Hopkins Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wyncote, Pennsylvania.
- Location
- 8100 Washington Lane, Wyncote, Pennsylvania 19095
- CMS Provider Number
- 395342
- Inspections on file
- 31
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 61
Citation history
Health deficiencies cited at Hopkins Center during CMS and state inspections, most recent first.
A nurse aide identified a bruise on a resident with severe cognitive impairment and promptly informed the assigned LPN, who failed to report the injury of unknown origin to facility administration as required by policy. This resulted in a delay in notifying the facility of a potential abuse allegation.
A deficiency occurred when residents were not offered nourishing snacks at bedtime, resulting in a 15-hour gap between the evening meal and breakfast. Although dietary staff prepared and delivered snacks, nursing staff did not consistently offer them to residents, leaving individuals hungry during the night.
A resident did not have a full privacy curtain in their room, resulting in inadequate privacy during morning care. For several months after admission, no curtain was provided, and later only a partial curtain was installed, which did not fully cover the resident's bed. This lack of privacy required the resident to ask a roommate's guests to leave during care, as confirmed by staff and direct observation.
A resident's bathroom sink repeatedly became clogged and leaked over a two-month period, causing standing water and water damage to both the bathroom floor and the ceiling of the conference room below. Despite notifications to maintenance staff, the issue persisted, resulting in an environment that was not clean, safe, or comfortable for residents and staff.
Two residents did not have complete care plans addressing their specific needs: one with bilateral below-knee amputations developed a pressure injury linked to improper prosthesis fit, and the care plan lacked interventions for skin checks and prosthesis evaluation; another resident with legal blindness had no care plan interventions for communication related to their condition, as confirmed by nursing staff.
LPNs failed to follow professional standards during medication administration by not verifying resident identity using full name, date of birth, or armband, and by not ensuring proper administration of medications. There was also a lack of documentation and assessment for self-administration of medication.
A resident with multiple medical conditions and at risk for pressure ulcers did not have their protein intake adjusted according to facility policy and professional standards. The nutrition assessment and dietary plan provided less protein than required, and there was no documented re-assessment after the resident was identified as at risk. The dietitian confirmed the resident should have received a higher protein amount.
A nurse administered a prescription Omega-3 capsule to a resident by cutting it open and mixing the contents with applesauce, contrary to professional standards and the medication's instructions, which require the capsule to be swallowed whole. The DON confirmed this was not appropriate and that a different form should have been used if swallowing was an issue.
Surveyors observed multiple medication administration errors, including improper administration of eye drops, incorrect handling of a fish oil capsule, and failure to apply lidocaine patches as ordered. LPNs did not follow physician orders or facility protocols, resulting in a medication error rate of 14.81%.
Staff failed to follow infection prevention protocols, including not wearing required PPE when providing care to a resident with a wound under Enhanced Barrier Precautions, and not performing hand hygiene between medication administration and resident care. An LPN also did not ensure proper medication administration or complete one resident's care before moving to another.
Two residents were exposed to unsafe and uncomfortable room temperatures due to malfunctioning air conditioning units, inconsistent temperature monitoring, and lack of clear maintenance responsibilities. Staff interviews and documentation revealed that temperature checks were not performed on all shifts, and there was no evidence that residents were offered room changes when high temperatures were identified.
A resident with bipolar disorder, alcohol dependence, and chronic pain was issued a discharge notice due to non-payment, but the care plan was not updated to reflect this change. Despite social services working on housing placement, the care plan still indicated long-term care placement, highlighting a failure in timely care plan revision.
The facility did not maintain the required staffing ratios for nursing assistants (NAs) on several occasions. Specifically, the facility failed to meet the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift on four out of seven days reviewed. This occurred with a census of 98 to 99 residents, affecting various shifts on different days.
The facility did not meet the required LPN staffing ratios on five out of seven days reviewed. With resident censuses of 98 and 99, the facility failed to provide the mandated number of LPNs per residents during day, evening, and overnight shifts, as identified through staff schedules and interviews.
A facility failed to develop a comprehensive care plan for a resident with alcohol dependency, resulting in multiple incidents of intoxication and hospitalization. Despite the resident's diagnosis and observed behaviors, staff were unaware of the condition, and a care plan was not implemented until after hospitalization.
A resident with alcohol dependency was found intoxicated multiple times, leading to hospitalization with a high blood alcohol level. The facility failed to provide appropriate supervision and did not develop a care plan addressing the resident's alcohol dependency, resulting in actual harm.
The facility did not complete annual performance reviews for five nurse aides, as required by personnel policies. Employees hired between 2004 and 2023 did not receive reviews in 2024 or 2025. The DON confirmed the oversight, violating 28 Pa. Code 201.19(2).
The facility failed to implement proper infection control measures for residents under special contact and droplet precautions. A resident with COVID-19 was not provided with adequate PPE by staff, and enhanced barrier precautions were not enforced for another resident receiving wound care. Additionally, staff did not follow PPE protocols for two residents, one of whom tested positive for COVID-19, indicating significant deficiencies in the facility's infection prevention program.
The facility did not provide necessary Medicare and Medicaid coverage notifications to three residents, failing to issue both a Notification of Medicare Non-Coverage (NOMNC) and an Advanced Beneficiary Notice of Non-Coverage (ABN). This was confirmed through documentation review and staff interviews, highlighting a compliance lapse.
The facility failed to provide operable call bells for two residents. One resident's call bell was found with a severed cord, rendering it non-functional, while another resident's adaptive call bell had been broken and remained unrepaired. Staff confirmed the issues, and parts for the specialty call bell were ordered.
The facility failed to maintain a sanitary and comfortable environment in four rooms on the third floor, with issues such as food crumbs, strong urine odor, and scattered debris observed. These findings were confirmed with a housekeeping employee, indicating a lapse in maintaining required sanitary conditions.
A resident with multiple complex medical conditions who required two-person assistance for care was left unattended by a nurse aide during bed mobility, contrary to the care plan and facility policy. The resident fell from bed during care, sustaining a left humerus fracture, T11 wedge compression fracture, and right shin contusion, resulting in hospitalization and further medical intervention.
The facility failed to ensure residents and their emergency contacts were properly informed and involved in care plan meetings. A resident with dementia did not have their emergency contact invited to a care plan meeting, despite requests for updates. Another resident did not have required meetings conducted, and a third resident had not had a meeting since May. The social worker admitted to late or missing meetings, and the Regional Nurse confirmed the lack of evidence for timely meetings.
The facility failed to maintain an effective pest control program, resulting in persistent pest issues. Despite a contract for bi-monthly pest control services, observations and reports indicated ongoing problems with roaches and other bugs in various rooms. Contributing factors included clutter and poor sanitation in resident rooms. Management acknowledged that recommendations from the pest control company were not implemented.
A facility failed to notify a resident and their emergency contact of a room change, as required by policy. The resident, with multiple health conditions including dementia, was moved from the second to the third floor without prior written notification. Staff interviews revealed inconsistent reasons for the move, and no documentation was provided to the resident or their emergency contact.
A resident with dementia was discharged from an LTC facility without necessary medication prescriptions due to a failure in the discharge planning process. The resident's emergency contact reported the issue, and the Medical Director was unaware of the discharge, leading to a delay in providing the prescriptions.
