Hilltop Heights Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnstown, Pennsylvania.
- Location
- 100 Woodmont Road, Johnstown, Pennsylvania 15905
- CMS Provider Number
- 395812
- Inspections on file
- 46
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Hilltop Heights Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that a large number of thermal coffee mugs stored near the kitchen entrance and dishwasher exit had a moderate to large amount of blackish brown removable residue inside, despite being considered washed and in active circulation for resident use. A dietary aide running the dishwasher, as well as the dietician, confirmed that these mugs were supposed to be clean and ready for serving beverages to residents. The Infection Preventionist stated that all food service items should be clean, and the Nursing Home Administrator acknowledged that the mugs were not in the expected sanitary condition.
Two residents did not receive wound care in accordance with wound consultant recommendations because staff did not promptly obtain physician review and orders. One resident with incontinence, morbid obesity, diabetes, and gluteal dermatitis had a recommended change from SSD to a Nystatin-based regimen for IAD that was delayed and not documented as reviewed by the physician until days later. Another resident with dementia, a wound infection, a Stage 3 pressure ulcer, and a left hip abscess had consultant orders for cleansing, Bacitracin, and dry dressings that were neither documented as reviewed by the physician nor carried out on the TAR. The DON and other leaders acknowledged that consultant recommendations are received the same day but are often not reviewed with the physician until weekly rounds, leading to these missed and delayed treatments.
The facility failed to ensure timely physician review and implementation of wound consultant recommendations for two residents with pressure ulcers. For one resident with multiple sacral and buttock pressure injuries, a wound consultant documented that ulcers had resolved and recommended discontinuing hydrogel and Bacitracin treatments, yet staff continued these treatments for weeks without documented physician review or updated orders. For another resident with dementia, incontinence, and a rapidly worsening unstageable sacral pressure ulcer, the consultant recommended a new regimen with wound cleanser, skin prep, Bacitracin, and bordered dressings, but this treatment was not started for several days and there was no documentation that the physician reviewed or acted on the recommendations until that time, as confirmed by the DON and administrator.
Surveyors observed that kitchen staff failed to maintain sanitary conditions, with numerous food service items—including mugs, pitchers, plates, pans, and serving carts—found dirty with food particles and grime. The walk-in freezer and kitchen floor also had significant dirt and debris, and these unclean items were confirmed to be in use for residents.
Residents repeatedly reported during council and committee meetings that their meals, including coffee and French fries, were not served at desired temperatures, and concern forms were generated. Multiple residents confirmed in interviews that their food was not consistently at preferred temperatures, with one stating her food was sometimes not edible. A test tray also found the food to be unpalatable, and the DON acknowledged these ongoing concerns.
A resident with heart failure and on hospice care experienced a change in condition, including cough, congestion, hoarse voice, and low-grade fever. Although an LPN documented symptoms and administered Tylenol, there was no evidence that an RN performed an assessment at the time. A hospice RN later assessed the resident and new medical orders were issued, but facility records lacked documentation of an RN assessment during the initial change.
The facility did not consistently serve food and beverages at palatable and proper temperatures, as evidenced by repeated resident complaints and direct observation of meal service. Multiple residents reported that their meals and drinks were not at their desired temperatures, and test tray measurements confirmed that hot foods were not hot enough and cold foods were not cold enough. The Regional Dietitian verified that the temperatures did not meet required standards.
A resident with a PICC line did not have the external catheter length measured and documented during dressing changes as required by physician orders and facility policy. Although dressing changes were performed, there was no evidence that staff measured or recorded the catheter length, and this was confirmed by the DON.
A resident with hemiplegia and a mechanically altered diet was not provided with the required adaptive eating and drinking equipment as ordered by the physician and recommended by the speech therapist. Staff gave the resident a Styrofoam cup with a lid and straw instead of two spout cups, and did not ensure the use of other adaptive utensils as specified in the care plan. Staff interviews confirmed the lack of adherence to the resident's meal ticket and therapy recommendations.
The facility did not ensure complete and accurate documentation of bathing records for two residents, as required by professional standards. Although both residents and the DON confirmed that showers or baths were provided according to resident preferences, there was no documentation for several scheduled dates, resulting in incomplete clinical records.
Surveyors found unsanitary conditions in the kitchen and food storage areas, including overflowing garbage, spilled food, dirty gloves on the floor, broken tiles, pooling water, and undated thickened liquids. Water was observed dripping onto food in both the walk-in freezer and cooler, and several coolers lacked thermometers. Staff confirmed that cleaning tasks were not being completed as scheduled and acknowledged the general uncleanliness of the kitchen.
A resident with a deep tissue injury and pelvic fracture did not receive wound care as recommended by a wound consultant, as the updated treatment orders were not clarified or implemented for several days. Documentation showed the physician was not notified of the consultant's recommendations in a timely manner, resulting in a delay in appropriate wound care.
Essential kitchen equipment was not maintained in safe operating condition, as evidenced by a broken garbage disposal causing water accumulation, a malfunctioning hot box, a nonfunctional steamer installed with missing parts, an inoperative steam table, a cooler with water pooling inside, and leaking faucets in the dishwashing area. These deficiencies were confirmed by staff interviews.
A resident who was diagnosed with Covid and placed on isolation precautions did not have their emergency contact notified of the diagnosis until two days after the event, contrary to facility policy requiring prompt notification of changes in condition. This delay was confirmed by record review and staff interviews.
A resident's care plan was not updated to reflect a change in smoking status, as documentation continued to require staff supervision for smoking despite a later assessment and resident interview confirming the resident was safe to smoke independently. Facility leadership acknowledged the care plan should have been revised.
Three residents who required staff assistance for oral or denture care did not receive documented oral hygiene at bedtime on multiple occasions. Facility policy required staff to provide this care, but records showed repeated omissions without explanation, as confirmed by the DON.
A resident who experienced a significant change in status did not have a documented care plan conference with themselves or their responsible party within the required timeframe. Although staff reported sending invitations and attempting follow-up, there was no evidence that the resident or responsible party participated in the care planning process as required.
The facility did not update care plans for two residents to reflect their current needs and preferences. One resident's care plan called for an alternating air mattress, but this was not in place, and the care plan was not revised. Another resident's care plan indicated a preference for showers twice weekly, but documentation showed the resident preferred showers once a week, and the care plan was not updated accordingly.
The facility failed to complete comprehensive annual MDS assessments within the required timeframe for 35 residents. The RAI User's Manual mandates that these assessments be completed no later than 14 days after the ARD, but the facility did not adhere to this guideline. Specific examples include assessments for several residents being completed well beyond the required timeframe, as confirmed by clinical records and staff interviews.
The facility failed to complete Quarterly MDS assessments within the required timeframe for 37 residents, as confirmed by the RNAC and DON. The assessments were consistently late, ranging from two to eleven days past the due date, violating state regulations on clinical records and nursing services.
A facility failed to maintain personal hygiene for a resident with Parkinson's disease who required extensive assistance. Despite a care plan indicating weekly showers, records showed only three showers were provided over several months. The resident reported not receiving showers as scheduled, and the DON confirmed the lack of documentation for the missed showers.
The facility failed to monitor and document a resident's weight as per policy for a resident on tube feedings and did not address significant weight loss in another resident with Parkinson's disease. Despite drastic weight changes, there was no evidence of interventions or physician notification, as confirmed by the DON.
The facility did not follow their planned menu for a lunch meal, resulting in a deficiency. The menu specified baked fish with seasonings, but the pureed version lacked these seasonings, making it bland. The Corporate Dietary Director confirmed the pureed fish should have been prepared with the same ingredients as the regular portion.
The facility failed to serve palatable food at safe temperatures. Residents reported receiving cold food, and observations confirmed that food temperatures were below acceptable levels. The Corporate Dietary Manager acknowledged that food should be served at proper temperatures.
The facility failed to maintain sanitary conditions in food storage and preparation. Observations revealed expired and undated food items, unsanitary kitchen equipment, and improper storage practices, such as uncovered flour and food boxes on the floor. The facility lacked a dietary manager, with tasks managed by the dietitian and corporate dietary manager.
A resident with a nephrostomy tube was observed being assisted to the therapy department with his gown held in a way that exposed his brief, legs, and drainage bag, compromising his dignity. Interviews with the Director of Therapy and DON confirmed that the resident should have been dressed to maintain dignity.
The facility failed to accurately complete MDS assessments for several residents, including incorrect documentation of pain medication administration, missing mental status and mood interviews, and an incorrect discharge status. These errors were confirmed by the DON.
