Julia Pound Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indiana, Pennsylvania.
- Location
- 1155 Indian Springs Road, Indiana, Pennsylvania 15701
- CMS Provider Number
- 395568
- Inspections on file
- 25
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Julia Pound Care Center during CMS and state inspections, most recent first.
Multiple dietary aides were observed plating and serving food with portions of their hair not properly covered by hairnets while working around uncovered food, in violation of the facility's hygiene policy. The Dietary Manager confirmed that staff should have had their hair fully covered during food preparation and service.
The facility did not accurately complete MDS assessments for four residents, including errors in coding residents' communication abilities and cognitive status, and incorrectly documenting a resident's discharge location. These inaccuracies were confirmed through record review and staff interviews.
The facility did not update care plans for two residents after significant changes in their care needs. One resident's care plan continued to reference the use of PRAFO boots even after they were discontinued, while another resident's plan still included monitoring urine output after her catheter was removed and she became incontinent. These lapses were confirmed by staff interviews and review of clinical records.
Staff failed to document the administration of controlled pain medications for two residents, despite signing out doses on the controlled drug record. In both cases, there was no evidence in the clinical records or MARs to confirm that the medications were given as required by facility policy.
Surveyors found that opened medications in two medication carts were not labeled with the required date opened and expiration date stickers, and expired medical supplies were present in a medication room. LPNs and the DON confirmed that these items were in use and not properly labeled or removed, contrary to facility policy.
The QAPI committee failed to correct and prevent recurring deficiencies in assessment accuracy, care plan timing and revision, pharmacy services, and food safety. Despite previous plans of correction, the same issues were cited again, showing ineffective monitoring and oversight by the committee.
A resident with pressure ulcers, who had a physician's order for Enhanced Barrier Precautions (EBP), did not have required EBP signage posted outside their room, and an LPN performed wound care without donning a gown as required. Facility leadership confirmed that both the signage and proper PPE use were necessary according to policy and current CDC guidance.
A resident with cognitive impairment and a history of sternal fracture was transferred into a recliner chair by a nurse aide who was unaware of the resident's restriction against recliner use. The care plan intervention was not linked to the aide's electronic charting, resulting in the resident falling and sustaining a sternal fracture.
A resident with diabetes and dementia did not receive prescribed insulin doses and blood glucose monitoring as ordered. The MAR showed missing documentation for Lantus Solostar and insulin lispro administration, as well as unrecorded blood glucose checks. The DON confirmed these omissions.
A resident with diabetes and dementia did not receive multiple prescribed medications on specific dates, as confirmed by the MAR review and the DON. The facility failed to follow physician's orders, impacting the resident's treatment and care.
A facility failed to maintain accurate clinical records for a resident with diabetes and dementia. Documentation inaccurately stated that the resident ate 100% of her lunch, while a grievance investigation revealed the tray was removed untouched by the DON. This discrepancy was confirmed by the DON.
The facility failed to maintain accountability for controlled medications for two residents. One resident had discrepancies between the controlled drug record and the MAR for hydrocodone-acetaminophen, with no documented evidence of administration. Another resident had a significant discrepancy in the amount of Lorazepam, with doses signed out but not documented on the MAR. The DON confirmed the lack of documentation and missing medication.
The facility failed to discard expired Nepro nutritional milkshakes in the Crossroads unit, with 18 expired drinks found in the medication room and pantry refrigerator. The Dietary Manager confirmed these should have been discarded, violating the facility's food storage policy.
A facility failed to maintain complete clinical records for a resident with an indwelling catheter, as there was no documented evidence of catheter care on multiple dates. The resident, who was cognitively intact and had a history of urinary tract infections, was admitted to the hospital for a severe infection attributed to inadequate catheter care. The Director of Nursing confirmed the lack of documentation, highlighting a failure to adhere to the care plan.
A facility failed to document the opportunity for a resident to formulate advance directives, as required by policy. Despite being cognitively intact and needing care assistance, the resident's clinical record lacked evidence of offered assistance or the resident's decision regarding advance directives. An interview with the Nursing Home Administrator confirmed this documentation gap.