A resident with diabetes, hypertension, and bipolar disorder was involved in a verbal altercation with a nurse after requesting medication post-smoke break. The facility failed to conduct a thorough investigation or report the incident timely, despite identifying the nurse as the perpetrator. The deficiency lies in the lack of comprehensive investigation and timely reporting.
A facility failed to notify the Department of Health of a verbal altercation between a registered nurse and a resident in a timely manner. The incident occurred but was not reported to the Event Reporting System until later, and the report lacked specific details about the event. The Nursing Home Administrator confirmed this oversight during an interview.
A facility failed to provide a functional heating unit in a resident's room, where the unit was used for storage instead. A resident reported that a temporary portable heating unit emitted only cold air. The Director of Maintenance confirmed that an air conditioner was mistakenly installed and not connected. An order for new units was placed months prior, but no delivery date was available, and two portable heating units were unused.
The facility's pest control program was ineffective, with multiple reports of pests like mice, roaches, and gnats not being addressed by the contracted pest control company. Despite bi-monthly services, pest issues persisted from May to September 2024, with specific incidents on the 2nd floor not being serviced. Interviews revealed a lack of recommendations from the pest control company to improve the situation.
A resident with diabetes went on a leave of absence without proper education on insulin administration and blood sugar monitoring, leading to an immediate jeopardy situation. The facility failed to locate the resident when they did not return as scheduled, and staff did not follow protocol for medication education and LOA procedures.
The facility failed to update the PASARR for three residents with mental health diagnoses, including schizophrenia, bipolar disorder, and depression. The PASARRs did not reflect the residents' current conditions, as required by federal and state regulations. An interview with the social worker confirmed the oversight.
The facility failed to conduct Level 2 PASARR evaluations for two residents with mental disorders. One resident had a history of multiple mental health conditions, yet no Level 2 evaluation was documented. Another resident, with serious mental illness, was incorrectly screened as having no mental health conditions, resulting in no further evaluation. The director of social services confirmed these deficiencies.
The facility failed to maintain an effective antibiotic stewardship program, lacking a system to monitor antibiotic usage over seven months. Monthly reports were insufficient, missing critical information such as antibiotic duration, lab results, and infection details. Interviews confirmed no documentation evidence of an effective program, and the facility could not provide requested policies or evidence of surveillance and tracking.
The facility did not adhere to its abuse prohibition policy by failing to conduct an FBI fingerprint check for a newly hired LPN, Employee E8, who was hired from out of state. This oversight was identified during a review of personnel records and confirmed by the Administrator.
A resident with dementia and other medical conditions attempted to elope and sustained a head injury after a combative incident with a maintenance assistant. The facility's investigation was incomplete, lacking interviews with nursing staff and timely reporting to the State Survey Agency. The resident was hospitalized and later discharged.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific care needs. A resident with dementia was on antipsychotic medication without a care plan, another with stroke-related impairments lacked a restorative nursing program, and a third frequently refused care without documented interventions or education. These issues were identified through observations, clinical record reviews, and staff interviews.
The facility failed to provide required supervision for two residents, leading to deficiencies in care. A resident with dysphagia was left unsupervised during meals despite orders for 1:1 supervision, while another resident with a history of falls and aggressive behavior was left unattended, resulting in a fall and hip fracture. These failures were confirmed by the facility's DON and administrator.
A facility failed to implement restorative programs for a resident with limited range of motion (ROM) due to a stroke. Despite recommendations from therapy discharge summaries for a restorative ROM program and ambulation, the resident reported not receiving these services, and staff confirmed they did not perform the exercises. There was no documentation of the program's implementation, indicating a deficiency in nursing services.
A resident with severe cognitive impairment and benign prostatic hyperplasia did not receive two scheduled doses of Cephalexin for a urinary tract infection due to the medication being unavailable. The facility failed to document informing the physician of the missed doses, requesting alternate treatment, or monitoring the resident. There was also no documentation of efforts to obtain the medication or reasons for its unavailability.
A resident with multiple health conditions, including insulin-dependent diabetes, was placed in immediate jeopardy due to the facility's failure to manage their leave of absence effectively. The resident left with insufficient medication and without proper education on managing their condition, leading to a lapse in critical medication administration. The facility did not locate the resident or notify the physician when the resident extended their leave, resulting in a significant delay in ensuring the resident's safety.
A facility failed to develop a comprehensive care plan for a resident with a PICC line receiving IV antibiotics for sepsis. Despite physician orders for cefazolin infusions, there was no documentation in the care plan addressing the resident's IV therapy needs. The DON confirmed the absence of a care plan for the PICC line and IV infusions.
A facility failed to document IV catheter site dressing changes for a resident with a PICC line, as required by physician orders and facility policy. The resident, admitted with pneumonia and septicemia, had orders for weekly dressing changes with measurements of external catheter length and arm circumference. However, on two occasions, the necessary documentation was missing, and the Director of Nursing confirmed the lack of records.
The facility failed to ensure nursing staff had the necessary competencies for medication administration and infusion therapy, resulting in a medication error where an IV medication intended for one resident was administered to another. A graduate nurse, without documented competency evaluations, administered the wrong medication, while an agency LPN responsible for orientation lacked documented competencies. The facility lacked a process for evaluating skills competencies, contributing to the error.
A medication error occurred when a new nurse, under orientation, administered an IV medication intended for another resident to a resident with pneumonia and septicemia. The error happened due to improper verification and supervision, despite the facility's policy requiring thorough checks. The resident experienced no negative effects, and the other resident received their medication as prescribed.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when a nurse aide discovered a bruise with red and purple discoloration on a resident's left hand while providing care. The resident, who had diagnoses of chronic obstructive pulmonary disease and vascular dementia and was documented as severely cognitively impaired, exhibited pain and would not allow the aide to touch the affected area. The nurse aide immediately reported the injury to the assigned LPN, who observed the bruise and attributed it to possible poor circulation. However, there was no documented evidence that the LPN reported this injury of unknown origin to facility administration as required by facility policy. Facility policy mandates that any incident or injury of unknown origin be reported immediately to a supervisor, who must then notify the administrator. The failure of the LPN to escalate the report of the resident's injury resulted in a delay in the facility being made aware of a potential abuse allegation. This lapse was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the required reporting procedures were not followed when the bruise was initially found.
Failure to Provide Bedtime Snacks Between Evening Meal and Breakfast
Penalty
Summary
The facility failed to ensure that nourishing snacks were provided to residents when there was a 15-hour gap between the evening meal and breakfast on all three nursing units. According to the facility's policy, bedtime snacks are to be provided to all residents, with the dining services department responsible for assembling and delivering snacks to each unit, and nursing services responsible for offering these snacks to residents. However, interviews with residents during a council meeting revealed that snacks were not being offered at bedtime, and residents reported feeling hungry later in the evening after eating dinner at 4:45 p.m. Further interviews with dietary and nursing staff confirmed that while night snacks were prepared and delivered by dietary staff, it was unclear whether nursing staff were actually offering them to residents. The established meal schedule showed that dinner was served as early as 4:45 p.m. and breakfast was not offered until 7:45 a.m. the next day, resulting in a 15-hour interval without a substantial meal or snack. This failure to provide snacks as required by policy and resident needs was observed on all three nursing units.
