John J Kane Regional Center-ro
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 110 Mcintyre Road, Pittsburgh, Pennsylvania 15237
- CMS Provider Number
- 395606
- Inspections on file
- 44
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at John J Kane Regional Center-ro during CMS and state inspections, most recent first.
A resident with neurogenic bladder, lymphedema, and frail skin sustained a significant skin tear when staff improperly placed a Foley catheter bag down her pants during dressing, contrary to the care plan. The catheter bag hook caught the resident's leg, causing a laceration that required emergency room care. Staff interviews and documentation confirmed the injury resulted from improper catheter bag handling.
A resident with traumatic spinal cord dysfunction, anemia, neurogenic bladder, and lymphedema suffered a significant leg wound during care, yet the care plan was not updated to include interventions for lymphedema or skin integrity. Staff and administration confirmed the care plan did not reflect the resident's current needs.
A resident was not properly assessed or prepared for transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
A resident who required two-person assistance for bed mobility due to an air mattress was left unattended by a nursing assistant, resulting in a fall and injuries including a forehead hematoma, laceration above the eye, and knee hematoma. The care plan and assignment sheet specified the need for two staff, but the NA was unaware and left the resident near the bed's edge, leading to the incident. Staff interviews confirmed the assistance requirement was documented, and the DON acknowledged the failure as neglect.
Two residents experienced actual harm when staff failed to provide necessary equipment and supervision: one resident with dementia and a fractured foot was transported in a wheelchair without footrests, resulting in further injury, while another resident requiring two-person assistance for bed mobility was left unattended and fell from bed, sustaining multiple injuries. Staff interviews and observations revealed inconsistent use of safety equipment and lack of awareness of care plan requirements.
Two residents with cognitive impairments and histories of confusion and wandering were able to elope to unsupervised or unauthorized areas due to the facility's failure to update elopement assessments and care plans after significant changes or incidents. Despite the use of wanderguards and supervision requirements, staff did not consistently monitor or revise interventions, and there were gaps in communication and documentation regarding residents at risk for elopement.
Surveyors observed that food items in the Main Kitchen were not properly stored, labeled, or dated, and expired food products were present in the walk-in cooler. The Food Service Director confirmed that these practices did not follow facility policy and that expired items, including bologna, pepperoni, turkey, and pureed egg salad, were not removed.
The facility failed to provide adequate supervision and implement person-centered care plan interventions, resulting in two residents at risk for elopement exiting to unsupervised or unauthorized areas without staff knowledge. This lack of effective management by the Administrator and DON created an immediate jeopardy situation and did not meet professional standards of care.
Four residents with diabetes and other chronic conditions had physician orders for FreeStyle Libre devices, but their care plans did not include instructions for the care and management of these devices, as confirmed by the RN Assessment Coordinator and review of clinical records.
The facility did not ensure proper care for residents with enteral feeding tubes, including failing to label and date feeding and flush bags, and not verifying tube placement before medication administration. These deficiencies were observed in three residents with complex medical conditions, and staff confirmed the lapses in required procedures.
Three residents did not receive proper respiratory care, including one receiving oxygen at an incorrect rate with an empty humidification bottle, another whose BiPAP mask was not stored in a bag as required, and a third using an undated nasal cannula. Nursing staff and the DON confirmed these failures to follow respiratory care protocols.
Essential emergency equipment, including two crash carts and three AEDs, were not properly maintained, with missing documentation of required checks and expired AED electrodes. Interviews with the DON and NHA confirmed that regular maintenance and testing were not consistently performed, leaving critical equipment potentially non-operational.
Staff failed to provide a dignified dining experience by standing while assisting a resident with lunch, contrary to facility policy. Additionally, a housekeeping employee entered two residents' rooms without knocking or requesting permission, failing to respect their privacy. Both the DON and the involved staff confirmed these lapses.
A resident room was found unlocked and unattended, containing a large maintenance cart with tools, exposed wires where lights had been removed, and a light bulb on the floor. The room, which lacked beds or furniture, shared a bathroom with an occupied room. The Environmental Services Director and the Nursing Home Administrator confirmed the safety risk and the failure to maintain a clean, safe, and homelike environment.
Two residents with diabetes experienced low blood glucose episodes, but staff did not notify the physician or fully implement the hypoglycemia protocol as required by orders and facility policy. The DON confirmed these lapses in care.
Two residents with limited mobility and physician orders for palm guards did not consistently receive the required equipment and care. One resident's care plan omitted management of a prescribed palm guard, while another was repeatedly observed without bilateral palm guards despite orders. Nursing staff and the DON confirmed these failures to provide appropriate services and equipment to maintain or improve ROM.
Surveyors found that one medication cart and one medication room contained insulin pens and vials without open or expiration dates, as well as an expired insulin vial and a tuberculin multi-dose vial used past the allowed 28 days. An LPN and the DON confirmed these deficiencies, which were not in accordance with facility policy or regulatory requirements.
Two residents' medical records contained nutrition progress notes that used non-standard abbreviations to describe pressure injuries and dietary recommendations. The registered dietitian confirmed using these terms, which were not recognized as acceptable medical terminology, and the assistant director of nursing acknowledged that this practice did not meet professional standards, resulting in incomplete and inaccurate documentation.
A resident with a G tube and multiple medical conditions had orders and a care plan requiring enhanced barrier precautions (EBP). Despite EBP signage, an LPN was observed administering medication through the G tube without wearing a gown, as required by facility policy. The DON confirmed the failure to follow EBP protocols.
Two registered nurses did not receive required training on the facility's Quality Assurance and Performance Improvement (QAPI) Program, as confirmed by review of education records and staff interviews.
Two residents experienced neglect when one was given food despite being NPO and requiring enteral feeding, and another was showered by a single nurse aide despite needing two-person assistance per physician order. Staff failed to follow care plans and facility policy, resulting in unapproved actions for both residents.
The facility failed to properly reheat food items in two unit pantries, creating a risk of cross-contamination and food-borne illness. Staff did not use thermometers to ensure food reached a safe temperature, relying instead on feeling the outside of containers. Residents reported meals were often cold, and the Director of Nursing confirmed the absence of thermometers, acknowledging the facility's failure to ensure food safety.
A facility failed to ensure accurate accounting of controlled medications and proper handling of medication cart keys during a shift change. An LPN left without conducting a required medication count and took the keys, leading to missing narcotics. The incident was confirmed by the DON.
The facility failed to secure medications in the 3-West Low hall medication cart, as observed on two occasions without staff present to lock it. The ADON confirmed the deficiency, which violated the facility's policy and state regulations.
The facility failed to implement proper infection control measures, including incorrect PPE removal procedures for a resident under respiratory precautions. Additionally, unsanitary conditions were observed, such as soiled linens on the floor, unclean commodes, and dirty floor mats in several residents' rooms. These issues were confirmed by staff and acknowledged by the DON.
The facility did not meet the required staffing levels for nurse aides during a night shift, with only 6 nurse aides present instead of the required 7.67 for 115 residents. This occurred once during the review period, as confirmed by the Nursing Home Administrator.
A resident with documented allergies was administered hydralazine by an RN, despite having an allergy to the medication. The resident, diagnosed with dementia, hypertension, and renal insufficiency, experienced a hypertensive episode and gastrointestinal symptoms following the administration. The pharmacy alerted the staff to the allergy, and the resident was subsequently transferred to a hospital for further care.
A facility failed to report an incident of neglect involving a resident with dementia, hypertension, and renal insufficiency in a timely manner. The resident experienced dark coffee ground emesis, and despite obtaining verbal orders for medication, the facility delayed reporting the incident to the State Office by 10 days, violating the 24-hour reporting requirement for non-serious bodily injury incidents.
A facility failed to develop and implement a comprehensive care plan for a resident with dementia, hypertension, and renal insufficiency. The care plan did not address high blood pressure, and staff did not follow the existing plan for the resident's adverse behaviors, including medication refusal. Documentation inconsistencies were noted in the administration of a Clonidine patch, with no record of refusal or staff intervention.
