John J Kane Regional Center-mc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mckeesport, Pennsylvania.
- Location
- 100 Ninth Street, Mckeesport, Pennsylvania 15132
- CMS Provider Number
- 395640
- Inspections on file
- 30
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at John J Kane Regional Center-mc during CMS and state inspections, most recent first.
A resident with cognitive communication deficits and CHF experienced a documented change in condition involving altered mental status. Facility policy required physician notification and documentation of findings and notifications in the nurses' notes. Although an RN stated the physician was notified via text message from a personal phone, there was no documentation in the nurse progress notes of the physician notification, follow-up assessments, or treatment plans. The DON confirmed the absence of this documentation, resulting in incomplete and inaccurate clinical records.
A resident with COPD and Alzheimer's disease, requiring moderate assistance for transfers, sustained a deep laceration to the right lower leg during a stand-to-pivot transfer with a CNA. The injury occurred when the resident's leg caught on the wheelchair's leg rest hinge bracket, resulting in profuse bleeding and the need for staples, sutures, and repeated hospital visits. The facility failed to provide adequate supervision and assistance during the transfer, leading to actual harm.
A newly admitted resident with high blood pressure and alcohol abuse disorder eloped from the facility due to inadequate supervision. The resident left the unit independently and was mistaken for a visitor by security, who allowed him to exit. Staff failed to conduct proper safety checks, with a nurse aide relying on previous reports and pre-charting care activities without verification. The RN also did not complete safety checks or inform the doctor of the admission, contributing to the resident's unsupervised departure.
The facility failed to accurately complete MDS assessments for two residents and BIMS/PHQ-9 assessments for six residents. Discrepancies included incorrect documentation of hospice services and incomplete cognitive and mood assessments, as confirmed by staff interviews.
A facility failed to provide a resident with the Notice of Medicare Non-Coverage (NOMNC) form, which is crucial for informing beneficiaries about their rights regarding service termination. Despite the resident having intact cognition, neither the resident nor their emergency contact received or signed the NOMNC form. This was confirmed by the Director of Nursing, highlighting a failure to ensure residents' rights to make informed decisions.
A facility failed to complete a Significant Change MDS assessment for a resident who was admitted to hospice care, despite the requirement to conduct a comprehensive assessment within 14 days of a significant change in condition. The oversight was confirmed by facility staff, highlighting a lapse in regulatory compliance.
The facility did not provide transfer notices to the LTC Ombudsman for eight months, as required by federal regulations. The facility's policy mandates sending a monthly list of facility-initiated transfers or discharges to the Ombudsman, but this was not done from December 2023 to August 2024. The DON confirmed the oversight during an interview.
A resident with morbid obesity and osteoarthritis, requiring substantial assistance for bed mobility, was injured due to neglect when a CNA failed to follow the care plan requiring three staff members for assistance. The CNA attempted to assist the resident alone, resulting in the resident falling and sustaining a leg fracture and a skin tear requiring sutures. The facility's investigation confirmed the neglect, as the CNA did not adhere to the prescribed care plan or verify the bed mobility order.
A resident with morbid obesity and osteoarthritis, requiring substantial assistance for bed mobility, suffered a leg fracture and skin tear after a CNA failed to follow the care plan requiring three staff members for assistance. The CNA allowed the resident to roll onto a bedpan without additional help, resulting in a fall and subsequent injuries.
A resident with dementia and post-surgical care needs was prescribed gabapentin 100 mg twice daily for anxiety, but due to a pharmacy error, received 800 mg twice daily for several days. The error was confirmed by the DON after the family refused the medication.
A resident with cognitive impairment and multiple diagnoses was found with a sheet and gown tied in a manner that restricted movement. The responsible Nurse Aide had a prior warning for abuse and neglect and was subsequently terminated. The incident was reported to the physician, and the facility initiated staff education on physical restraints.
Failure to Document Physician Notification and Follow-Up After Change in Condition
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident who experienced a change in condition. Facility policy titled "Notification of Changes in Resident Condition and Treatment Changes" required nursing staff to notify the physician of changes, accidents, and injuries, obtain treatment and diagnostic orders, and document findings and notifications in the nurses' notes. The resident was admitted with diagnoses including cognitive communication deficits and congestive heart failure, and a subsequent MDS confirmed these diagnoses remained current. A change in condition report documented that the resident was observed with altered mental status on a specified date. Despite the documented change in condition, the resident’s nurse progress notes did not contain any documentation of physician notification, follow-up assessments, or treatment plans related to this event. An RN reported that the physician had been notified of the change in condition via text message from the RN’s personal phone but acknowledged that this communication was not documented in the medical record. The DON confirmed that the medical record lacked documentation of the physician notification and related follow-up, resulting in incomplete and inaccurate clinical records for this resident in violation of 28 Pa. Code 211.5(f)(g)(h).