Failure to Provide Adequate Privacy Curtain During Resident Care
Penalty
Summary
The facility failed to maintain personal privacy for one resident during the provision of morning care. On August 4, 2025, while maintenance staff were addressing a plumbing issue in a nearby conference room, it was observed that the privacy curtain in the resident's room only covered a quarter of the bed, leaving the resident exposed during care. The resident reported that for the first nine months of admission, no privacy curtain was provided, and five months prior to the observation, only half of a curtain was installed, which still did not provide adequate privacy. The resident stated that when a roommate had guests and care was being provided, the lack of a full curtain required the resident to ask guests to leave to maintain privacy. An observation with the Administrator confirmed the lack of a full privacy curtain in the room, resulting in insufficient privacy during care. These findings were based on a review of facility policies, staff interviews, and direct observations, and were determined to be noncompliant with 28 Pa. Code 201.29(a) regarding resident rights.
Repeated Plumbing Failures Lead to Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment on the second-floor nursing unit, as evidenced by repeated plumbing issues in a resident's bathroom. On multiple occasions, the sink in a specific room became clogged and overflowed, causing standing water on the bathroom floor and leaks into the first-floor conference room below. These incidents were directly observed by surveyors and reported by a resident, who stated that the problem had recurred three to four times over the past two months and that maintenance staff had been notified. Staff interviews confirmed that the sink leak was an ongoing issue, resulting in repeated water damage to both the bathroom and the conference room ceiling. The administrator acknowledged the recurring bathroom leak.
Failure to Develop Comprehensive Care Plans for Residents with Prosthetic and Communication Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with bilateral below-knee amputations and a history of peripheral vascular disease, the clinical record showed the development of a stage 2 pressure injury on the left knee, which the resident attributed to a prosthesis being too tight. Despite the facility's policy requiring routine inspection of prosthetic devices and skin checks at contact points, the care plan did not include interventions for skin checks before or after wearing the prosthesis, nor did it address evaluating the fit and function of the prosthetic devices. This omission was confirmed by the lead wound care nurse, who acknowledged that these interventions were not included in the resident's care plan. Another resident, admitted with a diagnosis of legal blindness, did not have a care plan that addressed communication needs related to their visual impairment. Interviews with the Director of Nursing and the Regional Nurse confirmed that there were no care plan focuses, interventions, or goals documented for the resident's legal blindness. These findings demonstrate that the facility did not complete comprehensive care plans to meet the specific needs of these residents as required.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice during three observed medication administrations. In each instance, the LPNs did not verify the resident's first and last name, date of birth, or check the resident's armband prior to administering medications, as required by the five rights of medication administration. Specifically, one LPN prepared and administered medication to a resident without confirming their identity, and then interrupted the process to take another resident's vital signs before completing the initial medication administration. The LPN also did not ensure that the resident was administering eye drops as ordered by the physician. Additionally, there was no documented evidence that the resident had a physician's order for self-administration of medication, nor was there an assessment or care plan developed for medication self-administration. Another LPN also failed to verify a resident's identity before administering medication, only calling the resident's first name. Staff interviews confirmed that the required verification steps were not followed during these medication administrations.
Failure to Adjust Protein Intake for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to modify and implement appropriate protein interventions for a resident who was at risk for developing pressure ulcers. According to the facility's policy, residents at risk for pressure ulcers should receive 1.2g/kg of protein. However, the nutrition assessment for the resident prescribed only 1.0g/kg, and the dietitian documented a daily protein prescription of 86 grams based on this lower factor. The resident's Braden Scale assessment indicated a risk for pressure ulcers, but there was no documented evidence that the resident's protein needs were re-assessed after this risk was identified. The resident involved had multiple medical conditions, including aphasia, obesity, dysphasia, multiple sclerosis, and hemiplegia. Despite these complex needs and the identified risk for pressure ulcers, the facility did not update the resident's nutritional plan to align with current professional standards and the facility's own policy. The registered dietitian confirmed that the resident should have received at least 1.2g/kg of protein, but this adjustment was not made or documented.
Improper Administration of Prescription Omega-3 Capsule
Penalty
Summary
A deficiency was identified when a nurse administered a prescription Omega-3 fatty acid capsule to a resident by cutting open the capsule and mixing its contents with applesauce, rather than administering it whole as required by professional standards and the medication's prescribing information. Observation revealed that some of the medication remained in the capsule shell after this process. The physician's order specified that the capsule should be given by mouth once daily, and drug information indicated that the capsule should not be broken, crushed, dissolved, or chewed. The Director of Nursing confirmed that the medication should not have been opened and that an alternative form should have been provided if the resident was unable to swallow the capsule whole.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations and record reviews involving three residents during medication administration. One LPN administered eye drops to a resident but did not complete the medication administration before attending to another resident's vital signs. The nurse also failed to ensure the resident was administering the eye drops correctly as ordered by the physician, and there was no documentation of an order or assessment for self-administration of the medication. Additionally, another LPN administered a fish oil capsule to a resident by cutting it open and mixing the contents with applesauce, contrary to the physician's order and drug instructions, which specified the capsule should be swallowed whole. Observation revealed that some medication remained in the capsule shell after administration. For another resident, the LPN removed and applied lidocaine patches to the resident's knees instead of the lower back as ordered, and did not follow the prescribed wearing schedule. The nurse, who was from an agency and unfamiliar with facility protocols, could not provide further details regarding the administration. These actions resulted in a medication error rate of 14.81%, significantly exceeding the acceptable threshold.
Failure to Follow Infection Control and Medication Administration Protocols
Penalty
Summary
The facility failed to implement proper infection prevention and control techniques on the second-floor nursing unit and during two observed medication administration passes. On one occasion, a nursing assistant provided care to a resident with a wound, who had Enhanced Barrier Precaution (EBP) signage posted on the door, without wearing any personal protective equipment (PPE) as required by facility policy. Additionally, there was no appropriate disposal container for PPE inside the resident's room. Interviews with staff revealed a lack of awareness regarding the reason for the EBP signage, and the infection preventionist confirmed that staff were not consistently using EBP gowns when providing care to the resident. The resident also reported that this was the first time a nursing aide had worn a PPE gown during care, indicating a pattern of non-compliance with EBP protocols. During medication administration, an LPN failed to complete one resident's medication pass before moving to another resident to take vital signs, and did not ensure the correct administration of eye drops as ordered by the physician. The LPN also did not perform hand hygiene after administering medication to one resident and before providing care to another, nor after taking vital signs and before handling medication again. These actions were in direct violation of the facility's infection control policies and standard precautions, as well as state regulations regarding nursing services.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment for residents, as evidenced by excessively high temperatures in two of eleven resident rooms reviewed. Facility policy requires maintaining room temperatures between 71 and 81 degrees Fahrenheit, but observations and temperature logs revealed that several rooms, including those occupied by two residents, consistently exceeded this range, with recorded temperatures as high as 98.4 degrees Fahrenheit. The issue was exacerbated by malfunctioning air conditioning units, inadequate monitoring, and delayed or incomplete maintenance responses. Interviews with staff, including the Director of Maintenance and the Nursing Home Administrator, revealed confusion and lack of clarity regarding responsibilities for monitoring room temperatures, especially during second and overnight shifts. The Director of Maintenance was unable to provide comprehensive temperature logs prior to his employment and noted a backlog of incomplete maintenance requests. Additionally, there was no evidence of an external air conditioning servicing company being used, and all maintenance was handled internally, with the Regional Director of Maintenance unavailable due to personal reasons. Documentation showed that temperature checks were not consistently performed, particularly on weekends, and that the facility was unable to provide proof that residents or their representatives were offered room changes when unsafe temperatures were identified. The Nursing Home Administrator admitted to not overseeing the temperature monitoring process or reviewing temperature logs, and there was no documentation to confirm that residents were given options for relocation. These failures resulted in residents being exposed to unsafe and uncomfortable environmental conditions.