A resident with dementia and hypertension was hospitalized due to the facility's failure to administer a prescribed Clonidine patch, resulting in withdrawal and uncontrolled hypertension. The resident was also mistakenly given Hydralazine, to which they were allergic. The oversight was only identified after the resident was sent to the hospital.
A resident with dysphagia and specific dietary needs was given a regular diet instead of the prescribed pureed diet, leading to a coughing episode requiring suctioning. The resident's medical history included muscle weakness and hemiplegia/hemiparesis following cerebral infarction. The incident was confirmed by the Nursing Home Administrator.
A resident with Pica and dysphagia experienced two choking episodes due to inadequate supervision and failure to update the care plan. The first incident involved ingestion of chewing tobacco pouches, leading to a fall and injury. The second required the Heimlich maneuver after the resident choked on food items. Despite known risks, the facility did not provide consistent monitoring or update the care plan, resulting in actual harm.
The facility failed to properly label and date opened food packages in the Main Kitchen, as observed in the walk-in cooler where opened containers of iced tea, lemonade, and peaches lacked labels or dates. Additionally, an opened bottle of iced tea was improperly stored among chemicals in the chemical room. These deficiencies were confirmed by the FSD, indicating non-compliance with the facility's food storage policy.
The facility failed to communicate necessary resident information during transfers for four residents with significant medical conditions, such as heart failure and Alzheimer's disease. Required details like care plan goals and advance directives were not documented as sent to the receiving health care provider, as confirmed by the DON.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the hospital transfers of three residents, as required by federal regulations. These residents, with various medical conditions including heart failure, hypertension, and Alzheimer's disease, were transferred and returned without the necessary notifications being documented. This deficiency was confirmed by a Social Services employee.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy. Four residents with various medical conditions were transferred to the hospital without receiving the necessary notifications. The Director of Nursing confirmed these deficiencies.
The facility failed to provide baseline care plan summaries to three residents and their representatives within 48 hours of admission. Despite significant medical conditions, these residents did not receive the required documentation. Interviews with staff, including the MDS Coordinator and DON, confirmed this deficiency.
The facility failed to provide trauma-informed care for three residents with PTSD, as their care plans did not identify specific triggers or strategies to mitigate them. This deficiency was confirmed by a social worker, highlighting a lapse in adhering to the facility's policy on Behavior Management and Trauma Informed Care.
The facility failed to obtain necessary hospice diagnoses for four residents with various medical conditions, including stroke and Alzheimer's. Additionally, the hospice communication binder for a resident was incomplete, missing essential documents like the plan of care and consents. This deficiency was confirmed by the Nursing Home Administrator.
A resident with dementia and dysphagia ingested non-food items, including chewing tobacco, leading to a choking incident. The facility's investigation was incomplete, lacking a statement from a nurse aide present during the event. The Director of Nursing confirmed the investigation's inadequacy, as she was on vacation, and the facility failed to adhere to its policies on neglect.
A resident with a history of dementia and pica ingested chewing tobacco pouches and a paper towel, leading to a choking incident. Despite security footage showing the event and staff presence, the facility failed to obtain a witness statement from a nurse aide involved, resulting in an incomplete investigation. The DON confirmed the investigation was not thorough, highlighting a deficiency in the facility's compliance with its abuse and neglect policy.
A facility failed to notify a physician of abnormal CBG levels for a resident with diabetes and did not assess for hyper-/hypoglycemia. Another resident experienced emesis and elevated temperature, but the facility did not obtain physician orders for a Quad swab or isolation. The DON confirmed these deficiencies.
The facility failed to provide appropriate urinary catheter care for two residents. One resident's drainage bag lacked a dignity cover, and another resident's catheter irrigation tray was not changed daily as required. The LPN and DON confirmed these deficiencies.
A facility failed to provide colostomy care consistent with professional standards for a resident with a colostomy. The resident, with diagnoses including heart failure and hypertension, lacked necessary physician orders for colostomy care, such as the type and size of the appliance and monitoring instructions. Both an LPN and the DON confirmed the absence of these orders, highlighting a deficiency in adhering to the facility's policy.
The facility failed to implement Enhanced Barrier Precautions for two residents with indwelling urinary catheters, as staff did not wear required PPE during high-contact care. Additionally, the facility did not track active infections for a resident with symptoms of a respiratory virus, despite performing a Quad swab. These deficiencies indicate lapses in infection control practices and staff education.
A resident with multiple medical conditions eloped from the facility due to inadequate supervision and a faulty magnetic lock on an employee exit door. The resident was found outside by a bystander and was later assisted back inside by facility staff. The incident revealed lapses in supervision and security measures.
The facility failed to provide appropriate catheter care for six residents, with issues such as uncovered drainage bags on the floor, improper placement of bags, and lack of documentation for required procedures. A resident expressed concerns about staff's ability to manage her catheter, confirmed by the Nursing Home Administrator.
The facility failed to notify a resident's representative of a change in prescribed medication. The resident, admitted with acute respiratory failure and other conditions, was prescribed azithromycin for pneumonia. Despite the medication being administered, there was no documentation of family notification. The Director of Nursing confirmed this oversight.
Failure to Protect Resident from Neglect During Catheter Care and Dressing
Penalty
Summary
A deficiency occurred when staff failed to protect a resident from neglect during the provision of catheter care and dressing. The resident, who had a history of traumatic spinal cord dysfunction, anemia, neurogenic bladder, lymphedema, and frail skin, was dependent on staff for all toileting and hygiene needs. According to the care plan, a string was to be used to hang the Foley catheter bag, not a plastic clip. However, staff placed the catheter bag down the leg of the resident's pants while dressing her, contrary to the care plan instructions. During the dressing process, the hook from the urine bag caught the resident's leg, resulting in a laceration on the right anterior medial shin. The wound was described as a v-shaped skin flap with visible fatty tissue and serosanguinous discharge, and the surrounding skin was noted to be shiny, fragile, and edematous. The injury required assessment by a physician assistant and transfer to the emergency room, where it was determined that the wound was non-reparable and was closed with steri-strips. Staff interviews and documentation confirmed that the injury occurred as a direct result of improper handling of the catheter bag during dressing. The resident reported that staff continued to use the same technique despite her daughter's request for a different approach. The facility's own investigation acknowledged that the catheter bag should not have been threaded through the resident's pants, and staff were subsequently educated on safer practices.
Failure to Update Care Plan for Resident with Lymphedema and Skin Integrity Issues
Penalty
Summary
The facility failed to revise and update the care plan to accurately reflect the current status and care needs of a resident with multiple medical conditions. Upon review, it was found that the resident had diagnoses including traumatic spinal cord dysfunction, anemia, neurogenic bladder, and lymphedema with frail skin. The resident sustained a laceration to the right anterior medial shin when staff were assisting with dressing, which was attributed to the hook from a urine bag catching the leg. Documentation indicated the wound was significant, with a v-shaped skin flap, visible fatty tissue, and serosanguinous drainage, and the resident's skin was described as shiny, fragile, and edematous. Despite these findings and the resident's history of lymphedema and skin integrity issues, the current care plan did not include any interventions for lymphedema or preventative measures for impaired skin integrity. Interviews with staff, including a nurse aide and a registered nurse, confirmed that the care plan lacked these necessary interventions. The Nursing Home Administrator also acknowledged that the care plan had not been revised to reflect the resident's current needs, resulting in a deficiency under the cited regulations.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Failure to Provide Required Two-Person Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) failed to provide the required two-person assistance for bed mobility to a resident with an air mattress, as specified in the resident's care plan and assignment sheet. The resident, who was cognitively intact and had diagnoses including depression, hypertension, and diabetes, required total assistance for toileting and bed mobility, and substantial assistance for bathing. The care plan clearly indicated that two staff members were needed for bed mobility tasks due to the increased risk of injury associated with the air mattress. On the day of the incident, the NA placed the resident in a lateral position near the edge of the bed and left the resident unattended while stepping out to consult with a nurse about a spinal cord stimulator. During this time, the resident rolled out of bed and sustained injuries, including a hematoma on the left side of the forehead, a laceration above the left eye, and a hematoma to the right knee with associated pain. The NA later stated that she was unaware of the two-person assistance requirement, despite the assignment sheet reflecting this instruction. Multiple staff interviews confirmed that the assignment sheets contained information about required assistance levels and that residents on air mattresses or with similar needs should not be left unattended during care. The incident resulted in actual harm to the resident, as documented by physical assessments and progress notes, and was acknowledged by the Director of Nursing as a failure to provide appropriate goods and services to prevent falls, constituting neglect.