A resident's wheelchair was found with a moderate accumulation of dust and debris, despite the facility's policy to maintain a clean environment. Staff interviews confirmed the oversight, with a housekeeper admitting the wheelchair should have been cleaned as needed. The resident, who requires assistance due to heart failure and osteoarthritis, was observed in this condition on multiple occasions.
A resident with a history of wandering and verbal aggression entered another resident's room and physically assaulted him, resulting in physical harm. The facility lacked an effective plan to manage the wandering resident's behavior, relying solely on a wanderguard, which failed to prevent the incident. The Director of Nursing confirmed the absence of a comprehensive plan to address the wandering behavior.
The facility failed to provide written notification to residents and their responsible parties regarding hospital transfers for four residents. These residents, with varying cognitive and medical conditions, were transferred for issues such as gastrointestinal bleeding, chest pain, behavioral health concerns, and medical evaluations without the required written notices. Interviews confirmed the lack of compliance with notification regulations.
The facility failed to notify residents and/or their responsible parties about the bed-hold policy upon hospital transfers, as required by their policy. This deficiency was identified for four residents, including those with cognitive impairments and those requiring assistance for daily care. Interviews confirmed the lack of documentation for these notifications, violating resident rights and clinical record-keeping regulations.
The facility did not complete admission MDS assessments within the required 14-day timeframe for three residents. The assessments were completed 15, 20, and 16 days after admission, respectively, as confirmed by the RNAC responsible for these assessments.
The facility failed to accurately complete MDS assessments for two residents. One resident's assessment did not reflect the administration of an antibiotic for a urinary tract infection, despite it being given during the look-back period. Another resident's assessment incorrectly indicated that a BIMS interview should not be attempted, despite the resident being clearly understood. These errors were confirmed by the RN Assessment Coordinator.
The facility failed to develop baseline care plans for two residents, one receiving a diuretic and another with dementia and respiratory issues. Despite physician's orders, there was no documented care plan for their specific needs, confirmed by the DON.
A facility failed to update a resident's care plan to reflect the need for a long-term antibiotic for recurrent UTIs. The resident, who had a foley catheter and neurogenic bladder, was cognitively intact and required assistance with care needs. Despite a care plan for recurrent UTIs, it was not revised to include the physician-ordered Nitrofurantoin. This was confirmed by the DON.
The facility failed to follow physician's orders for medication administration for two residents. One resident received a blood pressure medication despite having a systolic blood pressure below the prescribed threshold, while another resident was given a higher dose of Lorazepam than ordered. These discrepancies were confirmed by the DON.
The facility failed to obtain required hospice recertification documentation for two residents receiving hospice services. One resident, moderately cognitively intact, had no documented evidence of recertification since starting hospice care. Another cognitively intact resident also lacked certification documentation. Both deficiencies were confirmed by the Nursing Home Administrator.
The facility's QAPI committee failed to address recurring deficiencies, including inaccuracies in MDS assessments, incomplete resident records, and issues with hospice services. Despite having plans of correction, the same deficiencies were identified in multiple surveys, indicating ineffective implementation of corrective actions.
Dietary Staff Failed to Properly Cover Hair During Food Service
Penalty
Summary
Dietary staff failed to adhere to the facility's personal hygiene policy, which requires that food be prepared, stored, and distributed in a safe and sanitary manner to prevent the spread of foodborne illness. During lunch meal service in the 100-200 hall kitchenette, multiple dietary aides were observed plating and serving food with portions of their hair not properly covered by hairnets. Specifically, one aide had three-inch tendrils of hair on each side of her head and two inches of loose hair at the nape of her neck exposed while plating baked beans and hot dogs. On a subsequent day, the same aide was observed with two inches of hair exposed while plating hamburgers and standing over uncovered pudding dishes. Additional observations revealed that another dietary aide had three to four inches of bangs outside her hairnet while placing drinks on trays over uncovered pudding, and a third aide had two inches of hair at the nape of her neck not covered by a hairnet while assisting with plating hamburgers. The Dietary Manager confirmed that all three aides should have had their hair fully covered when working around uncovered food. These findings indicate a failure to follow established sanitary practices during food preparation and service.