Failure to Revise Care Plan for Discharge Planning
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely manner concerning discharge planning for a resident. The resident, who was admitted to the facility with diagnoses including bipolar disorder, alcohol dependence, and chronic pain, received a discharge notice due to non-payment. Despite the issuance of this notice, the resident's care plan, developed earlier in the year, still indicated plans for long-term care placement at the facility. Interviews with the Nursing Home Administrator and the social worker revealed that social services had been working with the resident to find suitable housing since February. However, the care plan was not updated to reflect the change in discharge planning status, indicating a lapse in the facility's adherence to regulatory requirements for timely care plan revisions.
Plan Of Correction
Resident R2 careplan has been updated to reflect the change in discharge planning status. An initial audit of current residents has been conducted to ensure the discharge careplan is reflective of the residents discharge planning status. New admissions will be reviewed during clinical meeting to ensure the discharge planning status is current and/or updated as indicated with changes. The DON or designee will re-inservice the Social Workers on the Discharge Policy with the focus on careplans. The Social Worker or designee will conduct weekly audits of 10 residents to verify discharge careplans are reflective of the residents current discharge planning status. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
Failure to Maintain Required NA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nursing assistants (NAs) on multiple occasions, as evidenced by a review of nursing staff schedules and interviews with staff. Specifically, the facility did not meet the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift on four out of seven days reviewed. On April 1 and April 2, 2025, with a census of 99 residents, the facility did not meet the staffing ratios for the day and evening shifts, and the day and overnight shifts, respectively. On April 4, 2025, with a census of 98 residents, the facility failed to meet the staffing ratios for the evening shift. On April 5, 2025, with a census of 99 residents, the facility did not meet the staffing ratios for the day shift.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Maintain LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on five out of seven days reviewed, specifically on April 1, 2, 3, 4, and 5, 2025. The regulation mandates a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. On April 1 and 2, with a census of 99 residents, the facility did not meet the staffing ratios for all shifts. On April 3 and 4, with a census of 98 residents, the facility failed to meet the staffing ratios for the evening and overnight shifts. On April 5, with a census of 99 residents, the facility again did not meet the staffing ratios for all shifts. These deficiencies were identified through a review of nursing staff schedules and interviews with staff.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Failure to Develop Care Plan for Alcohol Dependency
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident R75, who was diagnosed with alcohol dependency, among other conditions. Despite the facility's policy requiring a person-centered care plan within 48 hours of admission, there was no evidence of such a plan addressing the resident's alcohol dependency. This oversight persisted even after multiple incidents of intoxication were observed, including one where the resident was found with a water bottle containing alcohol and exhibited signs of intoxication. Resident R75, who was cognitively intact with a BIMS score of 15, was admitted with diagnoses including alcohol dependence, bipolar disorder, and alcohol cirrhosis of the liver. The resident was found intoxicated on several occasions, with incidents involving slurred speech, aggressive behavior, and possession of alcohol. Despite these occurrences, the facility did not implement a care plan to address the resident's alcohol dependency until after the resident was hospitalized for alcohol intoxication. Interviews with staff revealed a lack of awareness regarding the resident's alcohol dependency diagnosis and the incidents of intoxication. The Director of Nursing confirmed that the care plan was only updated after the last known occurrence of intoxication. This failure to develop and implement a timely and appropriate care plan resulted in actual harm to the resident, who required hospitalization and intravenous therapy for alcohol intoxication.
Failure to Supervise Resident with Alcohol Dependency
Penalty
Summary
The facility failed to provide appropriate staff supervision and a thorough assessment of the resident environment for a resident with a diagnosis of alcohol dependency. This deficiency resulted in actual harm to the resident, who was found with symptoms of intoxication and required hospitalization. The resident was admitted to the facility with multiple diagnoses, including alcohol dependence, bipolar disorder, and alcohol cirrhosis of the liver. Despite being cognitively intact and independent with ambulation, the resident was found with alcohol on multiple occasions. On September 17, 2024, the resident was discovered with a water bottle containing alcohol and exhibited signs of intoxication, such as slurred speech. The resident refused to disclose how the alcohol was obtained and declined a room search. Despite these incidents, there was no evidence of a care plan addressing the resident's alcohol dependency or the incident itself. The facility documentation did not show any interventions to monitor and supervise the resident's environment for alcohol presence and consumption. Further incidents occurred, including a drinking episode over the weekend of September 29-30, 2024, leading to a 30-day discharge notice due to endangerment of resident safety. On October 3, 2024, the resident was again found intoxicated, with multiple empty alcohol containers discovered in their room. The facility conducted an investigation, but it was inconclusive regarding how the resident obtained the alcohol. The lack of documented interventions and supervision led to the resident's hospitalization with a blood alcohol level of 0.27%, requiring intravenous therapy.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for nurse aide staff as required, affecting five nurse aides. Personnel records for Employees E5, E6, E21, E22, and E23 were reviewed, revealing that none had received an annual performance review. Employee E5 was hired on June 13, 2023, Employee E6 on July 16, 2004, Employee E21 on October 2, 2006, Employee E22 on April 1, 2020, and Employee E23 on June 23, 2021. An interview with the Director of Nursing confirmed that no performance reviews were conducted for these employees during 2024 or 2025, violating the facility's personnel policies and procedures as outlined in 28 Pa. Code 201.19(2).
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for residents under special contact and droplet precautions. Specifically, Resident R15, who tested positive for COVID-19, was observed to have inadequate protective measures in place. A licensed nurse, Employee E4, entered Resident R15's room without wearing the required personal protective equipment (PPE), such as a gown and gloves, despite the room being marked with a sign indicating the need for such precautions. Employee E4 incorrectly believed that only handwashing was necessary, demonstrating a lack of adherence to the facility's infection control policies. Additionally, the facility did not enforce enhanced barrier precautions for Resident R7, who was receiving wound care. Both the hospice licensed nurse, Employee E16, and the nursing aide, Employee E17, were observed wearing only gloves without gowns during the procedure. This was contrary to the facility's policy and the CDC guidelines, which require gowns and gloves for high-contact care activities to prevent the transmission of multidrug-resistant organisms (MDROs). Furthermore, the facility's staff failed to follow proper PPE protocols for Residents R69 and R75. Despite Resident R69 testing positive for COVID-19 and both residents' rooms being marked with signs for special contact and droplet precautions, Employee E24, a nurse aide, entered their room wearing only a surgical mask and did not perform hand hygiene. This lack of compliance with infection control measures highlights significant deficiencies in the facility's implementation of its infection prevention and control program.
Failure to Provide Medicare/Medicaid Coverage Notifications
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare and Medicaid coverage to three residents. Specifically, the facility did not issue a Notification of Medicare Non-Coverage (NOMNC) or an Advanced Beneficiary Notice of Non-Coverage (ABN) to Resident 91, Resident 151, and Resident 152. This deficiency was identified through a review of facility documentation and confirmed during interviews with the Administrator in Training and the Nursing Home Administrator. Both staff members acknowledged the absence of these critical notifications for the residents in question, indicating a lapse in the facility's compliance with regulatory requirements.