Failure to Prevent Accidents Due to Lack of Equipment and Supervision
Penalty
Summary
The facility failed to provide appropriate equipment and supervision to prevent accidents for two residents, resulting in actual harm. One resident with severe cognitive impairment and a history of right foot fracture was transported in a wheelchair without footrests by nursing assistants. During transport, the resident's foot dropped to the floor, her shoe came off, and she sustained a bruise and an acute fracture of the right fifth toe. Staff interviews revealed a lack of awareness and inconsistent use of wheelchair leg rests, with some staff stating they would ask residents to hold their legs up if footrests were unavailable. Observations confirmed multiple residents being pushed in wheelchairs without leg rests, and the DON acknowledged that staff were not informed about which residents required leg rests, relying instead on whether the equipment was present on the chair. Another resident, who was cognitively intact but required two-person assistance for bed mobility due to an air mattress, was left unattended by a nursing assistant during care. The assistant placed the resident near the edge of the bed in a lateral position and stepped out of the room to consult with a nurse, leaving the resident unsupervised. The resident subsequently rolled out of bed, sustaining a hematoma and laceration above the left eye, a hematoma to the right knee, and reported pain. Documentation and staff interviews confirmed that the resident's care plan and assignment sheet specified the need for two-person assistance, but the nursing assistant was unaware of this requirement despite having access to the assignment sheet. Facility policies required maintaining an environment free from accident hazards and providing adequate supervision and assistive devices. However, the facility did not ensure staff were aware of or followed these requirements, resulting in residents being exposed to preventable harm. Staff interviews and observations highlighted gaps in communication and adherence to care plans, directly contributing to the incidents of injury.
Failure to Provide Adequate Supervision and Person-Centered Interventions Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and person-centered care plan interventions, resulting in elopement incidents for two residents identified as at risk for elopement. Both residents had documented cognitive impairments and histories of confusion, agitation, and wandering behaviors. Despite these risk factors, the facility did not consistently update or revise elopement assessments or care plans following significant changes in the residents' conditions or after incidents indicating increased risk. One resident, with diagnoses including metabolic encephalopathy, repeated falls, and diabetes, exhibited fluctuating cognition, periods of confusion, and a history of wandering and falls. The resident was found unsupervised in restricted areas of the facility on multiple occasions, including the basement and another floor, despite care plan interventions such as a wanderguard and supervision requirements. Documentation showed that after these incidents, the facility did not complete timely elopement observations or update the care plan to reflect the increased risk or necessary interventions. Another resident, diagnosed with dementia and severe cognitive impairment, was found unsupervised in a closed and unstaffed unit's break room. The resident's care plan and elopement risk assessment were not updated after documented episodes of increased confusion, sundowning, and behavioral changes. The care plan failed to reflect a resident-centered approach or include appropriate interventions until several months after the incident. Staff interviews revealed inconsistencies in the identification and monitoring of residents at risk for elopement, lack of updated wander lists, and unclear responsibilities for the wander management program.
Removal Plan
- DON/Designee will immediately re-evaluate Resident R6 and Resident R111 for elopement risk.
- DON/Designee will re-evaluate all residents for exit seeking behaviors.
- Nursing staff/Designee will provide every one-hour safety checks on all residents. Residents who are at risk of elopement will have every one-hour safety checks ongoing to ensure resident safety.
- DON/Designee will provide appropriate supervision levels for all residents in their orders and person-centered care plans to include interventions such as resident specific activities such as 1:1 interactions, cards, outside to courtyard with supervision, etc. Review and update quarterly, annually or with any significant changes or with any event where elopement is an identified risk.
- DON/Designee will audit appropriate supervision levels.
- DON/Designee will thoroughly investigate all incidents for root cause analysis and follow up with interventions.
- DON/Designee will audit all incidents.
- DON/Designee will implement interventions for residents identified as an elopement risk to prevent residents from eloping.
- DON/Designee will audit all interventions.
- DON/Designee will update elopement assessments quarterly, annually or with any significant change or with any event where elopement is an identified risk.
- Security/Designee to take photographs of residents upon admission to the facility to ensure updated wander books, if they are at risk of elopement. Security providing all nursing units with wander books, with photographs and names/room numbers of residents, and will be updated upon resident's admission and/or discharge.
- Policy for Wanderguard and elopement has been reviewed and facility will add addendum regarding supervision levels and also Security/Designee taking photos of residents upon admission to the facility to ensure resident at risk of elopement are placed in wander books are updated with names/room numbers. Wander books to be updated upon resident admission/discharge and with room changes.
- Staff Educator/Designee will educate all staff on policies for Elopements, Assessments, Care Plan, Supervision, and Accidents.
- Facility will review incidents at QI/QAPI.
Failure to Properly Store, Label, and Date Food in Main Kitchen
Penalty
Summary
The facility failed to properly store, label, and date food items and did not monitor expiration dates of food products in the Main Kitchen. During an observation in the Main Kitchen Walk-in Cooler, an opened bag of French fries was found unsealed, unlabeled, and undated. Additionally, a plastic bag containing bologna, a plastic bag of pepperoni, and a plastic bag of turkey were all marked with use-by dates that had already passed. A container of pureed egg salad was also found with a use-by date that had expired. The Food Service Director confirmed these findings and acknowledged that the facility did not adhere to its own policies regarding food storage, labeling, dating, and monitoring of expiration dates.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that necessary care and services were provided to residents requiring adequate supervision to prevent elopement. Review of job descriptions, clinical records, and staff interviews revealed that the facility failed to maintain necessary supervision and implement person-centered care plan interventions, resulting in two residents exiting to unsupervised or unauthorized areas without the facility's knowledge. This failure constituted an immediate jeopardy situation for two of the 21 residents identified as at risk for elopement. The facility did not ensure that residents received treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person-centered policy.
Failure to Include FreeStyle Libre Device Management in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the care and management of the FreeStyle Libre 2 Sensor or Reader for four residents. Each of these residents had physician orders specifying the use and scheduled changes of the FreeStyle Libre device as part of their diabetes management. However, reviews of their care plans revealed that none included instructions or interventions related to the care and management of these devices, despite the orders being present in their clinical records. The residents involved had diagnoses including high blood pressure, diabetes, muscle weakness, heart failure, and arthritis. The deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the care plans for these residents did not reflect the required care and management of the FreeStyle Libre devices. This failure was found to be inconsistent with the facility's own policy on comprehensive person-centered care planning and relevant state regulations.