Failure to Provide Adequate Supervision During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent an injury to a resident with chronic obstructive pulmonary disease and Alzheimer's disease, who required partial to moderate assistance for transfers and had a physician order for one-person assist with a rolling walker. During a stand-to-pivot transfer from bed to wheelchair, the resident became weak, buckled at the knees, and was assisted by a nurse aide into the wheelchair. After the transfer, it was discovered that the resident had sustained a deep laceration to the right lower leg, which was bleeding profusely. The laceration was caused by the resident's leg coming into contact with the wheelchair's leg rest hinge bracket during the transfer. Immediate first aid was provided, and the resident was sent to the emergency department, where the wound required multiple staples, sutures, and application of hemostatic dressings due to continued bleeding. The injury resulted in repeated hospital visits within a short period due to ongoing bleeding from the wound site. Documentation and staff interviews confirmed that the transfer was performed with a single staff member as per the care plan at the time, but the incident revealed that this level of assistance was insufficient to prevent injury for this resident. The facility's failure to provide adequate supervision and appropriate transfer assistance directly led to the resident sustaining actual harm in the form of a significant laceration requiring medical intervention.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a newly admitted resident, identified as Resident R1. The resident, who had diagnoses of high blood pressure and alcohol abuse disorder, was admitted to the facility in the evening. Despite being a new admission, the resident was able to leave the facility without being noticed by the staff. The resident was last seen on CCTV leaving the unit independently and fully dressed, and was mistaken for a visitor by the security guard, who allowed him to exit the building. The deficiency was further compounded by the failure of the staff to conduct proper safety and accountability checks. A nurse aide, Employee E1, admitted to not physically checking on the resident and instead relied on the report given by the previous shift. The nurse aide also pre-charted care activities without verifying the resident's presence. Similarly, RN Employee E2 did not complete the required safety checks and failed to inform the doctor of the new admission. These lapses in protocol allowed the resident to leave the facility unnoticed. The security personnel, Employee E3, also contributed to the deficiency by not recognizing the resident as a newly admitted individual and assuming he was a visitor. This assumption led to the security guard unlocking the door for the resident, facilitating his elopement. The facility's policies on elopement prevention and safety checks were not adequately followed, resulting in the resident's unsupervised departure from the facility.
Inaccurate MDS and BIMS/PHQ-9 Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed accurately for two residents and that Brief Interview for Mental Status (BIMS) and/or Patient Health Questionnaire-9 (PHQ-9) assessments were completed accurately for six residents. Specifically, Resident R41's MDS inaccurately indicated that they did not receive hospice services, despite being on the facility's list of residents receiving such services. Additionally, discrepancies were found in the cognitive and mood assessments for several residents, where the BIMS and Resident Mood Interviews were not completed despite indications that they should have been. The report highlights specific instances where the facility did not adhere to the guidelines outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual. For example, Resident R13 was noted to be sometimes understood, yet the BIMS and Resident Mood Interview were not completed. Similar issues were identified for Residents R35, R41, R53, R169, R174, and R190, where the assessments were either incomplete or inaccurately documented. These deficiencies were confirmed through interviews with the Registered Nurse Assessment Coordinator and the Social Services Director.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that residents were properly informed about their Medicare coverage and potential liabilities for services not covered. Specifically, the facility did not provide Resident R203 with the Notice of Medicare Non-Coverage (NOMNC) form, which is essential for informing beneficiaries of their right to request a review of service termination. Despite Resident R203 having intact cognition, as indicated by a BIMS score of 15, neither the resident nor their designated emergency contact received or signed the NOMNC form. The deficiency was confirmed during an interview with the Director of Nursing Registered Nurse Assessment Coordinator (RNAC), who acknowledged that the NOMNC was not explained to Resident R203 or their representative in a comprehensible manner. This oversight was identified as a failure to uphold resident rights to make informed decisions about their health, safety, and welfare, as required by the relevant Pennsylvania codes.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident, identified as R40, who experienced a significant change in condition. According to the Resident Assessment Instrument 3.0 User's Manual, a comprehensive assessment must be conducted within 14 days after determining a significant change in a resident's physical or mental condition. Resident R40, who was admitted to the facility, had diagnoses of Alzheimer's disease and neuropathy. A physician order dated 10/7/24 indicated that the resident was admitted to hospice care, which is a significant change in condition requiring an updated MDS assessment. Upon review of Resident R40's MDS assessments, it was found that a significant change MDS was not completed to include the hospice services. This oversight was confirmed during interviews with the Registered Nurse Assessment Coordinator and the Nursing Home Administrator. The failure to complete the required MDS assessment for Resident R40 was acknowledged by the facility staff, indicating a lapse in adhering to the regulatory requirements for resident assessments.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide transfer notices to the representatives of the Office of the Long-Term Care Ombudsman Division for eight out of ten months, specifically from December 2023 through August 2024. According to the facility's policy dated January 6, 2024, a monthly list of residents who were facility-initiated transfers or discharges should be sent to the Ombudsman. However, this procedure was not followed. The federal regulation Title 42 Code of Federal Regulations S483.15(c)(3) requires that before a facility transfers or discharges a resident, the facility must notify the resident and their representative(s) in writing and send a copy of the notice to the Ombudsman. The Director of Nursing confirmed during an interview on November 7, 2024, that the facility had not provided these notices since December 31, 2023.