Inoperable Call Bells for Two Residents
Penalty
Summary
The facility failed to ensure that call bells were available and operable for resident use, affecting two residents. Resident R63 was observed with a call bell that was wound around the bedrails, with the cord cut off and lying on the floor. The severed cord was still attached to the plug in the wall jack, and pressing the button did not activate the call system. An interview with a licensed nurse confirmed that the call bell was not functioning. Resident R39 had an adaptive call bell that she could blow into to call for help, which had been broken since the night before and remained non-functional the following day. The Unit Manager confirmed that the call bell was not working and mentioned that parts for this specialty call bell had been ordered, as none of the sister facilities had this type of call bell available.
Sanitation and Comfort Deficiency in Resident Rooms
Penalty
Summary
The facility failed to ensure a sanitary and comfortable environment for residents in four out of eleven rooms observed on the third floor unit. Observations revealed various cleanliness issues, including food crumbs on the floor, a strong urine odor, a dry yellow substance under a chair, and a urinal on the floor. Additional observations noted mustard packets, an empty soda can, sweetener packets, a lotion cap, papers, and a brief bag scattered on the floor. Further inspection showed food crumbs under a bed, snack wraps on the floor, and a dirty and dusty bedside table. These findings were confirmed with a housekeeping employee, indicating a lapse in maintaining the required sanitary conditions as per the facility's policy 'Accommodation of Needs,' revised on February 1, 2023.
Failure to Follow Safe Resident Handling Guidelines Resulting in Resident Harm
Penalty
Summary
The facility failed to prevent neglect of a resident by not following established safe resident care guidelines, resulting in significant harm. According to the facility's Safe Resident Handling Program and the resident's care plan, the resident required two-person assistance for all care and extensive or total assistance for turning and repositioning in bed. Despite these documented requirements, a nurse aide provided care to the resident alone, without the required assistance, and allowed the resident to roll over independently during care. This action was contrary to the resident's care plan and the facility's policies, which were designed to prevent such incidents. The resident involved had multiple complex medical conditions, including heart failure, respiratory failure, renal failure, diabetes, morbid obesity, and lymphedema, and was assessed as being at risk for falls due to impaired mobility. The resident was cognitively intact and required substantial or maximal assistance for bed mobility. During the incident, the resident rolled out of bed while the nurse aide was providing care alone, resulting in a fall. The aide admitted to performing care without assistance, believing the resident could roll over independently, and this was confirmed by both the resident and facility documentation. As a result of the fall, the resident sustained a left humerus fracture, a T11 wedge compression fracture, and a right shin contusion, requiring hospitalization and further medical intervention. The facility substantiated the incident as neglect, as the care provided did not adhere to the resident's care plan or the facility's policies, directly leading to the resident's injuries.
Failure to Involve Residents and Contacts in Care Planning
Penalty
Summary
The facility failed to ensure that residents and their emergency contacts were properly informed and involved in care plan meetings, as required by 42 CFR Part 483.10(c)(2)(3). Specifically, the facility did not provide advanced notice of care plan meetings to residents and their emergency contacts, nor did they hold these meetings in a timely manner. This deficiency was identified for three residents, all of whom were not given the opportunity to participate in the planning of their care. Resident R1, who had impaired thought processes due to dementia, was not provided with the opportunity for his emergency contact to participate in care plan meetings. Despite the emergency contact's requests for updates and meetings with the medical director, there was no evidence that she was invited to the care plan meeting held on November 24, 2024. The social worker admitted to only contacting responsible parties if the resident was not alert or oriented, and often did so with insufficient notice. For Resident R2, the facility failed to conduct the required care plan meetings prior to the one held on January 7, 2025. Similarly, Resident R3 had not had a care plan meeting since May 2, 2024, and reported not remembering the last time a meeting was held. The social worker acknowledged that some care plan meetings were late or not held at all, and the Regional Nurse confirmed the lack of evidence for timely meetings. This lack of compliance with care planning requirements was corroborated by interviews with facility staff, including the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
Res R1, R2 and R3 careplan meetings have been conducted. Current residents scheduled for careplan meetings and their emergency contact are being notified by the Social Worker or designee in advance of upcoming careplan meetings and documented. The Social Worker and Nursing management team have been re-inserviced on the careplanning process with the focus on advance notifications to the resident, emergency contact, and timely completion of care plan meetings. The Social Worker or designee will schedule and notify the resident and emergency contacts and review upcoming care plan meetings during the morning meetings. Scheduled careplan meetings are being reviewed during morning meeting with the management team. The Social Worker or designee will conduct weekly x4 weeks, then monthly x2 audits of upcoming care plan meetings to verify advance notification of the resident and emergency contact have been completed and documented, and the careplan meeting has been conducted. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and reports of pest activity. The pest control contract, which began in May 2024, covered mice, ants, roaches, and stinging insects but excluded bed bugs, termites, and wildlife. Despite the contract stipulating bi-monthly services, pest control logs and observations indicated persistent pest issues, including roaches and other bugs in various rooms and common areas. Interviews and observations revealed that residents and their emergency contacts frequently reported sightings of bugs, particularly in bathrooms and living areas. Specific rooms were noted for having clutter and poor sanitation, which were identified as contributing factors to increased pest activity. For instance, one resident's room was cluttered with food items and had a soiled floor, while another room had flying bugs and debris under the radiator. Additionally, a room was found with numerous deceased roaches in a mouse trap, and residents reported frequent sightings of roaches. The facility's pest control logs documented several instances of pest sightings, yet there was no evidence that recommendations from the pest control company were implemented to address these issues. Interviews with facility management, including the Regional Nurse, NHA, and DON, confirmed that the recommendations from the pest control company were not acted upon, leading to ongoing pest problems in the facility.
Plan Of Correction
Room 221, 225, and 316 clutter has been removed, trash and debris was cleaned from under the heating unit, and rooms deep cleaned. Recommendations from December pest control visits have been completed. An initial audit was conducted of resident rooms to ensure trash and debris was removed if found under the heating unit. All resident rooms are maintained on a deep cleaning schedule. NHA will re-educate the Maintenance department to ensure recommendations/comments made during pest control visits have been addressed. Housekeeping Director and/or designee will re-educate the housekeeping department to ensure that trash and debris under a heating unit is removed. A biweekly audit will be conducted of the pest control logbook for 3 months to verify recommendations/comments made during pest control visits have been addressed as an effort to achieve a pest-free environment. Results of the monthly audit will be reviewed in subsequent QAPI for recommendations.
Failure to Notify Resident and Emergency Contact of Room Change
Penalty
Summary
The facility failed to provide documented room change notifications to a resident and their emergency contact, as required by regulations. This deficiency was identified for one resident, who was admitted with multiple diagnoses including dementia, heart failure, and diabetes. The facility's policy on room changes, revised in January 2024, mandates that notifications be provided within a reasonable time and that social services coordinate room change requests. However, the resident's emergency contact reported not being informed of the room change from the second to the third floor, which was discovered during a visit when the resident was not found in their original room. Interviews with facility staff, including the Regional Nurse and the Nursing Home Administrator, revealed that the facility could not provide a consistent reason for the room change, citing various explanations such as the resident's long-term care status and the need for a more compatible roommate. Additionally, there was no evidence that the resident or their emergency contact received written prior notification of the room change, as required. The lack of proper documentation and communication regarding the room change led to the deficiency being cited.