Failure to Provide Appropriate Care for Residents with Feeding Tubes
Penalty
Summary
The facility failed to ensure that residents with enteral feeding tubes received appropriate treatment and services to prevent potential complications, as evidenced by multiple deficiencies in labeling, dating, and verifying feeding tube placement. For one resident with diagnoses including high blood pressure, dementia, and diabetes, the enteral feeding bag in use was observed to be outdated and not properly labeled with the resident's name or the formula, and the water bag for flushes was not dated. Staff interviews confirmed that feeding and flush bags should be changed daily and properly labeled, but this was not done. Another resident with a history of stroke and difficulty swallowing had a care plan requiring verification of feeding tube placement before medication administration. However, during observation, an LPN failed to check the tube's placement prior to administering medication, a lapse confirmed by the DON. A third resident with Alzheimer's disease and muscle weakness was also observed receiving enteral feeding from an unlabeled bag, with staff confirming the lack of labeling. The DON acknowledged that the facility did not provide appropriate treatment and services for these residents, as required by policy and physician orders.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents as evidenced by multiple observations and staff confirmations. One resident with diagnoses including high blood pressure and muscle weakness was observed receiving oxygen at a rate higher than ordered by the physician, and the humidification bottle attached to the oxygen setup was empty. A registered nurse confirmed that the resident was not receiving oxygen at the prescribed rate and that the humidification bottle was not filled as required. Another resident with chronic obstructive pulmonary disease, anemia, and obstructive sleep apnea had a physician's order and care plan for BiPAP use at night. However, the BiPAP mask was repeatedly observed left on the bed and not stored in a bag as required by facility policy, with two different LPNs confirming this failure. A third resident, diagnosed with Alzheimer's disease, difficulty swallowing, and muscle weakness, was observed receiving oxygen via nasal cannula that was not dated as required. A registered nurse confirmed the lack of dating on the nasal cannula. The Director of Nursing acknowledged that the facility failed to provide appropriate respiratory care for these three residents.
Failure to Maintain Crash Carts and AEDs in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that essential emergency equipment, specifically crash carts and Automated External Defibrillators (AEDs), were maintained in safe operating condition. Observations revealed that two of four crash carts did not have completed documentation verifying that they had been checked as required, and the associated AEDs had not been tested or confirmed operational on multiple occasions. One crash cart was found with a blank emergency cart log, indicating no checks had been performed or recorded for an extended period. Additionally, three of six AEDs were found with expired electrodes, and there was no evidence that these had been replaced or that the devices were fully operational. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed these lapses, with the NHA noting that AEDs were only serviced annually by an external safety officer. Facility policy requires regular checks and maintenance of emergency equipment, but documentation and observations showed these procedures were not consistently followed, resulting in equipment that may not have been ready for use in an emergency.
Failure to Ensure Dignified Dining and Respect Resident Privacy
Penalty
Summary
The facility failed to ensure a dignified dining experience and respect for residents' private space on the Three East unit. During a dining observation, a nurse assistant was seen standing while feeding a resident lunch, rather than sitting as required by facility policy. The nurse assistant acknowledged awareness of the expectation to sit while assisting with meals. Additionally, a housekeeping employee entered two residents' rooms without knocking or requesting permission, which did not protect or value the residents' private space. The Director of Nursing and the housekeeping employee both confirmed these failures during interviews.
Unsafe and Unattended Maintenance Area in Resident Room
Penalty
Summary
Facility staff failed to maintain a clean, safe, comfortable, and homelike environment in one of three resident areas, specifically in an unoccupied resident room. During an observation, a large maintenance cart containing handheld drills, scraping tools, a caulk gun, screws, wires, and other maintenance equipment was found left in the room, which had no beds or furniture. The lights above the bed areas had been removed, leaving wires visibly protruding from the wall, and a light bulb was found on the floor near the closet. The room was unlocked and unattended, and it shared a bathroom with an occupied resident room. The Environmental Services Director confirmed these observations and acknowledged the safety risk posed by the situation. The Nursing Home Administrator also confirmed the facility's failure to provide a safe and homelike environment in this area.
Failure to Notify Physician and Implement Hypoglycemia Protocol for Diabetic Residents
Penalty
Summary
The facility failed to notify the physician of decreased capillary blood glucose (CBG) levels as required by physician orders and did not implement the hypoglycemia protocol for two residents with diabetes. For one resident with diagnoses including depression, coronary artery disease, and diabetes, blood glucose readings below 70 mg/dL were recorded on multiple occasions, including values as low as 53 mg/dL and 59 mg/dL. Despite physician orders to call the physician for CBG readings less than 70 mg/dL, there was no documentation that the physician was notified or that the hypoglycemia protocol was followed during these incidents. Another resident with diagnoses of high blood pressure, diabetes, and hyperlipidemia also experienced hypoglycemic episodes, with blood glucose readings of 49 mg/dL and 61 mg/dL. Although the resident was treated with orange juice and graham crackers and blood glucose was rechecked, the physician was not notified as required by the physician order and facility protocol. The Director of Nursing confirmed that the facility did not notify the physician or fully implement the hypoglycemia protocol for these residents.
Failure to Provide Required Mobility Equipment and Services
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve their range of motion (ROM). For one resident with a history of high blood pressure, hemiplegia, and stroke, a physician order required the use of a right palm guard at all times except during hygiene. However, the resident's care plan did not include care and management of the palm guard, a fact confirmed by the Registered Nurse Assessment Coordinator. Another resident, also with diagnoses including high blood pressure, hemiplegia, and anemia, had physician orders for bilateral palm guards to be worn at all times except for hygiene, and for daily cleaning and reapplication of the hand braces. Despite these orders, observations on two separate occasions found the resident without the required palm guards applied. This was confirmed by a registered nurse, and the Director of Nursing acknowledged that the facility failed to provide the necessary services, equipment, and assistance to maintain or improve mobility for these residents.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in one of three medication carts and one of three medication rooms. During a review of the Three East Med Cart, surveyors observed multiple insulin products, including Insulin Glargine Pen, Tresiba Insulin Pen, and Humalog Insulin Pen, that lacked open dates or expiration dates. Additionally, a Humalog Insulin Vial was found to be expired. These findings were confirmed by an LPN who acknowledged the presence of expired and undated insulin products on the medication cart. In the medication room on the Three [NAME] unit, a tuberculin multi-dose vial was found to be past the 28-day permissible period after opening, as verified by another LPN. The Director of Nursing confirmed that the facility did not properly store medical supplies in the identified medication cart and medication room. These deficiencies were found to be in violation of facility policy and state regulations regarding pharmacy and nursing services.
Failure to Use Standard Medical Terminology in Resident Documentation
Penalty
Summary
The facility failed to maintain and complete accurate and appropriate documentation in the medical records for two residents. For one resident, the clinical record included nutrition progress notes that used non-standard abbreviations such as 'Gr X' and 'Gr 3' to describe pressure injuries, and 'bmf' to refer to between meal feedings. These terms were not recognized as acceptable medical terminology. The resident had diagnoses including high blood pressure, cerebrovascular accident, and muscle weakness, and was documented as having a stage three pressure injury to the coccyx and an unstageable pressure injury to the left ankle. For the second resident, the clinical record also contained a nutrition progress note using the term 'Gr2' to describe a stage two pressure injury. This resident had diagnoses of high blood pressure, dementia, and difficulty swallowing, and was documented as having a stage two pressure injury and an unstageable pressure injury to the coccyx. During staff interviews, the registered dietitian confirmed the use of these non-standard terms, and the assistant director of nursing acknowledged that such terminology does not meet acceptable standards of practice, resulting in incomplete and inaccurate documentation in the medical records.
Failure to Follow Enhanced Barrier Precautions During G Tube Medication Administration
Penalty
Summary
The facility failed to follow its own policy on enhanced barrier precautions (EBP) for infection control during high-contact resident care activities. According to facility policy, EBP requires the use of gowns and gloves during care involving devices such as a G tube. A resident with a history of stroke, difficulty swallowing, and high blood pressure had a physician order and care plan indicating the need for EBP due to a G tube. Despite signage indicating EBP at the resident's doorway, an LPN was observed administering medication through the resident's G tube without wearing a gown as required. The Director of Nursing confirmed this failure to adhere to EBP protocols for the resident.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program to two out of eight staff members, specifically two registered nurses. Review of facility education documents for the year 2024 showed that these two staff members did not have documentation of QAPI education. The Assistant Director of Nursing confirmed during interviews that the required QAPI training was not provided to these individuals. This deficiency was identified through review of facility documents and staff interviews, and it was determined to be non-compliant with state regulations regarding staff development and management responsibilities.