Inaccurate MDS Assessments and Discharge Documentation
Penalty
Summary
The facility failed to complete accurate and comprehensive Minimum Data Set (MDS) assessments for four residents. For three residents, the coding in Section B0700 indicated that the residents were at least sometimes understood by others, which should have prompted the completion of the Brief Interview for Mental Status (BIMS) in Sections C0200 through C0500. However, Section C0100 was incorrectly coded as 'No,' indicating the residents were rarely or never understood, and the BIMS interview was not completed as required. This discrepancy was confirmed by the Social Worker, who acknowledged the inaccurate coding on the MDS assessments for these residents. Additionally, for another resident, the discharge tracking MDS inaccurately recorded the discharge location. Nursing documentation showed that the resident was transferred to a local hospital for acute care, but the MDS indicated discharge to a nursing home. The Registered Nurse Assessment Coordinator confirmed that the wrong discharge location was entered on the MDS. These inaccuracies in the clinical records and MDS assessments were identified through review of the RAI User's Manual, clinical records, and staff interviews.
Failure to Update Care Plans Following Changes in Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect the current care needs of two residents. For one resident with muscular dystrophy and limited lower extremity range of motion, the care plan included the use of bilateral PRAFO boots with specific instructions for their application and removal. However, multiple observations revealed that the resident was not wearing the boots, and both the resident and therapy manager confirmed that the boots had been discontinued about one to two months prior due to discomfort and the resident's refusal to wear them. Despite this, the care plan was not revised to reflect the discontinuation of the PRAFO boots. For another resident who was cognitively intact and required maximum assistance for care, the care plan indicated frequent urinary tract infections and directed staff to monitor and record urinary output. Nursing documentation showed that the resident's indwelling urinary catheter had been removed and that she was now incontinent of urine. There was no evidence that the care plan was updated to reflect the change in urinary status or to revise interventions accordingly. The Director of Nursing confirmed that the care plan should not have included instructions to monitor urine output after the catheter was removed.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for two residents. Facility policy required that staff administering medications document the administration on the Medication Administration Record (MAR) immediately after giving the medication. For one resident, who was cognitively intact and receiving Tramadol for pain, the controlled drug record showed that multiple doses were signed out on specific dates and times, but there was no documentation in the clinical record or MAR to confirm that these doses were actually administered. This lack of documentation was confirmed by the Assistant Director of Nursing. Similarly, another resident, who was cognitively impaired with dementia and chronic pain syndrome and had orders for Tramadol as needed, had several doses signed out on the controlled drug record. However, there was no evidence in the clinical record that these doses were administered. The Assistant Director of Nursing also confirmed the absence of documentation for these administrations. These findings indicate that the facility did not ensure proper documentation and accountability for controlled substances as required by policy and regulation.
Failure to Label Opened Medications and Remove Expired Medical Supplies
Penalty
Summary
Surveyors identified that the facility failed to properly label and date medications after opening, as required by facility policy and professional standards. Specifically, in two of three medication carts reviewed, several topical medications, including diclofenac sodium gel, triamcinolone cream, and ammonium lactate cream, were found in use with broken seals but without the required date opened and expiration date stickers. Staff interviews confirmed that these medications were in use and should have been labeled according to policy. Additionally, in one of two medication rooms reviewed, multiple expired medical supplies were found in storage, including normal saline flushes, syringes, angiocaths of various sizes, culture and sensitivity test kits, blood drawing needles, claves, hemoccult developer, and hemoccult test screening cards. Staff interviews, including with the DON, confirmed that expired equipment should not be in circulation and that opened medications should be properly labeled, as per facility policy.