Plan Of Correction
The facility can not retroactively correct the cited deficient practice for Resident R1. Current residents with room changes for the past 7 days were reviewed to verify notification to the resident, emergency contact, and roommate were provided. The Social Worker and nursing management team have been re-inserviced on the Room Changes policy. Residents with upcoming room changes are being reviewed during morning meetings to verify notification to the resident, emergency contact, and roommate are completed and documented. The Social Worker or designee will conduct audits of residents with room changes weekly x4 weeks, then monthly x2 months to verify notification to the resident, emergency contact, and roommate have been completed and documented. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was reviewed for this care area. The resident, who had impaired thought processes due to dementia, was admitted for rehabilitation services and later discharged back to his home. However, the discharge process was not properly executed, as the resident was discharged without the necessary prescriptions for his medications, which included Bumetanide, Metoprolol Succinate ER, Haloperidol, and Ferrous Sulfate. The emergency contact for the resident reported that upon discharge, the resident needed prescriptions for his medications, but a physician was not available to write them, and the facility did not provide any medication samples. This lack of preparation left the resident without the necessary medications until the prescriptions could be fulfilled. The unit manager confirmed that the emergency contact called two days after the discharge, still without the medications or prescriptions. The Medical Director was unaware of the resident's scheduled discharge and received a call from the facility on the day of discharge, requesting him to write the prescriptions. However, he was unable to do so at that time. It was not until two days later that the Medical Director wrote the prescriptions, which were then faxed to the pharmacy. This series of events highlights the facility's failure to ensure a smooth and effective discharge process, as required by their policy.
Plan Of Correction
The facility can not retroactively correct the cited deficient practice for Resident R1. Current residents scheduled for discharges are being reviewed during morning meeting to verify an effective discharge plan is in place. The Social Worker and nursing management team has been re-inserviced on the Discharge Planning Process policy. Current residents scheduled for discharges are being reviewed during morning meeting to verify an effective discharge plan is in place. The Social Worker or designee will conduct audits of discharged residents to verify an effective discharge planning process was in place, and prescriptions/or medications were given as indicated. Audits will be completed weekly x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Investigate Alleged Mental Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation related to an allegation of mental abuse involving a resident diagnosed with diabetes mellitus, hypertension, and bipolar disorder. The incident occurred when the resident requested his scheduled medication after returning from a smoke break, leading to a verbal altercation with a registered nurse. The resident reported feeling intimidated by the nurse, who allegedly yelled at him. The facility's documentation included a grievance form and statements from involved parties, but the investigation was not comprehensive, and the incident was not reported to the department of health in a timely manner. The facility's documentation identified the registered nurse as the perpetrator of the verbal altercation, yet the follow-up investigation submitted to the State Survey Agency did not acknowledge this, nor did it determine whether the allegation was substantiated or unsubstantiated. Interviews with staff confirmed the occurrence of the verbal altercation, but the facility failed to submit a thorough investigation or a PB22 report form for the alleged abuse. This lack of a comprehensive investigation and timely reporting constitutes a deficiency in the facility's handling of the incident.
Plan Of Correction
1. The facility has completed a thorough investigation related to the allegation of mental abuse for Resident R1. 2. Current residents with allegations of alleged mental abuse will be reviewed for the past 14 days to verify a thorough investigation has been conducted. 3. The NHA or designee will re-inservice the management team on how to conduct a thorough investigation. Residents with allegations of mental abuse will be reviewed during morning meetings to verify a thorough investigation has been conducted. 4. The NHA or designee will conduct audits of allegations of alleged weekly x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Failure to Timely Report Verbal Altercation
Penalty
Summary
The facility failed to comply with the Pennsylvania Department of Health's regulation requiring immediate notification of noncompliance that seriously compromises quality assurance or patient safety. This deficiency was identified based on a review of facility documentation and interviews. Specifically, a verbal altercation occurred between a registered nurse and a resident on November 7, 2024. However, the facility did not report this incident to the Department of Health's Event Reporting System (ERS) until November 18, 2024, and even then, the report lacked details about the specific incident. During an interview, the Nursing Home Administrator confirmed the failure to submit the event to the ERS in a timely manner.
Plan Of Correction
1. The facility reported the allegation of mental abuse for Resident R1 on 11.7.24. 2. Current residents with allegations of alleged mental abuse will be reviewed for the past 14 days to verify they have been reported via the ERS to the Pennsylvania Department of Health. 3. The NHA or designee will re-inservice the management team on requirements of reporting abuse. Residents with allegations of mental abuse will be reviewed during morning meetings to verify that the allegation has been reported via the ERS to the Pennsylvania Department of Health. 4. The NHA or designee will conduct audits of allegations of alleged mental abuse weekly x4 weeks, then monthly x2 months to verify reporting to the Pennsylvania Department of Health has been completed. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.
Non-Functional Heating Unit in Resident Room
Penalty
Summary
The facility failed to provide a functional heating unit for one of the rooms observed, specifically room [ROOM NUMBER]. During an observation on November 6, 2024, it was noted that the heating unit in this room was non-functional and was being used to store the resident's hygiene supplies, linens, and personal belongings. A resident residing in the affected room reported that a portable heating unit was installed temporarily in late October 2024, but it only emitted cold air. Further investigation with the facility's Director of Maintenance revealed that an air conditioner, not a heating unit, was temporarily installed and was not connected to an outlet. The facility's administrator mentioned that an order for six units was placed on July 15, 2024, but there was no known delivery date. Additionally, the Director of Maintenance confirmed that the facility had two portable heating units available, which were not in use.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple reports of pest sightings, including mice, roaches, gnats, and flies, across various areas of the facility. Despite having a contract with a pest control company since May 2024, which included bi-monthly services, the facility's pest control logs from May to September 2024 indicated numerous instances where pest issues were documented by staff but not addressed by the pest control company. Specific incidents included reports of bed bugs, mice, and roaches on the 2nd floor on August 1, 2024, and widespread pest issues on the same floor from September 13 to September 19, 2024, which were not adequately serviced by the pest control company. Interviews with the facility's maintenance director and Nursing Home Administrator revealed that the pest control company provided written reports after each visit, but there was no evidence of recommendations being made to improve the pest control program. The pest control logs also showed that the company did not address specific areas of concern, such as room [ROOM NUMBER] on August 30, 2024, where gnats and a crawling bug were reported. The lack of action and recommendations from the pest control company contributed to the facility's inability to maintain a pest-free environment, as required by regulations.
Failure to Ensure Resident Safety and Education During Leave of Absence
Penalty
Summary
The facility failed to ensure the safety and proper education of a resident, identified as Resident R81, who went on a leave of absence (LOA) without adequate preparation and monitoring. The resident, who had a history of diabetes and required insulin, was not educated on how to monitor blood sugar levels or administer insulin before leaving the facility. This lack of education posed an immediate jeopardy to the resident's health, as they were insulin-dependent and at risk for complications related to improper medication management. The resident was approved for a LOA with family, but did not return at the scheduled time. The facility did not attempt to locate the resident until two shifts after the expected return time, leaving the resident's whereabouts unknown for an extended period. During this time, the resident did not take their medications as prescribed and failed to record blood sugar levels, which could have led to serious health consequences. The facility's policy required staff to review patient care and medication needs with the resident or responsible party before leaving, which was not adequately done in this case. Interviews with staff revealed a lack of communication and adherence to protocol regarding the resident's LOA. The resident was given a bag of medications without proper instruction, and there was no documented evidence of efforts to locate the resident or obtain a new physician order for an extended LOA. This oversight and failure to follow established procedures resulted in a deficiency that compromised the resident's safety and well-being.