Failure to Prevent Resident Neglect in Nutrition and Bathing Assistance
Penalty
Summary
The facility failed to protect two residents from neglect as required by policy and regulation. For one resident with diagnoses including high blood pressure, dementia, and diabetes, who was receiving nutrition through an enteral feeding tube and was designated NPO, an activity employee provided a cookie to the resident without proper authorization. The activity employee stated she had asked the speech therapist for permission, but the speech therapist denied giving approval, noting that the resident had returned from the hospital and required a full evaluation before any oral intake could be recommended. Documentation confirmed the resident was to remain NPO until assessed by the speech therapist. In a separate incident, another resident with high blood pressure, weakness, and wheelchair dependence, who required two-person assistance for bathing, was given a shower by a single nurse aide. The aide proceeded without a second staff member, contrary to physician orders and facility policy. The incident was observed and reported by a registered nurse, who reiterated the requirement for two-person assistance and educated the aide on proper procedure. Both the nursing home administrator and director of nursing confirmed that these actions constituted neglect of the residents involved.
Failure to Properly Reheat Food in Unit Pantries
Penalty
Summary
The facility failed to properly reheat food items in the unit pantries, which created the potential for cross-contamination and food-borne illness in two of the three units, specifically 2 East Pantry and 3 East Pantry. The facility's policy on reheating food, last reviewed on January 2, 2025, outlines the procedure for ensuring food is reheated to a safe temperature of 140 degrees or less. However, observations and staff interviews revealed that the policy was not being followed. Nurse Aid Employee E2 admitted to not using a thermometer to check food temperatures, instead relying on feeling the outside of the cup or plate. Similarly, LPN Employee E6 was unable to locate a thermometer in the pantry, indicating a lack of adherence to the facility's reheating policy. Residents reported that their meals, particularly breakfast and dinner, were often cold by the time they reached the units. While some residents mentioned that staff would reheat their meals upon request, the lack of proper temperature checks posed a risk of serving food at unsafe temperatures. The Director of Nursing confirmed the absence of thermometers in the pantries, acknowledging the facility's failure to ensure food safety. This deficiency was noted in the context of the facility's responsibility under 28 Pa. Code: 201.14(a) and 201.18(b)(1) to manage and ensure the safety of food services.
Medication Management Lapse During Shift Change
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of controlled medications and proper handling of medication cart keys during a shift change. On one occasion, an Agency LPN left the facility without conducting a required physical inventory of medications with the incoming nurse, as per the facility's policy. The LPN left the medication cart keys in her car, which was taken by her son, resulting in the keys being unavailable for the incoming nurse. This incident occurred on the 3-West low hall medication cart, and the failure to follow protocol was confirmed by the Director of Nursing. During the shift change, the incoming LPN was unable to access the medication cart due to the absence of keys and did not perform the necessary medication count with the outgoing LPN. The RN Supervisor and the incoming LPN later conducted a count and discovered discrepancies, with two narcotic medications missing. The facility's policy requires that any discrepancies be addressed immediately with a supervisor, but this procedure was not followed initially. The incident highlights a lapse in adherence to established protocols for medication management and key handling during shift changes.
Plan Of Correction
Immediate education regarding Policy M-N-19 Medications - Narcotics Controlled Substances, DEA's, was provided to every licensed staff member working the 3-11, 11-7 shift on 2-4-2025 and daylight on 2-5-2025. DON/ADON/Designee will continue education regarding Policy M-N-19 Medications - Narcotics Controlled Substances, DEA's to all licensed nursing staff daily and Policy will be included with orientation packet for all agency licensed nursing staff. Audits of the controlled inventory sheets will be done at change of shift daily x 7 days, 3x per week for 2 weeks, weekly x4. All results will be reported to the QAPI Committee for review.
Medication Cart Security Deficiency
Penalty
Summary
The facility failed to store medications securely in one of its medication carts, specifically the 3-West Low hall medication cart. According to the facility's "Medication administration general guidelines" policy, all medications must be kept secured and in a locked environment. However, during observations on February 3, 2025, at 12:13 p.m., the 3-West unit's low hall medication cart was found unlocked, with no registered nurse, licensed practical nurse, or any other staff member present to secure the cart. Further observations at 12:17 p.m. on the same day confirmed that the 3-West low hall medication cart #1 remained unlocked, again with no staff present to secure it. During an interview at 12:18 p.m., the Assistant Director of Nursing (ADON) confirmed the facility's failure to store medications securely in one out of six medication carts as required by regulations. This deficiency was noted under the relevant state codes for pharmacy and nursing services.
Plan Of Correction
- Immediate termination of agency RN assigned to the med cart on 3 West Low Hall during complaint survey. - Immediate education to all licensed nursing staff regarding Policy N-M-05 Medication Administration General Guidelines including emphasis on requirement that the medication cart MUST be locked at all times when not in use. - DON/ADON/Designee will continue education on policy N-M-05 Medication Administration General Guidelines including emphasis on requirement that the medication cart MUST be locked at all times when not in use to all licensed staff. - Audits of the meds cart are being completed 2x per shift x 10 days, 3x per week for 2 weeks and weekly x4. - All results will be reported to the QAPI Committee for review.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, particularly concerning respiratory precautions for a resident. Staff members, including registered nurses and licensed practical nurses, incorrectly indicated that the N95 respirator should be removed inside the respiratory precautions room, contrary to guidelines that require it to be removed outside the room. This misunderstanding was confirmed during an interview with a registered nurse who was unaware of the correct procedure. Additionally, the facility's policy on cleaning and preventative maintenance was not adhered to, as evidenced by the presence of soiled linens on the floor in a resident's room. Further observations revealed unsanitary conditions in several residents' bathrooms and living areas. Three residents had commodes with dried brown substances, indicating a lack of proper cleaning. Additionally, floor mats in the rooms of four residents were found to be dirty, with debris and dried food substances present. These findings were confirmed by staff members during tours of the facility. The Director of Nursing acknowledged the facility's failure to implement infection prevention and control monitoring policies effectively.
Plan Of Correction
Facility immediately had toilets in rooms 385, 293 and 284 cleaned and facility immediately removed soiled fall mats and replaced them with clean fall mats on 1/14/2025. Education provided to staff immediately on 1/14/2025 for proper doffing of face masks and respirators between resident rooms and dirty linen on the floor. Staff educator/designee will educate all staff on Infection Control Policy and Procedures. Staff educator/designee will educate all housekeeping staff on cleaning rooms/bathrooms properly and cleaning of the fall mats. Educator/Designee will provide education to nurses' aides regarding dirty linen and fall mats; aides are to stand mats up and lean them up against the wall (only when resident is out of bed) to facilitate thorough cleaning of the equipment by Housekeeping. Baseline whole house audit will be completed for both fall mats and resident bathrooms. Ongoing audits will continue weekly x 4 weeks, bi-weekly x 2 months and monthly x 3. Audits on PPE and dirty linen will occur; 10 random rooms will be checked daily for one week, then 3 times a week x 1 month, then 1 time a week x 1 month. All results will be reported to the QAPI Committee for review.
Staffing Deficiency on Night Shift
Penalty
Summary
The facility failed to meet the state-mandated staffing requirements for nurse aides during the night shift on one occasion within the reviewed period from December 24, 2024, to January 13, 2025. Specifically, on December 27, 2024, the facility had a census of 115 residents, necessitating a minimum of 7.67 nurse aides to comply with the regulation of one nurse aide per 15 residents. However, only 6 nurse aides were present, resulting in a staffing shortfall. This deficiency was confirmed by the Nursing Home Administrator during an interview conducted on January 14, 2025.
Plan Of Correction
DON/ ADON/ RN Charge Nurse will be re-educated on maintaining state required staffing levels. Daily audits will be completed by the Director of Nursing/ ADON/ Staffing Coordinator on maintaining state mandated staffing levels and ratios for each shift. Audits will be completed by DON/ Designee on state mandated PPD/ratio requirements weekly x 4 weeks and monthly x 3. All results will be presented to the QAPI committee, which will review for need of ongoing audits and evaluation to make recommendations as needed.