Repeated QAPI Failures in Addressing Quality Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to effectively address and correct recurring quality deficiencies, as evidenced by repeated citations in multiple areas. Despite developing plans of correction following a previous survey, the QAPI committee did not ensure sustained compliance with regulations related to the accuracy of assessments, care plan timing and revision, pharmacy services, and food safety. The current survey identified that the same deficiencies cited in the prior survey persisted, indicating that the QAPI committee's monitoring and oversight were ineffective. Specifically, deficiencies were again found under F641 for accuracy of assessments, F657 for care plan timing and revision, F755 for pharmacy services, and F812 for food safety. The facility's previous plans of correction had stated that these areas would be monitored by the QAPI committee, but the recurrence of these issues in the current survey demonstrates that the committee did not maintain compliance with the cited regulations.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC regarding Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers. According to facility policy and current CDC guidance, residents with chronic wounds require the use of gloves and gowns during high-contact care activities, such as wound care, and appropriate signage must be posted to alert staff of these requirements. However, during an observation of wound care for a resident with pressure ulcers, there was no EBP signage posted outside the resident's door, and the LPN performing the wound care did not don a gown as required by EBP protocols. Interviews with the RN Supervisor and the Assistant Director of Nursing confirmed that the resident should have had EBP signage and that the LPN should have worn a gown during wound care. The resident was cognitively intact and had a physician's order for EBP isolation due to pressure ulcers. The failure to implement these infection control measures was identified through review of clinical records, facility policy, and direct observation.
Failure to Communicate Resident Safety Restrictions Leads to Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was cognitively impaired and had a diagnosis of dementia and a sternal fracture, was transferred into a recliner chair by a nurse aide. The resident's care plan and therapy recommendations clearly indicated that she was not safe to sit in a recliner chair. Despite these documented interventions, the nurse aide was unaware of this restriction and proceeded to transfer the resident into the recliner in the TV room. Shortly after being placed in the recliner, the resident was found on the floor in front of the chair, complaining of severe pain under her right arm and chest. She was subsequently sent to the hospital, where an x-ray confirmed a sternal fracture. The incident investigation revealed that the nurse aide had transferred the resident into the recliner less than five minutes before the fall occurred. Further review determined that the care plan intervention regarding recliner safety was not linked to the nurse aide's electronic charting system, making the information inaccessible to the nurse aide. Interviews with facility leadership confirmed that the nurse aide did not have access to the necessary care plan information and was therefore unaware of the resident's restriction regarding recliner use.
Failure to Administer Insulin and Monitor Blood Glucose
Penalty
Summary
The facility failed to ensure that physician's orders were followed, resulting in significant medication errors for a resident with diabetes and dementia. The resident was supposed to have her blood glucose levels checked before meals and at bedtime, and receive specific doses of Lantus Solostar and insulin lispro according to a sliding scale. However, there was no documented evidence that the resident received 25 units of Lantus Solostar insulin at bedtime on a specific date, nor that she received 6 units of insulin lispro at various meal times on multiple dates. Additionally, there was no documentation of blood glucose checks before breakfast and at bedtime on several occasions, and no sliding scale insulin coverage was provided as required. The Medication Administration Record (MAR) revealed multiple instances where the resident's blood glucose levels were recorded, but the corresponding insulin lispro doses were not administered as per the physician's orders. For example, on one occasion, the resident's blood glucose was 172 mg/dL, requiring 2 units of insulin lispro, but there was no evidence of administration. Similarly, on another occasion, the resident's blood glucose was 361 mg/dL, requiring 10 units of insulin lispro, but again, there was no documentation of administration. An interview with the Director of Nursing confirmed the lack of documented evidence for the administration of blood glucose checks and insulin as ordered.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to follow physician's orders for a resident, identified as Resident 3, who had diagnoses including diabetes and dementia. The resident was prescribed several medications, including olanzapine, Tylenol, probiotics, buspirone, duloxetine, mirtazapine, rosuvastatin, and potassium chloride. However, a review of the Medication Administration Record (MAR) for November and December 2024 revealed that there was no documented evidence that the resident received these medications on specific dates as ordered by the physician. The Director of Nursing confirmed the lack of documentation for the administration of these medications during an interview. This deficiency was identified during a clinical record review and staff interviews, indicating a failure to provide appropriate treatment and care according to the physician's orders and the resident's needs.