Removal Plan
- Resident educated on how to assess, monitor, and administer blood sugar levels per sliding scale.
- Look back completed on resident with active LOA orders that receive insulin to ensure insulin education has been provided.
- DON or designee to re-educate Licensed nursing staff on insulin education prior to the resident leaving for an ordered LOA. Licensed nursing staff will also be re-educated on LOA policy and when to initiate effort/notification to locate a resident who does not return to the facility.
- Audits to be completed for all residents who went on a LOA that receive insulin to ensure education was provided prior to LOA occurring. Results of audits to be reviewed at QAPI meeting.
Failure to Update PASARR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to revise the Pre-Admission Screening and Resident Review (PASARR) for three residents with mental health diagnoses, as required by federal and state regulations. The facility's policy mandates that the social worker or designated staff ensure appropriate pre-admission screening and coordinate updates for residents with mental disorders. However, the review of clinical records revealed that the PASARR for Resident R15, who was admitted with diagnoses of paranoid schizophrenia, Parkinson's disease, bipolar disorder, and depression, was not updated to reflect these conditions. The PASARR Level I screen completed in 2019 failed to include the resident's mental health diagnoses, indicating a lack of compliance with the facility's policy. Similarly, Resident R37's PASARR Level I screen, completed in 2023, did not reflect the resident's diagnoses of schizoaffective disorder and depressive type, which were added in March 2023. The facility did not update the PASARR or conduct a significant change in status assessment. Additionally, Resident R63's PASARR Level I screen from 2021 did not include the resident's diagnoses of major depressive disorder and anxiety disorder, despite these being added in October 2021. An interview with the social worker confirmed that the PASARRs were not updated with the new diagnoses, highlighting a systemic issue in maintaining accurate and current assessments for residents with mental health conditions.
Failure to Conduct Required Level 2 PASARR Evaluations
Penalty
Summary
The facility failed to ensure that a Level 2 PASARR evaluation was conducted for residents with mental disorders as required. Specifically, two residents, R86 and R13, were identified as needing further evaluation based on their mental health diagnoses. Resident R86's clinical record indicated a history of psychosis, anxiety disorder, major depressive disorder, schizoaffective disorder, mood disorder, and unspecified disorder of adult personality and behavior. Despite meeting the criteria for a Level 2 PASARR evaluation, there was no documentation in the clinical record to show that this evaluation was completed, and the facility was unable to provide the necessary form upon request. Similarly, Resident R13, who had diagnoses including anxiety, depression, schizophrenia, paranoia, dementia, and Alzheimer's disease, was also not provided with a Level 2 PASARR evaluation. The resident's care plan indicated the need for such an evaluation due to a serious mental illness. However, the PASARR Level 1 form failed to indicate the resident's mental health diagnoses, incorrectly stating that the resident had no mental health conditions other than dementia. This oversight led to a negative screening outcome, and no further evaluation was conducted. The director of social services confirmed the incompleteness of the PASARR Level 1 and the absence of a Level 2 evaluation for Resident R13.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a period of seven months, as determined by a review of facility documentation, clinical records, and staff interviews. The facility did not have a system in place to effectively monitor antibiotic usage, which is a critical component of antibiotic stewardship. The CDC guidelines emphasize the importance of antibiotic stewardship in nursing homes to optimize infection treatment and reduce adverse events associated with antibiotic use. However, the facility's monthly antibiotic/infection analysis reports were found to be insufficient and missing critical information such as length of antibiotic use, lab results, site of infection, symptoms, and diagnosis. Some reports even lacked basic details like resident names, antibiotics used, and precautions taken. Interviews with the Infection Preventionist confirmed the absence of documentation evidence for an effective antibiotic stewardship program. The facility was unable to provide any policy or evidence of an antibiotic stewardship program, including surveillance, tracking, and analysis, despite requests made to the infection preventionist, the director of nursing, and nursing home administrators throughout the survey. This lack of documentation and monitoring indicates a significant deficiency in the facility's ability to manage and oversee antibiotic use effectively, as required by the CDC guidelines and state regulations.
Failure to Conduct FBI Fingerprint Check for New Hire
Penalty
Summary
The facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history. Specifically, the personnel file of a newly hired Licensed Practical Nurse (LPN), identified as Employee E8, lacked documented evidence of an FBI fingerprint check, which is a part of the screening process for potential hires. This deficiency was identified during a review of facility policies and procedures, employee personnel records, and staff interviews. The facility's policy, titled OPS300 Abuse Prohibition, mandates the screening of potential hires to prevent abuse, mistreatment, neglect, misappropriation of resident property, and exploitation. However, the absence of an FBI fingerprint check for Employee E8, who was hired from out of state, indicates a failure to adhere to this policy. The deficiency was confirmed during an interview with the Administrator, Employee E1.
Failure to Conduct Thorough Investigation of Resident Incident
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged violation involving a resident, identified as R252, who attempted to elope and sustained a head injury. The incident occurred when a maintenance assistant, employee E14, was exiting through a door, and R252 followed, attempting to exit as well. During the incident, R252 became combative, hitting E14, and subsequently sustained a laceration above the left eye. The resident was sent to the emergency room for evaluation, where it was reported that the resident claimed to have been hit by a staff member. The facility initiated an investigation, suspending E14 and notifying the police, but failed to interview the nursing staff assigned to R252 during the shift of the incident. The investigation report included statements from E14, a housekeeping employee E15, and another resident, R24, who witnessed part of the incident. However, the facility did not report the results of the investigation to the State Survey Agency within the required timeframe and was unable to provide the necessary documentation upon request. Additionally, the investigation report included a 'Mandatory Abuse Report' form naming E14 as the perpetrator, but lacked evidence of comprehensive interviews with all relevant staff. R252, who had no prior history of combative behavior, remained hospitalized and was later discharged from the facility.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, leading to deficiencies in addressing their specific care needs. Resident R92, who had moderate cognitive impairment and was diagnosed with dementia and adjustment disorder, was receiving antipsychotic medications. However, there was no documented evidence of a comprehensive care plan addressing the use of these medications. Similarly, Resident R89, who had moderate cognitive impairment and physical impairments due to a stroke, did not have a care plan for a recommended restorative nursing program to prevent contractures and functional decline. Resident R70, with a medical history of hemiplegia, cancer, and shoulder pain, frequently refused care and medications. Despite this, there was no evidence of interventions or education regarding the consequences and alternatives related to the refusal of care in the resident's care plan. These deficiencies were identified through observations, clinical record reviews, and interviews with residents and staff, indicating a failure to adhere to the facility's policy on person-centered care planning.
