John J Kane Regional Center-gl
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 955 Rivermont Drive, Pittsburgh, Pennsylvania 15207
- CMS Provider Number
- 395643
- Inspections on file
- 24
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at John J Kane Regional Center-gl during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was found physically restrained in bed using furniture and equipment, without a physician's order. Staff reported the restraint was used to prevent the resident from self-harm due to repeated attempts to get out of bed and combative behavior. Facility leadership confirmed that the restraint was applied without proper authorization, contrary to policy and regulatory requirements.
A resident with severe cognitive impairment and multiple comorbidities was not adequately supervised during bed mobility care, resulting in a fall from bed and a deep leg laceration that required hospital treatment. The resident was being assisted by a CNA and was care planned for one-person assist at the time, but the supervision and assistance provided were insufficient to prevent the accident.
Kitchen staff, including supervisors and the dietary manager, were observed not wearing required beard restraints and improperly wearing hair nets that did not fully cover their hair, in violation of facility policy and professional standards.
The facility did not maintain an ongoing activities program to meet the interests and support the well-being of residents with dementia on one unit. Most weekends had only one scheduled activity, and observations showed residents were often left with only television for engagement, with staff present but not interacting. Staff interviews confirmed minimal activity programming, especially during staff absences, and that residents from this unit did not participate in activities on other units.
The facility did not implement or maintain an effective training program for contracted nursing staff, as required by its own policies and facility assessment. When requested, the administrator could not provide training records for these staff, confirming the deficiency in staff development.
Two residents who required assistance with personal hygiene did not receive necessary care, resulting in one having long, unkempt fingernails and another with noticeable facial hair growth. Both residents' care needs were confirmed by staff and documented in their assessments.
Staff failed to assess, document, and notify physicians of abnormal blood glucose levels for three residents with diabetes, and did not appropriately respond to a change in condition for a resident with Alzheimer's and pulmonary hypertension who later required hospitalization. Nursing staff and the DON confirmed that required protocols for assessment and physician notification were not followed, and the facility lacked a specific diabetic care policy.
A resident with dementia, blindness, and mobility deficits, who required partial to moderate assistance with a manual wheelchair, fell forward from the wheelchair while being pushed by a nurse aide. The resident did not have leg rests, as therapy determined they were not needed for residents who could self-propel, though staff confirmed the resident could not propel herself. The facility lacked a specific policy for wheelchair transport, and the aide continued to push the wheelchair after the resident's feet were down, resulting in the fall.
The facility failed to provide eleven residents the opportunity to formulate an advance directive, as required by policy. A review of clinical records showed no documentation of advance directive discussions for residents with conditions like diabetes, high blood pressure, and congestive heart failure. The DON confirmed this deficiency.
The facility failed to notify physicians of abnormal blood glucose levels and did not assess residents for hyperglycemia and hypoglycemia, affecting four residents. Despite facility policies requiring staff to monitor conditions and notify physicians, these protocols were not followed. Interviews with nursing staff revealed inconsistencies in handling abnormal glucose levels, and the Director of Nursing confirmed the failure to notify physicians, highlighting a significant deficiency in diabetes care management.
The facility failed to provide mandatory QAPI training to four staff members, including a nurse aide, an environmental services employee, an administrative employee, and a unit clerk. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the lack of documented training within the required time frames.
Resident Restrained Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, as indicated by a BIMS score of 0 and diagnoses including vascular dementia, peripheral vascular disease, and anxiety disorder, was found physically restrained in bed without a physician's order. The resident was discovered by therapy staff with the bed pushed against the wall, an over-bed table placed over them, and multiple pieces of furniture, including two chairs, a wheelchair, and a nightstand, barricading them in the bed. Review of facility policies confirmed that residents are to be free from physical restraints unless required to treat a medical symptom and ordered by a physician, with ongoing evaluation of need. Staff interviews revealed that the restraint was implemented in an attempt to keep the resident safe after multiple incidents of the resident placing themselves on the floor and exhibiting combative and verbally aggressive behavior. There was no evidence of harm or distress to the resident at the time, and no restraint order was found in the clinical record. The facility's Director of Nursing and Nursing Home Administrator confirmed that the use of physical restraints occurred without a physician's order, in violation of facility policy and state regulations.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including diabetes, cardiomyopathy, congestive heart failure, and morbid obesity, was not provided adequate supervision during care. The resident, who required partial to moderate assistance with bed mobility and was care planned for one-person assist, rolled out of bed while being changed by a CNA after starting to cough. This resulted in a significant laceration to the right lower leg, exposing the tendon and requiring hospital treatment and sutures. The incident took place while the resident was on a bariatric air mattress, and the care plan at the time specified monitoring the resident's position in bed every two hours. The facility's policies require staff to provide necessary goods and services to prevent physical harm and to treat residents with dignity and respect. However, the review of clinical records and staff interviews confirmed that the supervision provided was not adequate to prevent the fall and subsequent injury. The resident's care plan and assistance level were only updated after the incident, indicating that the supervision and assistance provided at the time of the event did not meet the resident's needs, resulting in a preventable accident and injury.