Neglect Leads to Resident Injury Due to Non-Compliance with Care Plan
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm, including a leg fracture and a skin tear requiring sutures. The resident, who had diagnoses of morbid obesity and osteoarthritis, required substantial assistance for bed mobility. A physician's order specified that three staff members were needed to assist with the resident's bed mobility. However, during an incident, a CNA attempted to assist the resident alone, contrary to the care plan and physician's orders. The incident occurred when the CNA was providing care and attempted to place the resident on a bedpan. The resident, weighing 338 pounds, attempted to assist by grabbing the headboard, which led to her falling off the bed. The CNA was unable to prevent the fall, resulting in the resident sustaining a laceration to the left knee and a comminuted fracture of the distal femur. Emergency services were called, and the resident was transferred to a hospital for further evaluation and treatment. The facility's investigation revealed that the CNA did not follow the prescribed care plan or verify the bed mobility order before providing care. This failure to adhere to the care plan and physician's orders was identified as neglect, leading to the resident's injuries. The Director of Nursing confirmed the facility's failure to protect the resident from neglect, which resulted in significant harm.
Failure to Provide Adequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls, resulting in actual harm to a resident who suffered a leg fracture and a skin tear requiring sutures. The incident involved a resident with a history of morbid obesity and osteoarthritis, who required substantial assistance for bed mobility. A physician's order specified that the resident needed assistance from three staff members for bed mobility, which was also reflected in the resident's care plan. On the day of the incident, a CNA attempted to assist the resident onto a bedpan without the required assistance from two additional staff members. The CNA allowed the resident to grab the headboard to assist with rolling, which led to the resident losing balance and falling off the bed. The fall resulted in a laceration to the left knee and a comminuted fracture of the distal femur, necessitating emergency medical attention and transfer to a higher-level hospital for further evaluation. The facility's investigation revealed that the CNA did not follow the prescribed plan of care or physician orders, which required three staff members for bed mobility. The CNA's failure to verify the bed mobility order before providing care was identified as neglect, and the incident was confirmed by the Director of Nursing. The facility documented the incident as a substantiated case of neglect due to the CNA's actions.
Medication Error Due to Pharmacy Mismanagement
Penalty
Summary
The facility failed to implement pharmaceutical services accurately, resulting in a medication error for one resident. The facility's policy required the contracted pharmacy to dispense prescriptions accurately based on authorized prescriber orders. However, a review of the resident's medication administration record revealed that the resident was prescribed gabapentin 100 mg twice daily, but was instead administered 800 mg twice daily from August 9 to August 14. This error was confirmed by the Director of Nursing during an interview. The resident involved had a history of dementia and was receiving aftercare following surgery. A psychiatric evaluation had led to a new order for gabapentin to manage anxiety, but the incorrect dosage was provided due to a pharmacy error. The error was identified when the family refused the medication on two occasions, prompting a review and confirmation of the mistake by the facility's Director of Nursing.
Failure to Ensure Resident was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints. Resident R1, who was admitted on 10/6/23 and had diagnoses including unspecified dementia, muscle wasting, diabetes, and adult failure to thrive, was found on 3/13/24 with a sheet tied behind their lower back and the corners of their gown tied behind their thighs. The resident had a BIMS score of 5, indicating cognitive impairment. Nurse Aide Employee E1 was identified as the individual who tied the sheet and gown, and had a previous verbal warning for abuse and neglect on 4/4/23. Employee E1 was suspended on 3/13/24 and terminated on 3/20/24. The incident was reported to the physician on 3/16/24. The facility's policy on physical restraints, last reviewed on 2/07/23, defines a restraint as anything that restricts freedom of movement and limits one's sense of control and independence. The incident was discovered by the oncoming 7 a.m. shift Nurse Aide Employee E2, who reported the restraint. The facility initiated education on physical restraints on 3/18/24, which included defining restraints, identifying physical risks and psychosocial impacts, determining if position change alarms are restraints, and identifying key elements of non-compliance. Seven direct care staff confirmed receiving this education during interviews on 3/26/24.
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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