Failure to Protect Resident from Medication Allergy
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by the administration of a medication to which the resident was allergic. The resident, who had been diagnosed with unspecified dementia, hypertension, and renal insufficiency, was admitted to the facility with documented allergies to hydralazine, naproxen, and penicillin. Despite this, a registered nurse administered hydralazine to the resident after receiving a verbal order from a physician to manage the resident's high blood pressure. The nurse had access to the resident's clinical record, which included the allergy information, but failed to notice it. Following the administration of hydralazine, the resident experienced a hypertensive episode and was found to have dark coffee ground emesis, indicating potential gastrointestinal bleeding. The pharmacy later notified the nursing staff of the resident's allergy to hydralazine, prompting a reevaluation of the resident's condition. The resident's family was informed of the situation and requested that the resident be transferred to a hospital for further evaluation and treatment. The facility's failure to recognize and act upon the documented allergy resulted in the resident being exposed to a medication that could cause harm.
Plan Of Correction
This plan of correction constitutes my written allegation of compliance for the deficiencies in which the facility was cited for. However, the submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by state and federal law. - Immediately during complain survey, ERS submitted for Neglect on 12/18/2024. - All medication errors will be screened for abuse/neglect and reported if it meets criteria to ERS. - Electronic Medical Record feature activated for alert for all residents, related to resident allergies to specific medications, to populate red/pink screen alerting RN/LPN to allergy. - Licensed nursing staff will receive education on N-M-05 Medication Administration General Guidelines and N-M-300 Medication Documentation and N-M-150 Medication Error Reporting, Analysis and Correction (MERF). - DON/ADON/Designee to audit all medication errors for abuse/neglect weekly x4 and bi-weekly x2. - Results of audit will be reviewed and evaluated at QAPI meeting.
Failure to Timely Report Incident of Neglect
Penalty
Summary
The facility failed to report an incident of neglect in a timely manner, as required by regulations. The incident involved a resident who presented with dark coffee ground emesis on a specific date, and the nursing supervisor contacted the on-call physician to obtain verbal orders for medication. However, it was noted that the resident had a listed allergy to one of the medications prescribed. Despite the seriousness of the situation, the facility did not report the incident to the State Office until 10 days later, which is a violation of the requirement to report such incidents within 24 hours if they do not result in serious bodily injury. The resident involved had a medical history that included unspecified dementia, hypertension, and renal insufficiency. The facility's policy on abuse and reasonable suspicion of a crime mandates that any alleged violations must be reported immediately or within 24 hours, depending on the severity of the incident. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the late reporting of the incident, acknowledging the facility's failure to comply with the timely reporting requirements.
Plan Of Correction
Immediately during the complaint survey, ERS submitted for Neglect on 12/18/2024. All allegations of abuse and neglect will be reported in the required parameters. DON/ADON will be re-educated on policy A-A-05 - Abuse - Resident and Reasonable Suspicion of a crime and timely reporting requirements. All staff will receive education regarding policy A-A-05 and timely reporting requirements. DON/ADON/Designee will audit all medication errors for abuse/neglect and timeliness of reporting weekly x4 and biweekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident R1, who was admitted with diagnoses including unspecified dementia, hypertension, and renal insufficiency. The deficiency was identified through a review of facility documentation, clinical records, and staff interviews. The facility's policy requires staff to document all care and services provided, including identification, evaluation, intervention, and attempts to revise the care plan to address changing needs. However, the review revealed that there was no care plan specifically addressing the resident's high blood pressure, despite it being a significant medical condition. Additionally, the facility did not follow the existing care plan for Resident R1's identified adverse behaviors, which included resisting care. The medication administration record showed inconsistencies in the application of a prescribed Clonidine patch, with some entries left blank and no documentation of the resident's refusal or staff's attempts to address the refusal. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of a care plan for high blood pressure and acknowledged the failure to follow the care plan for behavioral issues related to medication refusal.
Plan Of Correction
Resident R1's care plan was immediately updated upon return from hospital. All like residents, with Hypertension and Dementia, that interferes with daily living, will have care plan(s) and orders to prevent or lessen the risk of negative outcomes as it relates to the diagnoses and adverse behaviors. All staff will receive education on policy N-A-01 All Policy and Procedures: General Guidelines, N-A-40 Assessment-MDS/RAI and Care Planning and N-A-44 Assessment-Comprehensive Person-Centered Care Planning. DON/ADON/Designee to audit all current care plans to ensure proper interventions for all residents as it relates to Hypertension and Dementia, potential interference with activities of daily living and med refusals, and able to document use of interventions in EMR weekly x4 and bi-weekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.
Failure to Administer Clonidine Patch Leads to Hospitalization
Penalty
Summary
The facility failed to adhere to a physician's order for a resident, resulting in a significant health event. The resident, who was admitted with diagnoses including unspecified dementia, hypertension, and renal insufficiency, was prescribed a weekly Clonidine patch to manage their blood pressure. However, the medication administration record (MAR) showed that the patch was not applied as scheduled on several occasions, with no documented reason for the omission on December 6th. This oversight led to the resident experiencing elevated blood pressure and other symptoms, necessitating hospitalization. Upon review, it was discovered that the resident had not received the Clonidine patch for several weeks, leading to Clonidine withdrawal and uncontrolled hypertension. The resident was sent to the emergency room with symptoms including elevated blood pressure, increased pulse, and vomiting. The hospital staff identified the presence of an old Clonidine patch dated from a previous month, indicating a lapse in medication administration. Additionally, the resident was mistakenly given Hydralazine, to which they were allergic, further complicating their condition. Interviews with the resident's family and facility staff confirmed the failure to follow the physician's order for the Clonidine patch. The family was informed of the resident's condition and the medication error after the resident was already hospitalized. The facility's administration acknowledged the oversight and the failure to identify the issue until alerted by the hospital, highlighting a significant lapse in the facility's medication administration and monitoring processes.
Plan Of Correction
Initial audit was performed by DON/ADONs of all medication patches. Initial education was provided to all licensed staff on policy N-M-05 Medication Administration General Guidelines and N-M-115 Medication Administration Transdermal. All licensed nursing staff will be educated on N-M-05 Medication Administration General Guidelines, N-M-115 Medication Administration Transdermal and N-M-150 Medication Error Reporting, Analysis and Correction (MERF). DON/ADON/Designee to audit medication patches weekly x4 and bi-weekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.
Failure to Provide Appropriate Food Consistency
Penalty
Summary
The facility failed to provide food in the appropriate consistency for a resident with specific dietary needs. The resident, who was admitted with diagnoses including muscle weakness, hemiplegia/hemiparesis following cerebral infarction, and dysphagia, had a physician's order for a pureed diet with thin liquids. However, on the morning of October 13, 2024, the resident was given a regular diet instead of the prescribed pureed diet. This led to an episode where the resident experienced coughing and required suctioning after consuming some of the regular consistency food items, such as French toast and oatmeal. The incident was confirmed by the Nursing Home Administrator during an interview on October 16, 2024.
Inadequate Supervision Leads to Choking Incidents
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident R52, who experienced two choking episodes. The first incident involved the resident ingesting chewing tobacco pouches and a paper towel, which led to a fall and a laceration on the forehead. Despite the resident's known diagnosis of Pica, a condition characterized by eating non-food items, the facility did not update the resident's care plan following this incident. The resident's care plan had previously identified risks related to placing non-food items in her mouth and taking food from other residents' trays, but interventions were not effectively implemented to prevent these behaviors. In a subsequent incident, Resident R52 was found choking on food items, including long red onions, which required the Heimlich maneuver to be performed by nursing staff. This episode occurred despite the resident being on a prescribed puree diet due to dysphagia, a condition that makes swallowing difficult. The facility's failure to provide one-to-one supervision and to ensure that non-food items and inappropriate food were kept out of the resident's reach contributed to the choking incident. Interviews with staff revealed a lack of consistent monitoring and supervision for Resident R52, despite her known risks. The Director of Nursing confirmed that the facility did not contact poison control after the first incident and did not update the resident's care plan. Staff members expressed an understanding of the need to monitor residents with Pica closely, but the facility's management did not ensure that these practices were consistently followed, leading to actual harm for Resident R52.