Inaccurate Documentation of Resident's Meal Consumption
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, as evidenced by discrepancies in documentation regarding the resident's meal consumption. A quarterly Minimum Data Set (MDS) assessment indicated that the resident, who had diabetes and dementia, was sometimes understood and could sometimes understand others. On December 3, 2024, nurse aide documentation inaccurately recorded that the resident ate 100 percent of her lunch meal. However, a grievance investigation revealed that the resident's lunch tray was removed from her room by the Director of Nursing at 3:45 p.m., and the resident did not eat anything from the tray. This discrepancy was confirmed by the Director of Nursing during an interview on December 16, 2024.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents. For Resident 67, who was cognitively intact and dependent on staff for daily care, there were discrepancies between the controlled drug record and the Medication Administration Record (MAR) for hydrocodone-acetaminophen. The controlled drug record indicated that doses were signed out as administered on several dates, but there was no documented evidence on the MAR that these doses were actually given. The Director of Nursing confirmed the lack of documentation for these doses. For Resident 80, who was cognitively impaired and required substantial assistance, there were issues with the accountability of Lorazepam. The controlled drug record showed a significant discrepancy in the amount of Lorazepam remaining in the medication bottle, with 14.75 ml unaccounted for. Additionally, doses of Lorazepam were signed out as administered on specific dates, but the MAR did not reflect these administrations. The Director of Nursing confirmed the missing Lorazepam and the lack of documentation for the signed-out doses.
Expired Nutritional Drinks Found in Facility
Penalty
Summary
The facility failed to ensure that nutritional drinks in the medication room and pantry were not expired. During observations in the Crossroads medication room, it was found that nine Nepro nutritional milkshakes, which are protein drinks generally used for dialysis residents, had expired. Similarly, in the Crossroads pantry refrigerator, another nine Nepro nutritional milkshakes were found to be expired. The Dietary Manager confirmed that a total of 18 expired Nepro nutritional milkshakes were in circulation on the Crossroads unit and should have been discarded earlier. This finding is in violation of the facility's policy regarding food storage, which mandates that food be stored under safe and sanitary conditions to prevent injury and food-borne illness.
Failure to Document Catheter Care for a Resident
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for Resident 60, as evidenced by the absence of documented catheter care on multiple dates across several months. Resident 60, who was cognitively intact and required assistance with care needs, had an indwelling catheter and a history of urinary tract infections. The resident's care plan, dated February 12, 2024, included an intervention for catheter care every shift. However, a review of the daily nurse aide charting revealed numerous instances where there was no documented evidence of catheter care being completed on specified dates during the day, evening, and night shifts. An interview with Resident 60 on July 11, 2024, revealed that she was admitted to the hospital for a severe urinary tract infection, which the hospital attributed to inadequate catheter care. Although the resident stated that the nurse aides performed good catheter care, she noted the difficulty due to her contracted legs. The Director of Nursing confirmed the lack of documented evidence for catheter care on the specified dates and shifts, indicating a failure to adhere to the care plan and maintain accurate clinical records as required by professional standards.
Failure to Document Advance Directive Assistance
Penalty
Summary
The facility failed to address and document the opportunity for a resident to formulate advance directives, as required by their policy. The policy, dated March 13, 2024, mandates that if a resident does not have an advance directive, staff must inform them or their representative of their right to establish one and provide assistance if desired. This must be documented in the resident's medical record. However, for Resident 70, who was cognitively intact and required assistance with care needs, there was no documented evidence that assistance was offered to formulate advance directives or that the resident's decision to accept or decline such assistance was recorded. The deficiency was identified during a review of facility policies, clinical records, and staff interviews. An admission checklist for Resident 70 indicated that information on advance directives was provided, but the clinical record lacked documentation of any follow-up actions or decisions regarding advance directives. An interview with the Nursing Home Administrator confirmed the absence of this documentation in Resident 70's clinical record, highlighting a failure to comply with the facility's policy and state regulations regarding resident rights.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident 27, as evidenced by observations and staff interviews. Resident 27, who is cognitively intact and requires assistance with daily care needs due to diagnoses including heart failure and osteoarthritis, was observed in his wheelchair with a moderate accumulation of removable dust and debris on the wheels and metal supports. This observation was made on two separate occasions, indicating a lapse in the facility's housekeeping practices. Interviews with staff, including a housekeeper and an LPN, confirmed the presence of the dirt and debris on the wheelchair. The housekeeper acknowledged that the wheelchair was last cleaned in June according to their documented process but admitted that it should have been cleaned as needed, given the heavy layer of dirt. The Nursing Home Administrator also confirmed that the wheelchair should have been clean, highlighting a failure to adhere to the facility's policy of providing a safe and clean environment for residents.