Failure to Ensure Proper Use of Hair and Beard Restraints in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff properly restrained their hair and facial hair in accordance with facility policy and professional standards. Multiple food service workers, including a food service supervisor and the dietary manager, were observed in the kitchen without required beard restraints. Additionally, a staff member was seen wearing a hair net that did not cover the front portion of her hair, and this issue was observed on more than one occasion with the same employee and another dietary aide. The dietary manager confirmed that all kitchen staff should wear hair nets to cover all hair and use mustache/beard restraints if facial hair is present. These observations were made during routine kitchen operations and were in direct violation of the facility's policy on hair restraints.
Failure to Provide Ongoing Activities Program for Dementia Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of residents on Nursing Unit 3B, a secure unit for residents with dementia. Review of the activities calendars from January through June 2025 showed that weekends typically had only one scheduled activity, with most Sundays limited to social visits. Observations over several days revealed that residents were often left in the dining room/lounge with only a television program or movie playing, and staff were present but not interacting with residents. On multiple occasions, no structured activities were occurring, and staff were either engaged in personal conversations or using electronic devices rather than engaging with residents. Interviews with staff confirmed that activity programming was minimal, especially during staff vacations, and that there was no additional staff coverage to maintain activity levels during these times. It was also confirmed that residents from Nursing Unit 3B did not participate in activities held on other units. On one occasion, only two out of 37 residents were provided an activity, while the rest had no engagement. The Nursing Home Administrator acknowledged that the facility failed to provide an ongoing program of activities to meet the needs of residents on this unit.
Failure to Provide Required Training for Contracted Staff
Penalty
Summary
The facility failed to implement and maintain an effective training program for individuals providing services under contractual arrangements, as required by their roles. The facility assessment indicated that all personnel, including contracted staff, should receive education and training in areas such as resident rights, abuse prevention, compliance, infection control, psychosocial needs, dementia care, emergency preparedness, accident prevention, communication, QAPI, person-centered care, trauma-informed care, behavioral health, and HR policy. The facility's own policy stated that in-service training applies to all employees, contractual staff, and volunteers. During the survey, the Nursing Home Administrator was unable to provide required training records for the contracted nursing staff when requested. The administrator confirmed that the facility had not implemented or maintained an effective training program for these contracted individuals, consistent with their expected roles. This deficiency was cited under 28 Pa. Code 201.20(a)(b)(c)(d) regarding staff development.
Failure to Provide Necessary Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary care and services to two residents who required assistance with activities of daily living. One resident, with a history of cerebral infarct, aphasia, and hemiparesis, was assessed as severely cognitively impaired and fully dependent on caregivers for personal hygiene. This resident was observed to have long, unkempt fingernails, indicating a lack of appropriate hygiene care. The clinical record confirmed the resident's dependency and need for full assistance. Another resident, diagnosed with cerebral infarct, dysarthria, and heart failure, was assessed as cognitively intact but required substantial to maximal assistance with personal hygiene. This resident was observed to have noticeable facial hair growth and expressed a desire for assistance in its removal. Staff interviews confirmed that both residents did not receive the necessary care and services as outlined in their care plans and facility policy.