Improper Food Storage and Labeling in Main Kitchen
Penalty
Summary
The facility failed to adhere to its food storage policy, which requires food products to be labeled and dated with the receiving date, and to ensure that chemicals are not stored with food and paper supplies. During an observation in the Main Kitchen's walk-in cooler, an opened gallon of iced tea, an opened half-gallon container of lemonade, and a plastic container of peaches were found without labels or dates. This was confirmed by the Food Service Director (FSD) Employee E18, indicating a failure to properly label and date opened food packages to prevent foodborne illness. Additionally, during another observation, an opened bottle of iced tea was found stored in the chemical room among chemicals, which was also confirmed by FSD Employee E18. This indicates a failure to properly segregate food and chemicals, further violating the facility's food storage policy.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for four residents. The facility's policy required that specific information, including contact details of the practitioner and resident representative, advance directives, care plan goals, and other necessary medical information, be sent to the receiving facility. However, upon review, it was found that for Residents R2, R41, R81, and R118, there was no documented evidence that this information was communicated when they were transferred to the hospital and expected to return. Each of the residents had significant medical conditions, such as heart failure, hypertension, anemia, Alzheimer's disease, quadriplegia, and bipolar disorder, which necessitated clear communication of their care needs. Despite these requirements, the clinical records for these residents lacked documentation of the necessary information being sent to the receiving health care provider. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to communicate the required information for these residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to the Office of the Long-Term Care Ombudsman Division for three residents, identified as R2, R41, and R81, when they were transferred to the hospital. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The regulations under Title 42 Code of Federal Regulations S483.15(c)(5) require that a written notice of transfer or discharge must include specific information, such as the reason for transfer, effective date, location, appeal rights, and contact information for the Ombudsman. However, the facility did not document evidence of providing this notification for the mentioned residents. Resident R2, who had diagnoses of heart failure, hypertension, and anemia, was transferred to the hospital and returned to the facility without the required notification being sent. Similarly, Resident R41, with heart failure, hypertension, and depression, and Resident R81, with high blood pressure, Alzheimer's disease, and muscle wasting, were also transferred to the hospital and returned without the necessary notification to the Ombudsman. The Social Services Employee E11 confirmed the facility's failure to provide the transfer notice during an interview.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy dated 1/3/24. This policy mandates that written notice of the bed-hold policy be provided upon admission, during hospital transfers, or when a therapeutic leave exceeds 24 hours. However, for four residents (R2, R41, R81, and R118), there was no documented evidence that such notifications were given at the time of their respective hospital transfers. Resident R2, diagnosed with heart failure, hypertension, and anemia, was transferred to the hospital on 9/29/23 without receiving the required notification. Similarly, Resident R41, with heart failure, hypertension, and depression, was transferred on 1/13/24, and Resident R81, with high blood pressure, Alzheimer's disease, and muscle wasting, was transferred on 12/31/23, both without documented notifications. Resident R118, diagnosed with quadriplegia, bipolar disorder, and neck pain, was also transferred on 4/3/24 without receiving the necessary information. The Director of Nursing confirmed these deficiencies during an interview.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided with a summary of their completed baseline care plans within 48 hours of admission. This deficiency was identified for three residents, each with significant medical conditions. Resident R41, who was admitted with heart failure, hypertension, and depression, did not receive a summary of the baseline care plan. Similarly, Resident R71, with coronary artery disease, atrial fibrillation, and a seizure disorder, and Resident R82, with chronic kidney disease, depression, and diabetes, also did not receive their baseline care plan summaries. Interviews with facility staff confirmed the deficiency. The MDS Coordinator, Employee E16, admitted to not providing residents or their families with copies of the baseline care plans. The Director of Nursing also confirmed the facility's failure to provide these summaries for the three residents in question. This lack of documentation and communication with residents and their representatives is a violation of the facility's obligations under the specified Pennsylvania Code regulations.
Failure to Provide Trauma-Informed Care for PTSD Residents
Penalty
Summary
The facility failed to provide trauma-informed care to three residents diagnosed with PTSD, as required by their policy on Behavior Management and Trauma Informed Care. The policy mandates that the Interdisciplinary Team should identify and address triggers that could lead to distress in residents with PTSD. However, upon review of the care plans for Residents R83, R88, and R99, it was found that the facility did not identify specific triggers for these residents, nor did they outline strategies to avoid or mitigate these triggers. The deficiency was confirmed during an interview with Social Worker Employee E17, who acknowledged that the facility did not identify PTSD triggers for the affected residents. This oversight could potentially lead to re-traumatization of the residents, as their care plans lacked the necessary information to prevent or manage distressing situations. The facility's failure to adhere to its own policy and provide adequate trauma-informed care was noted as a deficiency under the relevant Pennsylvania Code sections.
Failure to Obtain Hospice Diagnosis and Incomplete Documentation
Penalty
Summary
The facility failed to obtain a diagnosis for hospice services for four residents, which is a requirement for hospice care admission. The residents involved had various medical conditions, including stroke, dysphagia, muscle wasting, heart failure, hypertension, depression, Alzheimer's disease, and malnutrition. Despite these conditions, the physician orders for hospice services did not include a diagnosis related to the need for hospice care, which is necessary for the approval and authorization of hospice services according to the facility's policy. Additionally, the facility did not maintain a complete hospice communication binder for one resident. The binder, which is essential for communication between the facility and the hospice agency, was missing critical documents such as the resident's plan of care, consents, orders, and the facility notification of hospice admission form. This lack of documentation was confirmed during an interview with the Nursing Home Administrator, highlighting a deficiency in the facility's management of hospice services.
Incomplete Investigation of Choking Incident
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving potential neglect for a resident, identified as Resident R52, who experienced a choking incident. The facility's policy on abuse and neglect defines neglect as the failure to provide necessary goods and services to avoid physical harm or distress. However, the investigation into the incident involving Resident R52 was incomplete, as it did not include a witness statement from a nurse aide who was present during the event. Resident R52, who has a history of dementia, intellectual disabilities, and dysphagia, was involved in an incident where she ingested non-food items, including chewing tobacco pouches and a paper towel, leading to a choking episode. The resident was found on the floor with a laceration on her forehead and cyanotic in the face. After vomiting the ingested items, her condition improved. The incident was captured on security footage, showing Resident R52 taking the contents of another resident's chew cup and later falling in the hallway. The facility's investigation documentation was incomplete, as it failed to include a statement from NA Employee E3, who was seen on security footage interacting with Resident R52 shortly before the fall. The Director of Nursing confirmed that the investigation was not thorough, as she was on vacation at the time, and a statement from the nurse aide was not obtained. This lack of a complete investigation highlights the facility's failure to adhere to its policies and procedures regarding neglect.
Failure to Investigate Choking Incident Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation of a choking incident involving a resident, identified as Resident R52, who has a history of dementia, intellectual disabilities, and dysphagia. The resident's care plan noted a tendency to place non-food items in her mouth due to pica, with goals to prevent choking or aspiration on such items. On the day of the incident, Resident R52 was found on the floor with a laceration on her forehead and cyanotic in the face. Upon assessment, she began vomiting clear brown fluid with a strong smell of tobacco, along with 3-5 pouches of chewing tobacco and a paper towel, which she had ingested. The incident was captured on security footage, showing Resident R52 entering the dining hall and putting the contents of another resident's chew cup into her mouth. Despite the presence of staff, including a nurse aide who appeared to attempt to take something from Resident R52, the resident was able to ingest the tobacco pouches and paper towel. The facility's investigation documentation was incomplete, as it failed to include a witness statement from the nurse aide involved, NA Employee E3, who did not return a call from the State Agency for a statement. The Director of Nursing confirmed that the facility did not conduct a thorough investigation of the incident, as she was on vacation at the time and assumed a statement was not obtained from NA Employee E3. This lack of a comprehensive investigation to rule out neglect was identified as a deficiency by the surveyors, as it did not comply with the facility's policy on abuse and neglect, which requires obtaining written statements from all parties involved in such incidents.