The facility failed to develop comprehensive care plans for two residents, one with Parkinson's disease and dementia, and another with PTSD. Despite having physician's orders for medications, there were no care plans addressing the specific needs and triggers of these residents, as confirmed by the DON.
The facility failed to update care plans for three residents, leading to inaccuracies in medication administration and care preferences. One resident's care plan incorrectly included antidepressant and antianxiety medications, another's did not reflect changes in transfer status and shower preferences, and a third's was not updated when wound vac treatment was discontinued. The DON confirmed these discrepancies.
A facility failed to follow physician's orders for a resident receiving hospice care, who required morphine 30 minutes before wound care. The morphine was scheduled at 8:00 a.m., but wound care occurred at varying times, leading to inconsistent pain management. Observations and interviews confirmed the lack of documentation for timely medication administration.
The facility failed to notify physicians and implement interventions for significant weight loss in two residents with feeding tubes. One resident, severely cognitively impaired, lost 14 pounds in 15 days, while another, cognitively intact, lost 13 pounds in 17 days. The DON confirmed that neither case was addressed by the dietician or physician.
A resident with chronic respiratory failure was observed receiving oxygen therapy without a physician's order. Despite the care plan indicating the need for oxygen, there was no documented evidence of a physician's order in the clinical records. This was confirmed by the DON during an interview.
A resident with Parkinson's disease did not receive prescribed Butran's patches for pain management due to unavailability, leading to increased pain. The facility's policy required staff to manage pain effectively, but there was no evidence of alternative pain relief being offered. The DON confirmed a delay in delivery due to insurance issues.
The facility did not complete annual performance evaluations for three nurse aides as required by their hire dates. Evaluations for these aides were due but not documented, which was confirmed by the Nursing Home Administrator.
A facility failed to document the disposal of Lorazepam for a resident with cognitive impairment and Metabolic Encephalopathy. Despite a physician's order for Lorazepam, there was no record of administration or destruction of the medication, as confirmed by the DON.
The facility did not timely respond to a pharmacy recommendation for a resident who was cognitively intact and required assistance for daily care. The pharmacy suggested a stimulant laxative to manage constipation, but there was no evidence that the physician reviewed or addressed this recommendation, as confirmed by the DON.
The facility's QAPI committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys throughout 2024. These deficiencies included failure to provide notice of bed hold policy, timely completion of comprehensive assessments, development of resident care plans, and provision of activities of daily living care to dependent residents. Additionally, the facility was cited for inadequate quality of care, improper feeding tube management, failure to maintain accurate accounts of controlled medications, improper labeling and storage of drugs and biologicals, and failure to prepare and follow menus to meet residents' needs.
The facility did not maintain essential kitchen equipment in safe operating condition, as the steamer in the main kitchen was broken and had been non-functional for over a year. The Corporate Dietary Manager and Nursing Home Administrator confirmed the steamer was irreparable, and the facility was in the process of ordering a new one.
A resident with flaccid hemiplegia was found on the floor in their room, but the facility failed to conduct a thorough investigation to rule out abuse or neglect, as required by their policies. The Director of Nursing confirmed the absence of an incident report or investigation, despite the resident's dependency on staff for transfers and the facility's fall management policy.
A resident with flaccid hemiplegia, requiring two staff for transfers, was found on the floor after being transferred by one staff member. The resident was not injured and was assisted back to bed. The staff member attempted the transfer alone due to the resident's precarious position in the chair, contrary to physician's orders.
A facility failed to provide timely written notification to a resident, their responsible party, and the Ombudsman regarding the reason for the resident's hospital transfer. The resident, who was cognitively intact and required assistance for daily care, experienced a significant emesis, leading to a hospital transfer. The Director of Nursing confirmed the absence of written notification.
A facility failed to notify a resident or their representative about the bed-hold policy during a hospital transfer. The resident, who was cognitively intact and required assistance for daily care, was transferred due to a medical event. Despite the facility's policy, there was no documentation of notification, confirmed by the DON.
The facility did not document the disposition of medications for a resident who passed away. The policy requires a nurse to complete a medication disposition record, including the amount of each medication. However, there was no evidence of this documentation for the resident, as confirmed by the DON.
A resident did not receive the breakfast meal as specified in the facility's planned menu. Instead of an egg, bacon, and cheese croissant sandwich with two bowls of hot cereal, the resident was served scrambled eggs with cheese, cold cereal, and toast. The resident reported this issue to the kitchen staff, and the Corporate Dietary Manager confirmed the menu was not followed.
A resident with multiple sclerosis was found to have a wheelchair in poor condition, with heavy dust, debris, and a torn backrest. The physical therapist and nursing home administrator confirmed the wheelchair's filthy state, indicating a failure to maintain a clean and homelike environment as per facility policy.
A resident experienced an unwitnessed fall, and the facility failed to conduct neurological checks as per policy. Additionally, there was no documentation of medication administration for several days, despite an LPN stating she administered it. The DON confirmed the lack of documentation for both the neurological checks and medication administration.
The call bell system in the North hall was not functioning properly, with the sound not activating and the central call light remaining on continuously, making it difficult for staff to know when a call bell was ringing. The Director of Maintenance was initially unaware of the issue, which was later resolved by replacing a battery in a resident's bathroom call system.
A facility failed to follow physician's orders for a resident's PICC line care, which required weekly dressing and cap changes. Despite the resident being cognitively intact and needing staff assistance, there was no documentation of the required changes on specified dates. The DON confirmed the oversight.
A resident was administered an incorrect dosage of lacosamide, receiving two 200 mg tablets instead of one, leading to hospitalization due to vomiting. The error was confirmed by the DON.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident, admitted with orders for intravenous antibiotic therapy for cellulitis and wound care for multiple ulcers, did not have a documented care plan addressing these needs. This deficiency was confirmed by the RN Assessment Coordinator.
Unclean Thermal Coffee Mugs Found in Food Service Area
Penalty
Summary
The facility failed to maintain kitchen sanitation related to thermal coffee mugs used for residents. The facility’s kitchen sanitation and cleaning policy, dated August 18, 2025, stated that food and nutrition services staff would maintain the sanitation of the kitchen. During an observation in the main kitchen on March 4, 2026, at 9:16 a.m., 25 of 39 maroon and/or black thermal coffee mugs on a rack near the kitchen entrance and dishwasher exit were found to have a moderate to large amount of blackish brown removable substance inside. A dietary aide operating the dishwasher at that time confirmed that these mugs had been washed, were in circulation, and were ready for resident use, and acknowledged the visible brownish black buildup inside. The dietician also confirmed that the mugs, which were in circulation and ready to be used for residents, contained a blackish brown removable substance. The Infection Preventionist confirmed that all items used for serving food should be clean, and the Nursing Home Administrator confirmed that the 25 thermal coffee mugs should have been clean inside but were not. No specific residents were identified in the report, and no resident medical histories or conditions were described in relation to this deficiency.
Failure to Implement and Obtain Physician Review of Wound Consultant Recommendations
Penalty
Summary
The facility failed to ensure that wound consultant recommendations were promptly reviewed with the attending physician and implemented for two residents. For one resident who was cognitively intact with morbid obesity, diabetes, incontinence of bowel and bladder, dependence for lower body care and bed mobility, and use of pressure-relieving devices, a wound consultant identified gluteal dermatitis and recommended a change in treatment due to difficulty keeping the area dry and the resident’s refusal of side-lying positions. The consultant recommended discontinuing silver sulfadiazine and initiating a regimen including cleansing with soap and water, drying, applying Nystatin powder, and covering with a nonwoven dry gauze pad twice daily and as needed. Although the facility received the wound consultant’s recommendations the same day they were made, the treatment was not initiated until two days later, and there was no documentation that the physician reviewed and accepted or declined the recommendations until that later date. For another resident who was cognitively impaired, required assistance with daily care and bed mobility, was frequently incontinent, and had a wound infection and a Stage 3 pressure ulcer with dementia, the wound consultant documented a left hip abscess and recommended a specific treatment regimen involving cleansing with wound cleanser, applying Bacitracin ointment, and securing with a dry dressing daily and as needed. A subsequent consultant note recommended continuing this same treatment. However, there was no documented evidence that the physician reviewed these wound consultant notes to agree or disagree with the recommendations, and the Treatment Administration Record did not show that the recommended treatment to the left hip abscess was completed. The DON, Nursing Home Administrator, and facility consultant confirmed that wound recommendations are received the same day but are often not reviewed with the physician until weekly rounds, and the DON confirmed that for both residents the wound care recommendations were not reviewed with the attending physician, resulting in the recommended wound care not being completed.