Failure to Assess, Document, and Notify Physicians of Abnormal Blood Glucose and Resident Condition Changes
Penalty
Summary
The facility failed to assess, document, and notify physicians of abnormal capillary blood glucose (CBG) levels for three residents with diabetes. For these residents, there were multiple instances where CBG readings were either extremely high (noted as 'HI' on the glucometer) or low, but staff did not follow physician orders or care plan interventions that required assessment, documentation, and physician notification for such results. Specifically, the clinical records and electronic medication administration records (eMAR) showed that staff did not assess for signs and symptoms of hyperglycemia or hypoglycemia, did not monitor the effectiveness of any interventions, and did not notify the physician as required by the residents' individualized orders and care plans. Additionally, the facility failed to appropriately respond to a change in condition for a resident with Alzheimer's disease and pulmonary hypertension. This resident exhibited a significant and sustained increase in heart rate, behavioral changes, and signs of possible infection, including blood in the brief and increased aggression. Despite these changes, there was a delay in assessment, documentation, and physician notification. The resident was eventually hospitalized for urinary tract infection, dehydration, hypernatremia, and atrial fibrillation with rapid ventricular response, but the initial signs and symptoms were not promptly addressed by the facility staff. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not follow required protocols for assessment, documentation, and physician notification regarding abnormal blood glucose levels and changes in resident condition. The facility also lacked a specific policy for the care of diabetic residents, further contributing to the deficiencies identified during the survey.
Failure to Provide Adequate Supervision During Wheelchair Transport
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall from a wheelchair for one resident. The resident in question had multiple diagnoses, including dementia, anxiety, blindness, difficulty walking, cognitive and communication deficits, and agitation, and was also on blood thinners. The resident required a manual wheelchair and needed partial to moderate assistance to move it. Occupational therapy notes indicated the resident needed frequent adjustments for lateral supports due to leaning and falling asleep in the wheelchair. On the day of the incident, a nurse aide attempted to redirect the resident's wheelchair from behind, during which the resident put her feet down and subsequently fell forward out of the wheelchair. Staff statements and documentation confirmed that the resident could not propel herself and that leg rests were not provided, as therapy determined they would interfere with independence for residents who could self-propel. The facility did not have a specific policy for transporting residents in wheelchairs, and staff relied on the electronic kardex for resident-specific care needs. The nurse aide involved reported that she was pushing the resident, who then put her feet down and fell forward. Other staff confirmed the resident was unable to propel herself and did not have leg rests. The facility's administration acknowledged, after reviewing CCTV footage, that the aide continued to push the wheelchair after the resident's feet were down, resulting in the fall. The facility was unable to produce the resident's plan of care prior to the incident, but the current plan of care identified the use of leg rests.
Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to provide the opportunity for eleven out of nineteen residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated January 2, 2024, mandates compliance with maintaining written policies and procedures regarding advance directives, including informing and providing written information to all adult residents about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. The clinical records of residents with various medical conditions, including diabetes, high blood pressure, congestive heart failure, dysphagia, and obesity, were reviewed. For each of these residents, there was no documentation indicating that they were given the opportunity to formulate an advance directive. During an interview, the Director of Nursing confirmed the absence of such documentation for the residents in question, which is a violation of the residents' rights as per 28 PA. Code 201.29(b)(d)(j).
Failure to Notify Physicians of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting four residents. The facility's policies required staff to monitor residents' conditions and notify physicians of significant changes, but these protocols were not followed. For instance, Resident R13 had a CBG of 52 and a 'HI' reading on separate occasions, yet there was no documentation of physician notification or assessment for hyper-/hypoglycemia. Resident R89 experienced multiple instances of low CBG readings, with values as low as 41, but the facility did not notify the physician or reassess the resident's condition. Similarly, Resident R147 had several high CBG readings, exceeding 340, without any physician notification or documented assessment for hyperglycemia. The care plans for these residents included instructions to notify physicians of abnormal glucose levels, which were not adhered to. Interviews with nursing staff revealed inconsistencies in following the facility's protocols for managing abnormal blood glucose levels. Staff members provided varying responses on how they would handle such situations, indicating a lack of standardized practice. The Director of Nursing confirmed the failure to notify physicians of changes in residents' conditions related to blood glucose levels, highlighting a significant deficiency in the facility's management of diabetes care.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for four out of ten staff members, as required by their own facility assessment. The assessment, which was reviewed on multiple occasions, included QAPI as a necessary educational topic. However, upon reviewing the facility's documents and training records, it was found that Nurse Aide Employee E2, Environmental Services Employee E3, Administrative Employee E4, and Unit Clerk Employee E5 did not receive documented QAPI training within the specified time frames corresponding to their hire dates. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of training for these employees.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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