Failure to Notify Physician and Obtain Orders for Residents
Penalty
Summary
The facility failed to notify the physician of abnormal Capillary Blood Glucose (CBG) levels and did not assess a resident for hyperglycemia and hypoglycemia. Specifically, Resident R73, who had diagnoses of diabetes, muscle weakness, and depression, had several instances of abnormal CBG readings. On multiple occasions, the resident's CBG levels were either low or high, yet the facility did not implement its policy to assess the resident for hyper-/hypoglycemia or notify the physician of these abnormal results. Additionally, the facility did not obtain necessary physician orders for another resident, Resident R369, who had diagnoses of diabetes, chronic kidney disease, and osteoarthritis. This resident experienced episodes of emesis and an elevated temperature, prompting the facility to perform a Quad swab to rule out various respiratory viruses. However, the clinical record lacked a physician's order for the Quad swab and for placing the resident in isolation while awaiting test results. The Director of Nursing confirmed these deficiencies during interviews, acknowledging the failure to notify the physician of abnormal CBG levels for Resident R73 and the lack of physician orders for the Quad swab and isolation for Resident R369. These actions and inactions led to the identified deficiencies in the facility's care and services.
Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for the use of urinary catheters for two residents. Resident R2, who has diagnoses of heart failure, hypertension, and anemia, was observed with a urinary drainage bag hanging from the bed frame without a dignity bag, contrary to the facility's policy. The physician's order for Resident R2 required catheter care every shift for wound healing, but the observation indicated non-compliance with the policy to cover drainage bags with a dignity bag. Resident R82, diagnosed with diabetes, depression, and chronic kidney disease, was observed with an opened piston and irrigation catheter tray on the nightstand, dated two days prior to the observation. The facility's policy requires that open solutions be discarded after twenty-four hours, and the physician's order for Resident R82 specified flushing the urinary catheter with saline water three times a day. The LPN confirmed the tray was not changed daily as required, and the DON acknowledged the facility's failure to provide appropriate catheter care for these residents.
Failure to Provide Colostomy Care as per Professional Standards
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for Resident R41. The facility's policy on Colostomy and Ileostomy Care, dated January 3, 2024, requires that residents needing ostomy care receive it in accordance with professional standards, and that staff notify a practitioner if there are changes to the stoma or skin. However, upon review of Resident R41's current physician orders on June 24, 2024, it was found that there were no physician orders for colostomy care, including the type and size of the appliance or wafer, type of collection bag, or instructions to monitor the colostomy site. Resident R41, who was admitted to the facility with diagnoses of heart failure, hypertension, and depression, was observed to have a colostomy. Despite this, the necessary physician orders for colostomy care were missing. During interviews, both a Licensed Practical Nurse and the Director of Nursing confirmed the absence of these orders, indicating a failure to adhere to the facility's policy and professional standards of practice. This deficiency was identified for one of the three residents reviewed.
Failure to Implement Enhanced Barrier Precautions and Track Infections
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for two residents, R1 and R63, who had indwelling urinary catheters. Despite the presence of personal protective equipment (PPE) and signage indicating the need for gowns and gloves during high-contact care activities, staff members did not comply with these precautions. For Resident R1, two employees were observed taking the resident to the shower without wearing gowns, and one of the employees, NA Employee E14, admitted to not knowing about the requirement due to a lack of education on EBP. Similarly, for Resident R63, NA Employee E2 provided care without wearing a gown, dismissing the precautionary signage as unnecessary. Additionally, the facility failed to track active infections for Resident R369, who had experienced symptoms such as emesis and an elevated temperature. Despite performing a Quad swab to rule out respiratory viruses, the facility's Precaution List did not include tracking or precautions for this resident while awaiting test results. This oversight was confirmed by the Director of Nursing, indicating a lapse in the facility's infection prevention and control program. The deficiencies highlight a lack of adherence to established infection control policies and procedures, as well as inadequate staff education and monitoring. The facility's policies clearly outline the need for EBP in residents with indwelling medical devices, yet staff failed to implement these precautions, potentially increasing the risk of transmission of multidrug-resistant organisms. Furthermore, the failure to track active infections demonstrates a gap in the facility's ability to manage and prevent the spread of communicable diseases.
Resident Elopement Due to Inadequate Supervision and Faulty Security Measures
Penalty
Summary
The facility failed to provide adequate supervision, resulting in the elopement of a resident (Resident R1). Resident R1, who had a history of vertebra fracture, chronic kidney disease, coronary artery disease, dementia, and a paralytic gait, was found outside the facility near the employee entrance. The resident's care plan indicated that he should remain in common areas for increased supervision. However, on the day of the incident, Resident R1 was able to leave the building unsupervised by pushing through an employee exit door with a faulty magnetic lock. The security footage showed that the resident wandered through the facility, exited through the double doors with the assistance of a dietary aide who did not notice anything wrong, and eventually exited the building through the employee exit door after multiple attempts to push it open. The security guard was not at the desk at the time of the incident because they were assisting with a new admission and opening the respiratory room. The dietary aide who saw Resident R1 did not think anything was wrong because the wander guard alarm did not go off. The magnetic lock on the employee exit door was found to disengage when pushed hard enough, and it was later discovered that rust and debris had affected its functionality. The resident was found by a bystander from a nearby apartment building, who alerted the facility staff. The resident was assessed and assisted back inside the building, where he was found to have a small skin tear but no other significant injuries. Interviews with various staff members revealed that there was a lack of awareness and proper supervision at the time of the incident. The facility's elopement policy was not effectively followed, and the security measures in place were insufficient to prevent the resident from leaving the building. The incident highlighted the need for better supervision, functional security systems, and adherence to the facility's policies to ensure resident safety.
Inadequate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and services for six residents with indwelling urinary catheters. Observations revealed that several residents had their urinary drainage bags uncovered and placed on the floor, contrary to facility policy and CDC guidelines. Specifically, Residents R1, R2, and R3 were observed with their drainage bags uncovered and on the floor, which is against the facility's policy to store collection bags inside a protective dignity pouch and to keep the collecting bag below the level of the bladder. Resident R4 expressed concerns about the nursing staff's ability to manage her catheter care, including issues with staff not knowing how to properly handle her catheter and an aide's inability to empty her catheter due to long nails. This was confirmed by the Nursing Home Administrator. Additionally, Resident R5's urinary drainage bag was improperly placed on the bed between her feet and above the level of the bladder, which was confirmed by an LPN. Resident R6, who no longer had an indwelling catheter, had no documentation of required bladder scans following catheter removal, as confirmed by the Acting Director of Nursing. The facility's failure to adhere to its own policies and CDC guidelines resulted in inappropriate catheter care for all six residents. The Nursing Home Administrator confirmed the deficiencies, which included uncovered catheter bags, improper placement of drainage bags, and lack of documentation for required post-catheter removal procedures. These deficiencies highlight a lack of adherence to established protocols for catheter care and monitoring within the facility.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to notify the resident's representative of a change in prescribed medication for Resident R1. Resident R1, who was admitted with diagnoses including acute respiratory failure, muscle weakness, and dysphagia, was prescribed azithromycin for pneumonia. The medication administration record indicated that the resident received the antibiotic as ordered. However, there was no documentation of notification to the family regarding this change in medication. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to inform the resident's representative as required by the facility's policy and state regulations.
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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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