Failure to Timely Implement and Discontinue Wound Care per Consultant Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care in accordance with professional standards and its own policy requiring evidence-based interventions as ordered by a provider and coordination with the resident’s medical provider when using a consulting wound care provider. For one resident with traumatic ischemia of muscle and pressure ulcers, admission assessments showed the resident was cognitively intact and required staff assistance for daily care. Physician orders directed specific wound care to the right buttock, right sacrum, right lateral and proximal areas using wound cleanser, hydrogel, and dry dressings, and to the left sacrum using wound cleanser, Bacitracin ointment, and dry dressings, to be changed daily and as needed. Subsequent wound consultant notes documented that the right sacral pressure ulcer had resolved with a recommendation to discontinue treatment, and later that the left sacral pressure ulcer had also resolved with a recommendation to discontinue treatment. However, there was no documented evidence that the attending physician reviewed these wound consultant recommendations to agree or disagree. The Treatment Administration Record showed that staff continued to apply hydrogel to the right sacrum and Bacitracin to the left sacrum through early March, despite the consultant’s recommendations to discontinue treatment and the lack of documented physician review or updated orders. For another resident who was cognitively impaired, required substantial assistance with bed mobility, was frequently incontinent of bowel and bladder, and had dementia, a wound consultant documented an unstageable, rapidly progressing left sacral pressure ulcer with eschar and slight induration. The consultant recommended a change in treatment, including cleansing with wound cleanser, applying skin prep to the peri-wound, applying Bacitracin to the wound base, and securing with a bordered dressing daily and as needed. The Treatment Administration Record showed that this recommended treatment was not initiated until several days later, and there was no documented evidence that the physician reviewed and accepted or declined the recommendations until that time. Facility leadership confirmed that wound care recommendations are received the same day but are often not reviewed with the physician until weekly rounds, and that there was no documentation of timely physician review or initiation of the recommended treatment for this resident’s worsening pressure ulcer.
Unsanitary Food Storage and Preparation Conditions Identified
Penalty
Summary
Facility staff failed to maintain sanitary conditions in the kitchen, as required by facility policy and professional standards. During an observation, multiple items intended for food preparation and service were found to be unclean. Specifically, all examined coffee mugs, several coffee and water pitchers, dinner plates, drinking glasses, sheet pans, frying pans, and a cooking pot were noted to have visible food particles, grime, or removable films. Additionally, all serving carts inspected had significant accumulations of dirt and food debris, and the walk-in freezer contained a large, dried, sticky substance on the floor and shelf. The entire kitchen floor was also observed to have a moderate to large amount of dirt and debris. Interviews with the Dietary Manager, Dietician, and Dietary Consultant confirmed that these dirty items were in circulation and ready for resident use. The Nursing Home Administrator also acknowledged that the kitchen floor and all items used for preparing, cooking, and serving food were not clean at the time of inspection. No information was provided regarding specific residents affected or their medical conditions.
Failure to Address Resident Council Grievances on Food Temperature
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances presented by the Resident Council/Food Committee regarding food temperatures. Meeting minutes from June and July 2025 documented that residents repeatedly expressed concerns about meals, specifically that coffee and French fries were not served at desired temperatures, and that overall food temperatures were unsatisfactory. Concern forms were generated after these meetings. Multiple resident interviews confirmed that meals, including those served in the main dining room, were not consistently at preferred temperatures, and one resident reported that her food was sometimes not edible. A test tray conducted during a lunch meal further revealed that the food was not palatable. The DON confirmed that these concerns were documented in the meeting minutes and had been voiced by residents over multiple months.
Failure to Complete RN Assessment After Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) assessment was completed when a resident experienced a change in condition. The resident, who had diagnoses including heart failure and was receiving hospice care, exhibited symptoms such as a moist, non-productive cough, moderate nasal congestion, hoarse voice, and a low-grade fever. Nursing notes documented these symptoms and the administration of Tylenol by an LPN, as well as ongoing monitoring of the resident’s temperature and encouragement of oral fluids. Despite these changes in the resident’s condition, there was no documented evidence that an RN performed an assessment at the time of the change. Further documentation showed that a hospice RN later assessed the resident, noting persistent symptoms, crackles in all lung lobes, a moist cough, and an oxygen saturation of 90% on room air. New orders were received from the hospice physician for antibiotics and adjustments to the resident’s medications. However, the facility’s records did not show that an RN from the facility assessed the resident during the initial change in condition, as required by state regulations. The Director of Nursing confirmed that an RN assessment should have been completed in such circumstances.
Failure to Serve Palatable Food at Proper Temperatures
Penalty
Summary
The facility failed to serve food and beverages at palatable and proper temperatures, as required by its own policy and regulatory standards. Review of Resident Council/Food Committee meeting minutes revealed repeated resident complaints about food and drink temperatures, including coffee and French fries not being hot enough. Concern forms were generated following these meetings. Multiple residents interviewed confirmed that their meals were not consistently served at their desired temperatures, even when dining in the main dining room. One resident also reported that her food was not always edible. Observation of a lunch meal service showed that the food temperatures at the point of service were below recommended levels for hot foods and above recommended levels for cold foods. Specifically, the Swedish Meatballs/Mashed Potatoes/Gravy Casserole was 131.9°F, peas were 121.8°F, coffee was 116.6°F, and milk was 48.4°F. The meal was determined to be neither palatable nor at an appetizing temperature. The Regional Dietitian confirmed that these temperatures did not meet the required standards.
Failure to Document PICC Line Measurements During Dressing Changes
Penalty
Summary
The facility failed to ensure that physician's orders were followed for the care and maintenance of a peripherally-inserted central catheter (PICC) for one resident. According to facility policy, staff were required to measure the external catheter length of PICC lines on admission, with each dressing change, and as needed. Physician's orders also specified that the catheter length should be measured with each dressing change, the measurements should be documented in the order notes, and the physician should be notified if the length changed since the last measurement. Review of the resident's clinical records and the Medication Administration Record (MAR) showed that while PICC line dressing changes were performed on multiple occasions, there was no documented evidence that the catheter length was measured at the time of these dressing changes as required. An interview with the Director of Nursing confirmed the absence of documentation regarding catheter length measurements during dressing changes, indicating non-compliance with both facility policy and physician's orders.
Failure to Provide Ordered Adaptive Eating Equipment and Follow Speech Therapy Recommendations
Penalty
Summary
Staff failed to provide a resident with the required adaptive eating and drinking equipment as ordered by the physician and recommended by the speech therapist. The resident, who had hemiplegia following a stroke and was on a mechanically altered diet, was supposed to receive a two-handled spout cup, maroon spoon, inner lip plate, and scoop bowl, with explicit instructions for no straws to be used. Despite these orders and care plan directives, observations revealed that the resident was given a Styrofoam cup with a lid and straw, and only one two-handled cup with a spout lid, instead of the two spout cups required. The meal ticket also indicated no straws and two spout cups, but this was not followed. Interviews with staff confirmed the discrepancies, with a nurse aide acknowledging the incorrect equipment on the tray and an LPN unsure about the correct cup to provide. The speech therapist reiterated that the resident should only have two-handled cups with spout lids and no straws, both at meals and bedside, due to the resident's impulsive behaviors and increased aspiration risk. The facility's policy required adaptive equipment to be provided as determined by the therapist and ordered by the provider, but this was not consistently implemented for this resident.