Failure to Provide Required Supervision for Residents
Penalty
Summary
The facility failed to provide resident-directed care and treatment consistent with the comprehensive assessment and care plan, physician orders, and professional standards of practice for two residents. Resident R22, who was cognitively intact and diagnosed with dysphagia, had a physician order for 1:1 supervision during meals to prevent aspiration. However, observations and interviews revealed that Resident R22 was consuming meals in his room without the required supervision, contrary to the facility's policy for enhanced patient supervision. Resident R29, with a medical history including falling, major depressive disorder, PTSD, muscle weakness, dementia, and agitation, required 1:1 supervision at all times due to aggressive behavior. Despite this, an investigation revealed that Resident R29 was left unsupervised, leading to a fall that resulted in a left hip fracture. The facility's nurse aide admitted to leaving the resident unsupervised while performing other tasks, which contributed to the incident. These deficiencies were confirmed with the facility's director of nursing and administrator.
Failure to Implement Restorative Programs for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as Resident R89, to maintain or improve their range of motion and mobility. Resident R89, who had moderate cognitive impairment and a history of stroke resulting in hemiplegia or hemiparesis, was observed to have limited range of motion in the left upper extremity. The resident's occupational and physical therapy discharge summaries recommended a restorative range of motion program and a restorative nursing program for ambulation to prevent contractures and functional decline. However, there was no documented evidence that the nursing staff implemented these recommended programs. Interviews with the Director of Rehabilitation and nursing staff revealed that the nursing staff were expected to follow through with the restorative programs designed by the therapy department. Despite this expectation, Resident R89 denied receiving ambulation or exercise assistance from the nursing staff, and the nurse aides confirmed they did not complete the recommended exercises or ambulation. The facility's failure to document and implement the restorative programs for Resident R89 was a deficiency in providing necessary nursing services as required by the facility's policy and state regulations.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident R95, who had severe cognitive impairment and a diagnosis of benign prostatic hyperplasia. The resident was prescribed Cephalexin, an antibiotic, to be administered four times a day for a urinary tract infection. However, on the start date of the medication order, two doses scheduled for 4:00 p.m. and 9:00 p.m. were not administered as the medication was not available. The clinical record for Resident R95 indicated that there was no documented evidence that the physician was informed of the missed doses, nor was there any request for an alternate treatment or specific orders for monitoring the resident while the medication was unavailable. Additionally, there was no documentation showing that the licensed nurse determined the reason for the medication's unavailability, the expected duration of the unavailability, or the efforts made to obtain the medication.
Failure to Ensure Resident Safety During Leave of Absence
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to effectively manage the facility, resulting in an immediate jeopardy situation concerning the safety of a resident who was on a leave of absence. The facility did not ensure the resident's safety by failing to locate the resident after they did not return at the appointed time and did not notify the physician when the resident decided to extend their leave of absence. This led to a lapse in the administration of critical medications, as the resident was not properly educated on medication administration prior to the leave. The resident involved, identified as Resident R 81, has multiple diagnoses including asthma, depression, schizophrenia, seizure disorder, hypertension, renal failure, diabetes, and hyponatremia. The resident has moderate cognitive impairment and requires assistance with mobility. The resident's care plan indicates a risk for complications related to psychotropic drugs and insulin-dependent diabetes, requiring regular monitoring of blood glucose levels. Despite these needs, the resident left the facility with insufficient medication and without proper education on how to manage their blood sugar levels. The facility's policy requires a physician's order for a leave of absence and mandates that staff review patient care and medication needs with the resident before leaving. However, the facility failed to adhere to this policy, as evidenced by the resident's extended absence without additional physician orders and the lack of communication with the resident's family and healthcare providers. The resident was eventually located after two shifts, but the delay in action and communication posed a significant risk to the resident's health and safety.
Failure to Develop Comprehensive Care Plan for IV Therapy
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident receiving intravenous (IV) therapy. The resident, who was admitted with diagnoses of pneumonia and septicemia, had a peripherally inserted central catheter (PICC) line in place for the administration of IV medications, specifically cefazolin, as ordered by a physician. Despite the presence of the PICC line and the ongoing need for IV antibiotic infusions, there was no documentation available in the resident's care plan addressing these specific needs. During the survey, it was observed that the resident had a PICC line in the left upper arm, and the Director of Nursing confirmed the absence of a care plan related to the PICC line or IV antibiotic infusions. The lack of documentation and a tailored care plan for the resident's IV therapy needs was identified as a deficiency, as it did not meet the requirements outlined in the facility's resident care policies.
Failure to Document IV Catheter Site Dressing Changes
Penalty
Summary
The facility failed to administer intravenous (IV) medications in accordance with professional standards of practice for a resident who required IV therapy. The resident, who was admitted with diagnoses including pneumonia and septicemia, had a peripherally inserted central catheter (PICC) line in the left upper arm for the administration of IV medications. Physician orders required the dressing of the IV catheter site to be changed weekly, with measurements of the external catheter length and upper arm circumference to be documented. However, on two occasions, June 28 and July 5, 2024, the dressing changes were either not documented or lacked the required measurements. The facility's policy on Central Venous Access Device (CVAD) Dressing Change emphasized the importance of measuring the external catheter length and arm circumference to assess for line migration and potential blood clots. Despite this, the Medication Administration Records (MARs) and progress notes for the resident did not contain the necessary documentation for the dressing changes on the specified dates. The Director of Nursing confirmed the absence of documentation, indicating a failure to properly assess and monitor the resident's PICC line during dressing changes.
Medication Administration and Infusion Therapy Competency Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skills to administer medication and perform infusion therapy, leading to a significant medication error involving two residents. Employee E3, a graduate nurse, was hired without documented competency evaluations for medication administration and IV infusion therapy. Despite being on orientation, Employee E3 administered an IV medication intended for another resident, Resident R2, to Resident R1. This error occurred after Employee E3 discarded a medication bag due to air bubbles and subsequently used a bag labeled for Resident R2. Employee E4, an agency LPN, was responsible for orienting Employee E3 but did not have documented competency evaluations for medication administration or IV infusion therapy. Employee E4 assisted in priming the IV tubing but was unaware of the discarded medication bag and the subsequent error. The Director of Nursing confirmed that Employee E3 was not IV certified and that the facility lacked evidence of completed IV infusion education or skills competency evaluations for both employees. The facility did not have a process for evaluating skills competencies for licensed nursing staff related to medication administration and IV infusion therapy. The Director of Nursing acknowledged the absence of documentation for infusion therapy education and skills competency evaluations. This lack of oversight and documentation contributed to the medication error, as there was no evidence of training or competency assessments for the involved staff.
Medication Error Involving Incorrect IV Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident R1. The facility's policy on medication administration requires staff to verify the correct medication, dose, route, rate, time, and resident identification before administering any medication. However, on June 26, 2024, a graduate nurse, Employee E3, administered an IV medication intended for another resident, Resident R2, to Resident R1. This error occurred despite the nurse's acknowledgment that the medication bag bore the wrong resident's name. Resident R1, who was admitted with diagnoses including pneumonia and septicemia, was prescribed cefazolin to be infused intravenously every eight hours. During the administration of the afternoon dose, Employee E3 mistakenly used a medication bag labeled for Resident R2, who had different medical conditions, including a hip fracture and wound infection. The error was compounded by the fact that the nurse was still in orientation and was being supervised by an agency licensed nurse, Employee E4, who was unaware of the mistake until after the medication was infused. The Director of Nursing confirmed the medication error and stated that Resident R1 was monitored and experienced no negative effects from the incorrect medication. The facility's documentation and witness statements revealed that the error was due to a lack of proper verification and supervision during the medication administration process. Despite the error, Resident R2 received his prescribed dose of cefazolin without issue.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
