurses as required. The facility's policy for controlled substances requires that the charge nurse maintains the keys to controlled substance containers and that controlled medications are wasted or disposed of in the presence of a nurse and a witness who signs the disposition sheet. An interview with the Director of Nursing confirmed the lack of documentation for the administration of the signed-out doses of oxycodone for both residents. This deficiency was identified during a review of policies, clinical records, and staff interviews, highlighting a failure in the facility's processes for managing and documenting the use of controlled substances.
Inaccurate MDS Assessment for Wander/Elopement Alarm
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for one resident. Specifically, the quarterly MDS assessment for a resident, dated December 5, 2023, incorrectly indicated that the resident did not use a wander/elopement alarm, despite the resident having a physician's order and care plan for the use of a Wanderguard from November 2 through December 31, 2023. This discrepancy was confirmed by the Director of Nursing during an interview on January 25, 2024. The Resident Assessment Instrument (RAI) User's Manual specifies that if a wander/elopement alarm is used, it should be coded accordingly in Section P0200E of the MDS assessment.
Failure to Document Resident Elopement Incident
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed. Specifically, Resident 1, who was cognitively intact, was able to leave the building without staff knowledge. The resident observed staff exiting the building and used this knowledge to exit the door without triggering an alarm. She walked around the building until staff found her and returned her to the facility. This incident was not documented in the resident's clinical record, nor was there any evidence that the resident was assessed upon her return to the building. Interviews with the Social Services Director, a Registered Nurse, and a Nurse Aide confirmed that the incident occurred and that it was not documented in the resident's clinical record. The Social Services Director learned about the incident during a morning meeting, and the Registered Nurse and Nurse Aide described their actions in response to the resident's elopement. The Nursing Home Administrator and the Director of Nursing also confirmed that there was no documentation of the incident in the resident's clinical record, although there should have been.
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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