Incomplete Documentation of Resident Bathing Records
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for two of nine residents reviewed. For one resident, a quarterly MDS assessment indicated cognitive intactness and a need for supervision with showering, with a care plan specifying showers twice a week and honoring refusals. The facility's shower schedule aligned with this plan, but bathing records for specific dates showed no documentation that a shower or bath was provided or refused. Despite this, the resident reported receiving showers as expected. For another resident, the quarterly MDS assessment showed moderate cognitive impairment and independence with showering, with a care plan to follow the shower schedule and honor refusals. The shower schedule indicated weekly showers, but bathing records for certain weeks lacked documentation of showers provided or refused. The resident confirmed that their preferences were honored and showers were received as desired. The DON acknowledged that showers were provided according to preferences, but documentation was missing for the identified dates.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen and food storage areas. Overflowing garbage cans were found near the employee sink and dietary department entrance, with spilled syrup and a dirty glove on the floor. The dishwashing area had a musty odor, broken floor tiles, and pooling water that extended to the food cart storage area. The grout lines on the floor contained a thick, dark gray substance. The milk cooler and an upright cooler used for thickened liquids lacked thermometers, and the thickened liquids were not dated. Water was pooling inside the upright cooler, and trays and the bottom of the cooler were wet. The dry storage area had an accumulation of black dirt along the floor and wall junction. In the walk-in freezer, water was dripping from the ceiling onto boxes of food, and ice had accumulated on the floor. The walk-in cooler also had water dripping from the ceiling onto a cart and a box of beef patties, with shelving observed to be dirty. Staff interviews confirmed that dietary staff were responsible for cleaning but there was no evidence cleaning tasks were completed as scheduled. The dietician and dietary manager acknowledged the unsanitary conditions, including undated thickened liquids and overflowing garbage. The Maintenance Director confirmed that a cracked garbage disposal and broken tiles contributed to water accumulation and unpleasant odors.
Failure to Clarify and Implement Wound Care Orders
Penalty
Summary
A deficiency was identified when the facility failed to clarify and implement a provider's order for wound care treatment for one of eight residents reviewed. The resident, who was cognitively intact and required staff assistance for daily care, was admitted with a deep tissue injury and a pelvic fracture. Physician's orders initially directed specific wound care, and a subsequent wound consultant note recommended a change in treatment, including the use of acetic acid moist gauze. However, there was no documented evidence that the recommended treatment from the wound consultant was carried out between April 15 and April 20. Further review and staff interviews revealed that the physician was not informed of the wound consultant's recommendations until several days after they were made. This lapse resulted in a delay in updating the resident's treatment plan according to professional standards and the recommendations provided by the wound care consultant. The findings were based on clinical record review, staff interviews, and reference to the Pennsylvania Nursing Practice Act and relevant state codes.
Failure to Maintain Safe Operating Condition of Essential Kitchen Equipment
Penalty
Summary
The facility failed to ensure that essential kitchen equipment was maintained in safe operating condition. Observations revealed water accumulating on the floor near the dishwasher due to a broken garbage disposal, a hot box that would not shut off and required unplugging, a steamer that had never functioned since installation because it was missing parts, one of three steam tables not working, a small upright cooler with water pooling inside, and leaking faucets in the dishwashing area. These findings were confirmed through interviews with the Dietician and Maintenance Director, who acknowledged the ongoing issues with the equipment and their inability to repair or replace certain items.
Delayed Notification of Change in Condition to Resident's Representative
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative regarding a significant change in the resident's condition. According to the facility's policy, the physician and family or responsible party are to be notified as soon as the nurse identifies a change in condition and the resident is stable. In this instance, a resident who was cognitively intact and required staff assistance for daily care was diagnosed with Covid and placed on isolation precautions. However, documentation showed that the resident's emergency contact was not informed of the positive Covid diagnosis until two days after the diagnosis was made. This delay in notification was confirmed through review of clinical records and staff interviews, including with the Director of Nursing, who acknowledged that the family should have been notified as soon as possible per facility policy. The deficiency was identified for one of eight residents reviewed, and the failure to promptly inform the resident's representative constituted non-compliance with both facility policy and regulatory requirements.
Failure to Update Care Plan for Smoking Independence
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect changes in the resident's care needs regarding smoking. A quarterly MDS assessment showed that the resident was cognitively intact and dependent on staff for care needs. However, a smoking safety assessment later determined that the resident was safe to smoke independently and did not require staff assistance. Despite this, the resident's care plan continued to state that the resident was non-compliant with the facility's non-smoking policy and required a staff member to accompany him outside to smoke. Interviews with the resident confirmed that he always smoked independently, and facility leadership acknowledged that the care plan should have been updated to reflect this change.
Failure to Provide Bedtime Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary oral hygiene care at bedtime for three residents who required staff assistance, as evidenced by a review of policies, clinical records, and staff interviews. Facility policy required nursing staff to offer evening care, including oral care, to promote hygiene and comfort. Documentation for three residents, all of whom were either dependent on staff for oral care or required set-up assistance and had no natural teeth, showed multiple instances where there was no evidence that oral or denture care was provided at bedtime over several days in February and March. There was also no documentation explaining why oral care was not provided on those dates. The residents involved included individuals who were cognitively intact or impaired, but all required some level of staff assistance for oral care. The lack of documentation and absence of oral care provision was confirmed by the Director of Nursing during an interview. The findings indicate that the facility did not follow its own policy or ensure that residents unable to perform oral care independently received the necessary assistance at bedtime.
Failure to Involve Resident in Timely Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and/or the resident's responsible party was given the opportunity to participate in the timely development and implementation of a person-centered care plan. A significant change in status MDS assessment indicated that the resident was able to understand and be understood, and required staff assistance for activities of daily living. Although a care plan conference was held with the resident in October, there was no documented evidence that a care plan conference occurred in January following the significant change in status. Staff interviews confirmed that while invitations are sent and follow-up is attempted if families do not attend, there was no documentation of a care plan conference with the resident or responsible party during the required timeframe.
Failure to Update Care Plans to Reflect Residents' Current Needs and Preferences
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect the specific care needs and preferences of two residents. For one resident, a quarterly Minimum Data Set (MDS) assessment indicated cognitive intactness, risk for pressure sore development, and the use of a pressure-relieving device. However, observation revealed that the resident did not have the alternating air mattress specified in the care plan, and the Director of Nursing confirmed that the care plan required updating to reflect the resident's current needs. For another resident, a significant change in status MDS assessment showed that the resident required staff assistance for activities of daily living and had a care plan indicating a preference for showers twice weekly. Nursing documentation later revealed that the resident preferred showers only once a week, but there was no evidence that the care plan was updated to reflect this change. The Director of Nursing confirmed the lack of documentation updating the care plan to match the resident's current shower preference.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive annual Minimum Data Set (MDS) assessments within the required timeframe for 35 out of 79 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, annual MDS assessments must be completed no later than 14 calendar days after the assessment reference date (ARD). However, the facility did not adhere to this guideline, resulting in delayed assessments for numerous residents. Specific examples include Resident 4, whose annual MDS assessment was completed 25 days after the ARD, and Resident 6, whose assessment was completed 24 days after the ARD. Additionally, Resident 8's admission MDS assessment was completed 24 days after the ARD, and Resident 11's assessment was completed 16 days after the ARD. These delays were confirmed through a review of clinical records and staff interviews, indicating a systemic issue in meeting the required assessment timelines. The Registered Nurse Assessment Coordinator (RNAC) and the Director of Nursing confirmed that the comprehensive MDS assessments were not completed within the required timeframe. This deficiency was identified during a survey, and it highlights the facility's failure to comply with the regulatory requirements for timely resident assessments, as mandated by the RAI User's Manual and 28 Pa. Code 211.5(f) regarding clinical records.
Plan Of Correction
1. A comprehensive Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. 2. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required next annual MDS assessment or admission MDS assessment for the in-house residents. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. 3. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting comprehensive assessments by the Regional Clinical Reimbursement Specialist or a designee. 4. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of five random residents' annual and admission MDS assessments to ensure compliance with F636 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for 37 out of 79 residents reviewed. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual specifies that quarterly assessments must be completed within 14 days after the Assessment Reference Date (ARD), and these assessments are due every 92 days. However, the facility did not adhere to these guidelines, resulting in late completion of assessments for numerous residents. For instance, Resident 1 had an ARD of November 2, 2024, and the assessment was due by November 15, 2024, but it was completed 10 days late on November 25, 2024. Similarly, Resident 2 had two instances of late assessments, with one being seven days late and the other six days late. This pattern of delayed assessments was consistent across multiple residents, with delays ranging from two to eleven days past the required completion date. The Registered Nurse Assessment Coordinator (RNAC) and the Director of Nursing confirmed during an interview that the quarterly MDS assessments were not completed within the required timeframe. This deficiency was noted under the regulations 28 Pa. Code 211.5(f) Clinical Records and 28 Pa. Code 211.12(d)(5) Nursing Services, indicating a failure in maintaining timely and accurate clinical records as mandated by the state regulations.