Failure to Protect Resident from Abuse by Wandering Resident
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving an incident where a resident who wanders, identified as Resident 78, entered the room of another resident, Resident 64, and physically assaulted him. Resident 64, who was understood and could understand others, had no behaviors, and required assistance with daily care needs, was attacked by Resident 78, who was known to have episodes of being loud and verbally aggressive and wore a wanderguard due to his wandering behavior. On the night of the incident, Resident 78 was found in Resident 64's room, standing over him and threatening to kill him. Resident 64 reported being hit all over his body and having hands placed around his neck, resulting in reddened areas around his neck and chest. The Director of Nursing confirmed that there was no plan in place to manage Resident 78's wandering behavior other than the use of a wanderguard, acknowledging that Resident 78 did hit and threaten Resident 64. The facility's policy on abuse, which mandates a safe environment free from abuse by anyone, was not effectively implemented in this case, leading to the failure to protect Resident 64 from abuse by another resident. The incident highlights a deficiency in the facility's management of residents with wandering behaviors and the lack of adequate measures to prevent such incidents.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their responsible parties regarding the reasons for hospital transfers, as required by regulations. This deficiency was identified for four residents during a review of clinical records and staff interviews. Resident 23, who was cognitively impaired and required assistance for daily care, was transferred to the hospital due to gastrointestinal bleeding without written notice to her responsible party. Similarly, Resident 36, who was cognitively intact and had muscular dystrophy and non-Alzheimer's dementia, was transferred to the hospital for chest pain and difficulty breathing without written notification to her responsible party. Resident 46, who was cognitively impaired and had multiple diagnoses including schizoaffective disorder and dementia, was transferred to a hospital for behavioral health issues without written notice to her responsible party. Additionally, Resident 67, who was cognitively intact and had paraplegia, was transferred to the hospital twice for medical evaluations without written notification to her responsible party. Interviews with the Nursing Home Administrator confirmed the lack of written notices for these transfers, violating resident rights and discharge policy regulations.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents and/or their responsible parties about the bed-hold policy upon transfer to the hospital, as required by their policy dated March 13, 2024. This deficiency was identified for four residents during a review of facility policies, clinical records, and staff interviews. Resident 23, who was cognitively impaired and required assistance for daily care, was transferred to the hospital due to gastrointestinal bleeding without documented notification of the bed-hold policy. Similarly, Resident 36, who was cognitively intact and required assistance, was transferred to the hospital for chest pain and difficulty breathing, but there was no evidence that the responsible party was informed of the bed-hold policy. Resident 46, who had cognitive impairments and required assistance, was transferred to the hospital for behavioral health issues without documented notification to the responsible party about the bed-hold policy. Additionally, Resident 67, who was cognitively intact and dependent on staff, was transferred to the hospital twice for medical evaluations without evidence of notification about the bed-hold policy. Interviews with the Nursing Home Administrator confirmed the lack of documentation for these notifications. The facility's failure to provide written notification of the bed-hold policy upon hospital transfers violated resident rights and clinical record-keeping regulations.
Delayed Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required time frame for three residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following a resident's admission. However, the assessment for one resident was completed 15 days after admission, another 20 days after admission, and a third 16 days after admission. These delays were confirmed during an interview with the Registered Nurse Assessment Coordinator, who is responsible for completing MDS assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For one resident, there was a physician's order for the administration of Ceftazidime, an antibiotic, every eight hours for seven days to treat a urinary tract infection. Despite the medication being administered during the seven-day look-back period, the MDS assessment did not reflect this, as Section N0415F was not coded to indicate the receipt of antibiotic medication. This discrepancy suggests a failure to accurately document the resident's medication administration in the MDS assessment. Another resident's quarterly MDS assessment was inaccurately coded in Section B0700 as clearly understood, yet Section C0100 was marked as 'no,' indicating that a Brief Interview for Mental Status (BIMS) should not be attempted. According to the Resident Assessment Instrument (RAI) User's Manual, if a resident is at least sometimes understood, a BIMS interview should be conducted. The incorrect coding led to the omission of the BIMS interview, which should have been attempted given the resident's ability to be clearly understood. The Registered Nurse Assessment Coordinator confirmed these coding errors, highlighting a lapse in the facility's assessment process.