Plan Of Correction
1. A quarterly Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. 2. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required next quarterly MDS assessment for the in-house residents. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. 3. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting quarterly assessments by the Regional Clinical Reimbursement Specialist or a designee. 4. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents' quarterly MDS assessments to ensure compliance with F638 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Failure to Provide Scheduled Showers for a Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a dependent resident, identified as Resident 62, who was cognitively intact and required extensive assistance for personal hygiene due to Parkinson's disease. The resident's care plan indicated a weekly shower schedule on Mondays, but records showed that he received only three showers from August to December 2024. During an interview, the resident expressed that he had not been receiving showers as scheduled, despite requesting them. The Director of Nursing confirmed the lack of documentation explaining the missed showers and acknowledged the resident's desire to be showered weekly.
Plan Of Correction
1. Resident 62 offered shower and refused. 2. Residents were interviewed to identify shower preferences. 3. The Interdisciplinary team will review shower schedule during morning clinical meeting to determine if showers were provided or refused and documented. The Director of Nursing/designee will educate nursing staff including agency on the process of providing showers including documentation in the electronic medical record. 4. To maintain and monitor compliance, an audit of residents' showers will be completed by the Director of Nursing or designee weekly times four weeks then monthly for two months to ensure showers have been provided.
Failure to Monitor and Address Resident Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's weight was obtained and documented as per facility policy for a resident receiving tube feedings. Resident 1, who was dependent on staff for all care and had a traumatic brain injury, was not weighed in January, March, May, or June 2024, despite the facility's policy requiring monthly weight checks. This oversight was confirmed by the Director of Nursing, indicating a lapse in monitoring the resident's nutritional health over time. Additionally, the facility did not address significant weight loss in another resident, Resident 62, who was cognitively intact and had Parkinson's disease. The resident experienced a drastic weight loss of 117.9 pounds over four months, with weights recorded from August to October 2024 showing a significant drop. Despite dietary notes questioning the accuracy of the weights and indicating a 7.6 percent weight loss in 30 days, there was no documented evidence of interventions to prevent further weight loss or notification to the physician. The Director of Nursing confirmed the lack of action regarding the resident's weight loss.
Plan Of Correction
1. The facility cannot retroactively address the findings. 2. Weights completed. Those with significant changes to have completion of nutrition assessment with MD and responsible party notification. 3. Director of Nursing or Designee to educate nursing staff including agency regarding weights and implementation of follow through documentation and notification. 4. Director of Nursing or Designee to complete weekly weight audits to ensure follow through of significant weight changes as well as the completion of interventions or re-evaluation of weights. Audits to be completed weekly for 4 weeks then monthly for 2 months. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Follow Planned Menu for Pureed Baked Fish
Penalty
Summary
The facility failed to adhere to their planned menu, which was designed to meet the nutritional needs of residents. The written and posted menu for a lunch meal specified that residents were to receive baked fish, prepared with margarine, salt, and white pepper. However, during a test tray observation, it was found that the pureed version of the baked fish was snow white in color and lacked the seasonings present in the regular diet portion. This resulted in the pureed fish being bland and not as flavorful as intended. An interview with the Corporate Dietary Director confirmed that the pureed fish should have been prepared with the same ingredients as the regular portion, indicating a failure to follow the planned menu and recipe guidelines.
Plan Of Correction
1. The facility cannot retroactively address the findings. 2. Baseline audit of menus completed. 3. Dietary manager to educate dietary staff on menus, production sheets and recipes. Nursing staff to be educated on resident menus. 4. Weekly audits completed by contract Certified Dietary Manager or designee for 4 weeks then monthly for 2 months to ensure menus, spreadsheets and recipes are followed. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to serve food items that were palatable, as determined by observations and interviews with residents and staff. On December 10, 2024, a group of residents reported that the food delivered to their rooms was served cold. Further observations on December 11, 2024, during the lunch meal service revealed that a test tray left the kitchen and arrived at the North hall within two minutes. However, by the time the last resident was served and began eating, the temperatures of the food items were below the acceptable range. Specifically, the baked fish was 114.2°F, the pureed baked fish was 104.2°F, the pureed broccoli was 102°F, and the pureed noodles were 105.3°F, all of which were cool and unappetizing. The Corporate Dietary Manager confirmed that foods should be served at proper and palatable temperatures.
Plan Of Correction
1. The facility cannot retroactively address the findings. 2. Baseline audit completed regarding temperature and palatability. 3. Dietary Manager to educate dietary staff on serving meals at proper temperature. Nursing staff educated on the timing of meal service. 4. Contracted Dietary Manager/designee to complete food temperature audits/test during tray line weekly x 4 weeks, then monthly for 2 months. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure that food was stored and prepared under sanitary conditions, as evidenced by several observations and staff interviews. In the main kitchen, the walk-in refrigerator contained three bags of brussel sprouts, one of which was past its use-by date, and the other two were close to expiration. The brussel sprouts appeared discolored and had increased moisture. Additionally, there was an undated tray of cooked chicken tenders and a bag of cilantro that was discolored and moist, with an opened date but no use-by date. The Cook/Dietary Aide confirmed that the chicken tenders should have been dated and expired food discarded. The facility lacked a dietary manager, with the dietitian and corporate dietary manager handling kitchen tasks. Further observations revealed unsanitary conditions with kitchen equipment and storage practices. A large stand mixer and a meat slicer were found with dried food debris, and the Cook/Dietary Aide confirmed they had not been cleaned. In the dry storage area, a large container of flour was uncovered, and two boxes of food were placed directly on the floor. The dietitian confirmed that food should not be on the floor and the flour should be covered. Additionally, there was no thermometer in the milk cooler, which was later found in another cooler, as confirmed by the Corporate Dietary Manager.
Plan Of Correction
1. The facility cannot retroactively address the findings. 2. Baseline audit to be completed of kitchen food storage and preparation. 3. Contracted Dietary Manager to educate staff on proper food storage, handling, preparation and distribution to residents. 4. Contracted Dietary Manager/designee to complete weekly sanitation audits to ensure food is received, stored, prepared, served and distributed in accordance with food safety regulations. Audits to be completed weekly for 4 weeks then monthly for 2 months. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Maintain Resident Dignity During Ambulation
Penalty
Summary
The facility failed to maintain the dignity of Resident 97, who was admitted with a diagnosis of chronic ureteropelvic junction obstruction and had a nephrostomy tube. The resident was cognitively intact and required assistance for daily care needs. On December 9, 2024, during an observation, it was noted that while being assisted with ambulation to the therapy department by a therapy assistant, the resident's gown was held in a manner that exposed the back of his brief, legs, and drainage bag, compromising his dignity. Interviews with the Director of Therapy and the Director of Nursing confirmed that the resident should have been wearing clothing that maintained his dignity during ambulation.
Plan Of Correction
1. Unable to retroactively correct form of clothing for resident 97. 2. Baseline audit completed of residents to ensure dignity. 3. Non-clinical rounds to be completed by facility managers to make sure resident rights are met including dignity during ambulation. The Administrator/Designee will educate facility staff including therapy and agency on resident rights which includes dignity. 4. The Administrator or designee will complete dignity audits of 5 residents weekly for four weeks then monthly times one month. Identified issues will be addressed when found. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, as identified during a review of clinical records and staff interviews. For one resident, the MDS assessment inaccurately indicated that no as-needed pain medication was administered during the assessment period, despite records showing multiple administrations of morphine for pain. This discrepancy highlights a failure to accurately document the resident's pain management needs. Additionally, three residents who were able to communicate effectively did not have the required Brief Interview for Mental Status (BIMS) and mood interviews completed, as indicated by their MDS assessments. Another resident's discharge status was incorrectly coded as a hospital discharge, while documentation confirmed the resident was discharged home with home health services. These inaccuracies were confirmed through interviews with the Director of Nursing, indicating a pattern of incorrect MDS coding and documentation within the facility.
Plan Of Correction
1. The Minimum Data Set assessment for Resident 7 was modified to reflect the use of the pain medication. A Brief Interview for Mental Status (BIMS) observation was not completed during the look back period for Residents 33, 39 and 49. Thus, modifications of the MDS assessments could not be completed. The Minimum Data Set assessment for Resident 88 was modified to reflect the actual discharge location. 2. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the opening of the BIMS observation form associated with the assessment reference dates of the next 14 days of quarterly MDS assessments. She will ensure that the designated Interdisciplinary Team staff involved in the BIMS process are provided with the audit information to assure compliance of the observations. 3. The applicable members of the Interdisciplinary Team involved in the assessment process will be re-trained on the Resident Assessment Instrument (RAI) manual coding guidance for Section A discharge location, Section C BIMS and Section J pain management by the Regional Clinical Reimbursement Specialist or a designee. 4. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of five random residents' MDS assessments to ensure compliance with the coding of MDS Section A discharge location, Section C BIMS and Section J pain management twice weekly times two, weekly times two and monthly times two. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific medical needs. Resident 62, who was cognitively intact and required assistance for daily care, was diagnosed with Parkinson's disease and vascular dementia. Despite having physician's orders for medications to manage these conditions, there was no evidence of a care plan to address the care and treatment needs associated with his Parkinson's disease or dementia. Similarly, Resident 68, who was also cognitively intact and required assistance for daily care, was diagnosed with PTSD and had identified triggers. However, as of the survey date, there was no care plan developed to identify or address the resident's PTSD or his triggers. The Director of Nursing confirmed the absence of these care plans, acknowledging that they should have been developed.
Plan Of Correction
1. Resident 62 was discharged. The care plan for Resident 68 was updated. 2. The facility's Registered Nurse Assessment Coordinator and Social Worker, or designees, will audit the care plans of the in-house residents with diagnoses of post-traumatic stress disorder, dementia and Parkinson's Disease to assure they address these conditions. 3. The members of the Interdisciplinary Team involved in care planning will be re-trained on the care planning process by the Regional Clinical Reimbursement Specialist or a designee. 4. The Director of Nursing, or a designee, will conduct audits of five random residents' care plans related to the above diagnoses twice weekly times two, weekly times two and monthly times two. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect the specific care needs of three residents. For one resident, the care plan inaccurately indicated the use of antidepressant and antianxiety medications, which were not being administered according to the Medication Administration Record (MAR). The Director of Nursing confirmed that the resident should not have had a care plan for these medications. Another resident's care plan was not updated to reflect changes in transfer status and shower preferences, and it incorrectly included a plan for antipsychotic medication, which was not being administered. The Director of Nursing acknowledged these discrepancies. Additionally, a third resident's care plan was not updated when wound vac treatment was discontinued, despite new wound care orders being documented in the nurse's notes. The Director of Nursing confirmed that the care plan should have been updated to reflect the discontinuation of the wound vac. These deficiencies indicate a failure to maintain accurate and current care plans for residents, as required by facility policy and regulatory standards.
Plan Of Correction
1. The care plans for the in-house cited residents were updated. 2. The facility's Interdisciplinary Team staff responsible for care planning will audit the care plans of the in-house residents against the residents' current physician order sets. The care plans will be updated accordingly. 3. The members of the Interdisciplinary Team involved in care planning will be re-trained on the care planning process by the Regional Clinical Reimbursement Specialist or a designee. 4. The Director of Nursing, or a designee, will conduct audits of five random residents' care plans related to order changes twice weekly times two, weekly times two, and monthly times two. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Failure to Administer Pain Medication Prior to Wound Care
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice by not following physician's orders. The resident, who was cognitively impaired, required assistance for daily care, and was receiving hospice care, had specific orders for wound care and pain management. The orders included cleansing and dressing the resident's right foot daily and administering 15 mg of immediate-release morphine 30 minutes prior to wound care. However, the morphine was scheduled for administration at 8:00 a.m., while the wound care was scheduled to occur anytime between 6:00 a.m. and 6:00 p.m., leading to inconsistencies in pain management. On December 11, 2024, it was observed that the resident's wound care was performed at 10:22 a.m. without documented evidence of morphine administration 30 minutes prior, as ordered. An interview with the resident revealed that wound care was completed at varying times each day, depending on staff availability. The Director of Nursing confirmed the lack of documentation for the timely administration of pain medication before wound care, indicating a failure to adhere to the physician's orders.
Plan Of Correction
1. Immediate intervention completed. Medication and treatment time updated to reflect specific times of administration and completion. 2. The Interdisciplinary team will review pain medications with specific times as it relates to treatment/wound care. 3. Pain medications with specific times related to a treatment will be reviewed during morning clinical meeting to determine if the physician needs contacted related to the timing of order. The Director of Nursing/designee will educate licensed nursing staff including agency on pain medication and treatments related to residents with specific times of orders. Will discuss with physician as needed. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks then monthly for two months to ensure that physician orders are completed as ordered. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Address Significant Weight Loss in Residents with Feeding Tubes
Penalty
Summary
The facility failed to ensure timely physician notification and intervention for significant weight loss in two residents with feeding tubes. Resident 66, who is severely cognitively impaired and requires extensive assistance for daily care, experienced a 14-pound weight loss over 15 days. Despite this significant change, there was no documented evidence of interventions to prevent further weight loss or notification to the physician. The Director of Nursing confirmed that as of December 12, 2024, the weight loss had not been addressed by the dietician or physician. Similarly, Resident 78, who is cognitively intact and also requires assistance for daily care, experienced a 13-pound weight loss over 17 days. Like Resident 66, there was no documented evidence of any interventions or physician notification regarding the weight loss. The Director of Nursing confirmed that the weight loss for Resident 78 had not been addressed by the dietician or physician as of December 12, 2024. These deficiencies indicate a failure to adhere to the facility's policy on maintaining acceptable nutritional status and timely physician involvement.
Plan Of Correction
1. The facility cannot retroactively address the findings. 2. Weights completed. Those with significant changes to have completion of nutrition assessment with MD and responsible party notification. 3. Director of Nursing or Designee to educate nursing staff regarding weights and implementation of follow through documentation and notification. 4. Director of Nursing or Designee to complete weekly weight audits to ensure follow through of significant weight changes as well as the completion of interventions or re-evaluation of weights. Audits to be completed weekly for 4 weeks then monthly for 2 months. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident with chronic respiratory failure. The resident, who had moderate cognitive impairment and required assistance for care needs, was observed receiving oxygen therapy at four liters per minute on multiple occasions. Despite the care plan indicating the necessity of oxygen therapy, there was no documented evidence in the clinical records that a physician's order had been obtained for this treatment. This deficiency was confirmed through an interview with the Director of Nursing, who acknowledged the lack of documentation for the physician's order.
Plan Of Correction
1. An order for oxygen was obtained for resident 5. 2. The Interdisciplinary team will review progress notes and orders during the morning clinical meeting to determine if the oxygen orders were obtained on those residents that are using oxygen. An audit was completed 12/29 to make sure those residents using oxygen have physician orders. 3. Licensed Nursing staff educated on the process of monitoring those residents on oxygen have physician orders in the electronic record. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks, then monthly for two months on residents' rounds to make sure residents on oxygen have appropriate orders. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 62, who was cognitively intact and required assistance for daily care needs. The resident had a physician's order for a 10 mcg/hr Butran's patch to be changed every seven days for pain management. However, the Medication Administration Record (MAR) for December 2024 indicated that the Butran's patch was not available on December 4 or December 11, 2024, resulting in the resident not receiving the pain patch since November 27, 2024. This lack of availability led to the resident experiencing more pain than usual over the last two weeks, as confirmed during an interview with the resident on December 9, 2024. The facility's policy on pain management, dated January 14, 2019, required staff to implement a pain management program, including evaluation and re-evaluation for residents experiencing pain. Despite this policy, there was no documented evidence that nursing staff made efforts to provide effective pain management for Resident 62 when the pain patches were unavailable. An interview with the Director of Nursing on December 12, 2024, revealed that the pharmacy had an issue with the resident's insurance, delaying the delivery of the patches. Additionally, there was no evidence that alternative pain relief was offered to the resident during this period.
Plan Of Correction
1. The Director of Nursing contacted the pharmacy regarding resident 62 and the Butrans patch were delivered the same day. 2. Baseline audit of pain medication completed. 3. The Interdisciplinary team will review administration of pain medications during morning clinical meeting to determine pain medication effectiveness or need for further evaluation of treatment. The Director of Nursing /designee will educate licensed nursing staff including agency on the process for medication availability during a medication pass. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks, then monthly for two months, to ensure resident's pain medications are available or the physician has been notified to obtain further recommendations. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for three nurse aides, as required by their hire dates. Specifically, the evaluations for Nurse Aide 3, Nurse Aide 4, and Nurse Aide 5 were due on July 1, 2024, but as of December 12, 2024, there was no documented evidence that these evaluations had been conducted. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of evidence for the completion of the required evaluations.