Failure to Develop Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure that baseline care plans included the necessary information and instructions to provide person-centered care for two residents. For one resident, who was moderately cognitively impaired and receiving a diuretic, there was no documented evidence of a care plan addressing the individual's care needs related to the diuretic use. This was confirmed by the Director of Nursing during an interview. Another resident, who was cognitively intact but experienced hallucinations and required supplemental oxygen, also lacked a care plan addressing their dementia with hallucinations and altered respiratory status. Despite having physician's orders for medications and oxygen, there was no care plan developed to address these specific needs. The Director of Nursing confirmed the absence of such a care plan during an interview.
Failure to Update Care Plan for Long-term Antibiotic Use
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 60, to reflect changes in care needs. The resident, who was cognitively intact and required assistance with care needs, had a significant Minimum Data Set (MDS) assessment indicating the presence of a foley catheter, a recent urinary tract infection, and a diagnosis of neurogenic bladder. Despite having a care plan dated June 11, 2024, for recurrent urinary tract infections related to neurogenic bladder, there was no documented evidence that the care plan was revised to include the need for a long-term antibiotic, Nitrofurantoin, which was ordered by the physician on February 24, 2024, for recurrent urinary tract infections. This oversight was confirmed during an interview with the Director of Nursing on July 11, 2024.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for two residents, leading to deficiencies in care. Resident 62, who was cognitively intact and had diagnoses including atrial fibrillation and dementia, was prescribed Triamterene-hydrochlorothiazide with specific instructions to withhold the medication if the systolic blood pressure was below 110 mmHg. However, the medication was administered multiple times in May and June 2023 when the resident's systolic blood pressure was below the prescribed threshold, as confirmed by the Director of Nursing. Similarly, Resident 80, who required assistance with daily care and had a diagnosis of dementia, was prescribed 0.25 ml of Lorazepam for anxiety. Despite this, the resident was administered 0.5 ml of Lorazepam on two occasions in July 2024, exceeding the prescribed dose. This discrepancy was also confirmed by the Director of Nursing. These actions indicate a failure to follow the physician's orders, as required by the facility's medication administration policy.
Failure to Obtain Hospice Recertification Documentation
Penalty
Summary
The facility failed to obtain the required hospice recertification of terminal illness documentation from the contracted hospice provider for two residents receiving hospice services. Resident 8, who was moderately cognitively intact and required assistance for daily care, had been receiving hospice services since August 23, 2023. However, as of July 9, 2024, there was no documented evidence in either the resident's clinical record or the hospice provider's record that the facility had obtained the necessary recertification of terminal illness from the hospice provider. This was confirmed during an interview with the Nursing Home Administrator. Similarly, Resident 34, who was cognitively intact and also required assistance for daily care, had been receiving hospice services since March 17, 2023. As of July 9, 2024, there was no documented evidence in the resident's clinical record or the hospice provider's record that the facility had obtained the required certification/recertification of terminal illness from the hospice provider. This deficiency was also confirmed during an interview with the Nursing Home Administrator. The facility's failure to obtain these critical documents from the hospice provider constitutes a violation of the facility's policy and regulatory requirements.
Repeated Deficiencies in MDS Assessments and Records
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in multiple surveys. The deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, incomplete and inaccurate resident records, and issues with hospice services. Despite having plans of correction in place, the facility was unable to maintain compliance with the cited nursing home regulations. The QAPI committee's inability to implement these plans successfully was highlighted in the current survey, which identified the same deficiencies as previous surveys. The facility had previously developed plans of correction that involved conducting audits and reporting the results to the QAPI committee for review. However, the current survey revealed that these plans were not effectively implemented, as the same deficiencies were cited again. Specifically, the facility failed to ensure the accuracy of MDS assessments, maintain complete and accurate medical records, and comply with regulations regarding hospice services and records. These repeated deficiencies indicate a lack of effective action by the QAPI committee to address and resolve the issues identified in past surveys.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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