Plan Of Correction
1. Performance evaluation completed on Nurse Aide 3, Nurse Aide 4 and Nurse Aide 5. 2. An audit was done to monitor the completion of Nurse Aide evaluations. Hire dates will be reviewed monthly by the Director of Nursing. 3. The Nursing Home Administrator will educate RN Supervisors and the Director of Nursing on the evaluation process for Nurse Aides. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Nursing Home Administrator or designee for four weeks then monthly for two months on the completion of Nurse Aide performance evaluation. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Document Controlled Medication Disposal
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident, identified as Resident 89. The facility's policy on controlled substance disposal required that the destruction or disposal of such drugs be documented on the controlled medication count sheet and signed by a registered nurse and a witnessing licensed professional. However, there was no documentation to indicate that Lorazepam, a controlled medication prescribed to Resident 89, was destroyed or disposed of according to the facility's policy. Resident 89, who was cognitively impaired and had a diagnosis of Metabolic Encephalopathy, was prescribed Lorazepam for anxiety and restlessness. Despite the physician's order for Lorazepam to be administered every four hours as needed, the Medication Administration Record for October 2024 showed no documentation of the medication being administered. Furthermore, after Resident 89 ceased to breathe, there was no record of the controlled drug count or documentation of the medication's destruction. The Director of Nursing confirmed the absence of documentation for the destruction or disposal of Lorazepam.
Plan Of Correction
1. The Pharmacy confirmed Lorazepam was not sent for Resident 76. No medication disposition for destruction would be indicated for a medication not received by facility. 2. A baseline audit was completed to make sure accountability for controlled medications is complete. 3. The Director of Nursing/designee will educate nursing staff including agency on the process of maintaining accountability for controlled medications with corresponding documentation. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks then monthly for two months to make sure accountability is maintained for controlled medications. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Address Pharmacy Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a pharmacy recommendation for a resident. A quarterly Minimum Data Set (MDS) assessment for a resident, dated November 3, 2024, indicated that the resident was cognitively intact, required assistance for daily care needs, received routine and as-needed pain medication, and had a diagnosis of diabetes. A pharmacy Medication Regimen Review (MRR) recommendation, dated July 7, 2024, suggested that the physician consider ordering Senna, a stimulant laxative, once daily at bedtime while monitoring for signs and symptoms of constipation. However, there was no documented evidence that the physician reviewed or addressed this recommendation. An interview with the Director of Nursing on December 12, 2024, confirmed the lack of documented evidence that the physician addressed the pharmacy MRR for the resident, which should have been done according to the facility's policies and procedures.
Plan Of Correction
1. Physician to review medication recommendation with resident. 2. A baseline audit was completed for pharmacy recommendations. 3. The Director of Nursing/designee will educate nursing staff including agency on the process of following through with pharmacy recommendations. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks, then monthly for two months to ensure follow through of pharmacy recommendations. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Repeated Deficiencies in QAPI Committee's Effectiveness
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys throughout 2024. These deficiencies included failure to provide notice of bed hold policy, timely completion of comprehensive assessments, development of resident care plans, and provision of activities of daily living care to dependent residents. Additionally, the facility was cited for inadequate quality of care, improper feeding tube management, failure to maintain accurate accounts of controlled medications, improper labeling and storage of drugs and biologicals, and failure to prepare and follow menus to meet residents' needs. Despite developing plans of correction that included audits and reporting results to the QAPI committee, the facility consistently failed to maintain compliance with regulations. The repeated citations under various F-tags, such as F625, F636, F656, F677, F684, F693, F755, and F803, indicate that the QAPI committee's efforts were ineffective in ensuring ongoing compliance with nursing home regulations. The deficiencies were identified in surveys conducted on several dates, including January 18, February 23, June 19, September 19, and October 21, 2024, with the most recent survey ending on December 12, 2024.
Plan Of Correction
The center recognizes the need for the implementation of and the maintenance of effective Quality Assessment and Assurance/ Quality Assurance and Process Improvement activities to sustain system compliance. Current residents and new admissions have the potential to be affected. The facility Quality Assurance and Process Improvement committee will conduct a root cause analysis to determine steps to implement and sustain systemic correction as it relates to the cited deficiencies. To prevent recurrence, the Nursing Home Administrator and Director of Nursing will be reeducated on the policy for Quality Assessment and Assurance/Quality Assurance and Process Improvement including sustaining systemic correction by the Regional Director of Clinical Services or designee. To monitor and maintain compliance, the facility Quality Assurance and Process Improvement committee will conduct a weekly review of plan of correction audits and make recommendations as needed.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to ensure that essential equipment in the main kitchen was in safe operating condition. During an observation, it was noted that the steamer in the kitchen had a sign indicating it was broken and should not be used. An interview with the Corporate Dietary Manager revealed that the steamer had been non-functional for the entire duration of her one and a half years with the company, and it was deemed irreparable. The facility was in the process of ordering a new steamer. The Nursing Home Administrator confirmed that the steamer was not functioning and that the facility was obtaining price quotes for a replacement.
Plan Of Correction
1. The facility is in the process of obtaining quotes for repair or replacement. Other equipment is being used to prepare food. 2. The contracted Dietary Manager/designee will report equipment in need of repair and maintenance to the maintenance director and NHA. 3. Dietary staff are educated to report concerns as needed. 4. The contracted Dietary Manager or designee will monitor operating equipment weekly for 4 weeks, then monthly for 2 months. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation of a fall incident involving a resident, which is a violation of their policy for protection from abuse, neglect, or exploitation. The policy mandates immediate notification and investigation of all alleged violations, including falls, to rule out abuse or neglect. However, there was no documented evidence of an investigation being initiated following the fall of Resident 39, who was found on the floor in his room. This oversight was confirmed during an interview with the Director of Nursing, who was unable to locate an incident report or investigation related to the fall. Resident 39, who has flaccid hemiplegia affecting his left dominant side and is dependent on staff for transfers, was found on the floor between his bed and the window wall. The resident's quarterly Minimum Data Set assessment indicated that he was understood and able to understand others, highlighting the need for careful monitoring and support. Despite the facility's fall management policy requiring a review by an interdisciplinary team and updates to the care plan, there was no evidence that these steps were taken following the incident.
Plan Of Correction
1. Resident 39 who is understood and understands. Upon return demonstration, resident 39 indicated to licensed nursing staff he was sliding from chair and nursing assistant attempted to prevent fall. Resident 39 signed statement indicating he was sliding from chair and nursing assistant was attempting to prevent a fall. 2. A review of incident reports for past two weeks will be reviewed to ensure a thorough investigation was completed. 3. The Interdisciplinary team will review with report of falls during morning clinical meeting to determine if further information is needed to complete fall investigation. The Director of Nursing/designee will re-educate licensed nursing staff including agency nurses on the fall management process including completion of report/investigation at time of fall. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks to make sure the incidents of falls have incident report or investigation. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Safely Transfer Resident
Penalty
Summary
The facility failed to safely transfer a resident who required assistance from staff for transfers, leading to a deficiency. The resident, who had flaccid hemiplegia affecting his left dominant side, was dependent on staff for chair/bed-to-chair transfers. Physician's orders specified that the resident be transferred with the assistance of two staff members. However, an incident occurred where the resident was found on the floor in his room after being transferred by only one staff member, Nurse Aide 2. The resident was not injured and was assisted back to bed using a mechanical lift. The incident was further clarified through a witness statement from Nurse Aide 2, who attempted to transfer the resident alone when she found him at the tip of his chair about to fall. She tried to put him in bed, but his pants got stuck, and she was unable to unhook him, leading her to lower him to the ground. An interview with the resident confirmed that he sometimes was transferred with one staff member and sometimes with two, and he expressed a preference for two staff members for comfort. The Director of Nursing's interview revealed that the resident was not transferred according to the physician's orders because Nurse Aide 2 felt the resident was at risk of falling from his chair.
Plan Of Correction
1. The facility cannot retroactively address the incident. Resident 7 was not injured. 2. Residents reviewed to confirm their transfer status. The Interdisciplinary team will review changes in transfer status during morning clinical meeting to make sure the information is updated in the care plan. 3. The Director of Nursing or designee will educate the Nursing staff including agency will be educated on resident transfer status and asking for assistance if needed. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks then monthly for two months on residents transfers to determine if the transfer status is being followed per order. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Notify of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident, their responsible party, and the Ombudsman regarding the reason for the resident's transfer to the hospital. This deficiency was identified during a review of clinical records and staff interviews. The resident in question was cognitively intact and required assistance for daily care needs, as indicated by a quarterly Minimum Data Set assessment. On October 12, 2024, the resident experienced a large, liquid, and brown emesis, prompting the physician to be notified and the resident to be transferred to the hospital. However, there was no documented evidence that a written notice of the transfer was provided to the resident's responsible party or the Ombudsman. The Director of Nursing confirmed the lack of written notification during an interview on December 10, 2024.
Plan Of Correction
1. The facility cannot retroactively address the transfer to the hospital. Resident 24 returned to the facility after their hospitalization. No residents have been refused re-admission to the facility. 2. The Interdisciplinary team will review hospital transfers during morning clinical meetings to make sure the resident/responsible party received written notice that includes the reason for transfer. The Social Service Director or designee will complete missed forms upon discovery. 3. RN Supervisors including agency, Social Services, and Case Manager will be educated on the facility's policy for written notification that includes the reason for the transfer at the time of transfer. 4. The Administrator or designee will audit hospital transfers weekly for four weeks, then monthly for two months for documentation providing written notifications with the reason for hospitalization. Identified issues will be addressed when found. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Notify Resident of Bed-Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to notify the resident or the resident's representative in writing about the bed-hold policy during a transfer to the hospital. This deficiency was identified for one resident, who was cognitively intact and required assistance for daily care needs. The resident experienced a medical event involving large, liquid, and brown emesis, leading to a hospital transfer. Despite the facility's policy to track Medicaid bed hold days and notify appropriate parties, there was no documented evidence that the resident or their responsible party was informed of the bed-hold policy at the time of transfer. The Director of Nursing confirmed the absence of such documentation, acknowledging that a bed hold notice should have been issued.
Plan Of Correction
1. Unable to retroactively provide bed hold for Resident 24. 2. The Interdisciplinary team will review hospital transfers during morning clinical meeting to determine if the bed hold policy was communicated for residents transferred to the hospital. The Social Service Director or designee will complete missed forms upon discovery along with re-education to appropriate staff member. The Director of Nursing/designee will re-educate the Registered Nurse Supervisors including agency, Social Services and Case Manager on the facility's bed hold policy. 3. To maintain and monitor compliance, a weekly audit will be conducted by the Nursing Home Administrator or designee for four weeks and monthly for 2 months on residents transferred to the hospital to determine if the bed hold policy was communicated and documented. 4. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Document Medication Disposition for a Resident
Penalty
Summary
The facility failed to document the disposition of medications and the quantity of drugs disposed for one of the three closed clinical records reviewed, specifically for Resident 89. According to the facility's policy for discharge medications, a nurse is required to complete a medication disposition record, which should include the amount or quantity of each medication and the nurse releasing the medication. However, a nursing note for Resident 89 indicated that the resident ceased to breathe, and there was no documented evidence in the clinical record of the disposition of medications or the quantity upon the resident's death. An interview with the Director of Nursing confirmed the absence of this documentation, acknowledging that it should have been recorded.
Plan Of Correction
1. The facility is unable to retroactively correct the disposition of medications for resident 89. 2. Review will be completed of residents discharged 12/15-12/31/24 from the facility or discharged from the hospital to ensure a medication disposition was completed and identified issues will be corrected. 3. The facility discharges will be reviewed at morning clinical meeting to ensure the medication dispositions have been completed. Director of Nursing or designee will educate the RN Supervisors including agency on the medication disposition practice and their responsibility to document the disposition when there is a discharge from the facility. 4. The Director of Medical Records or designee will audit medication disposition on facility discharge weekly for four weeks then monthly for month. Identified issues will be addressed when found. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.
Failure to Follow Planned Menu for Resident's Meal
Penalty
Summary
The facility failed to adhere to its planned menu for a resident's breakfast meal on October 21, 2024. The written menu specified that the resident was to receive an egg, bacon, and cheese croissant sandwich along with two bowls of hot cereal. However, observations revealed that the resident was served scrambled eggs with cheese, two bowls of cold cereal, and two pieces of toast instead. The resident expressed that this was a recurring issue and had previously informed the kitchen staff about the discrepancies. The Corporate Dietary Manager confirmed that the menu and tray ticket were not followed as intended, acknowledging the error in meal preparation.
Failure to Maintain Clean and Homelike Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident 3, who was cognitively intact and required assistance with daily care needs due to multiple sclerosis. During an observation, it was noted that Resident 3's wheelchair, which was provided by physical therapy, had a heavy accumulation of removable dust and debris on the wheels and metal supports. Additionally, there was a white, stuck-on substance under the wheelchair seat cushion, and the seat cushion itself was dirty. The top of the seat backrest was torn and shredded in several places. Interviews with the physical therapist and the nursing home administrator confirmed the poor condition of the wheelchair. The physical therapist acknowledged the heavy accumulation of dust and debris, the presence of the white substance, and the torn backrest, describing the chair as filthy. The nursing home administrator also confirmed that the wheelchair should not have been in such a state and should have been cleaned, indicating a failure to adhere to the facility's policy on cleaning and disinfection of resident care equipment.
Failure to Conduct Neurological Checks and Administer Medication
Penalty
Summary
The facility failed to adhere to its policy regarding neurological checks and medication administration for a resident who experienced an unwitnessed fall. According to the facility's policy, neurological checks should be conducted by a licensed professional for residents who have sustained any form of head trauma or change in neurological condition. However, there was no documented evidence that these checks were performed for the resident following her fall, as confirmed by the Director of Nursing. The resident, who was cognitively impaired and required assistance with care needs, was found sitting upright on the right side of the bed after the fall, but no injuries were noted. Additionally, the facility did not follow physician's orders for medication administration for the same resident. The Medication Administration Record showed no documentation of medication being administered from the afternoon of September 13 through the morning of September 16. The Director of Nursing confirmed the lack of documentation and was unable to verify whether the medication was given as ordered. An LPN stated that she administered medication during this period but could not explain the absence of documentation.
Call Bell System Malfunction in North Hall
Penalty
Summary
The facility failed to ensure that the call bell system was in full working order for residents on the North hall. According to the facility's policy, the call bell system should function properly throughout the facility. However, an interview with a nurse aide revealed that while the light above a resident's room would activate when the call bell was pressed, the sound was not activated. Additionally, the central call light at the nurse's station remained on continuously, making it difficult for staff to determine when a call bell was ringing if they were in another hallway. The nurse aide mentioned that maintenance had been informed of the issue. Observations in other halls showed that the call bell system functioned correctly, with both the light and sound activating and deactivating appropriately. The Director of Maintenance was initially unaware of the problem and had no record of it being reported. Upon investigation, he attempted to fix the issue by resetting the buzzer box, which resulted in the call bell tone remaining on despite no call lights being activated. The Director of Maintenance later reported that the issue was resolved by replacing a battery in a resident's bathroom call system. The Director of Nursing confirmed that the call bell system in the North hall was not functioning properly as it should have been.
Failure to Follow PICC Line Care Orders
Penalty
Summary
The facility failed to ensure that physician's orders were followed for the care of a Peripherally Inserted Venous Catheter (PICC) for a resident. The facility's policy required that dressings for PICC lines be changed weekly or as needed per physician's orders. The resident, who was cognitively intact and required assistance from staff for care, had a PICC line and received intravenous medication. Physician's orders specified that the PICC line dressing and cap should be changed weekly on Mondays. However, there was no documented evidence in the resident's clinical record indicating that the PICC line dressing and cap were changed on the specified dates. An interview with the Director of Nursing confirmed that the PICC dressing should have been changed weekly but was not.
Medication Error: Overdose of Lacosamide
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Physician's orders for the resident, dated June 25, 2024, specified that the resident was to receive one 200 mg tablet of lacosamide, a medication for seizures, twice a day. However, on July 19, 2024, a nurse administered two 200 mg tablets instead of the prescribed one. This error led to the resident being sent to the emergency room for observation. The resident was admitted to the hospital on July 20, 2024, due to vomiting after receiving the incorrect dosage of lacosamide. The resident returned to the facility on July 23, 2024, after being discharged from the hospital. An interview with the Director of Nursing confirmed that the resident should have only received one 200 mg tablet of lacosamide, highlighting the medication error that occurred.
Failure to Develop Baseline Care Plan for Resident's Immediate Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident was admitted with orders for intravenous antibiotic therapy for cellulitis and treatments for multiple wounds and ulcers on the lower extremities. Despite these specific medical needs, there was no documented evidence of a baseline care plan addressing these requirements. The deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the resident did not have a baseline care plan for the necessary intravenous antibiotic therapy and wound care treatments. This oversight was identified during a review of the facility's policies, clinical records, and staff interviews, highlighting a lapse in meeting the resident's immediate care needs as per the facility's policy.
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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