Juniper Village At Brookline-rehabilitation And Sk
Inspection history, citations, penalties and survey trends for this long-term care facility in State College, Pennsylvania.
- Location
- 1950 Cliffside Drive, State College, Pennsylvania 16801
- CMS Provider Number
- 395756
- Inspections on file
- 17
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Juniper Village At Brookline-rehabilitation And Sk during CMS and state inspections, most recent first.
The facility did not meet the required nurse aide staffing levels as per Pennsylvania regulations. During the day shift, the facility was understaffed on four occasions, with insufficient nurse aides for the resident census. On September 1, November 24, November 29, and January 18, the number of nurse aides fell short of the required amount. Additionally, on January 19, the night shift was also understaffed. These deficiencies were identified through a review of nursing staff care hours and staff interviews.
The facility did not meet the required LPN staffing levels on the day shift, with only 2.00 LPNs scheduled for 53 residents, falling short of the required 2.12 LPNs. This deficiency was identified during a review of staffing hours for specific periods, and the DON was informed of the findings.
The facility failed to maintain the ambulation and strength of two residents as per their restorative nursing programs. One resident's ambulation program was not completed on multiple occasions, while another resident's program showed numerous 'not applicable' entries and refusals. Staffing issues were cited as a reason for the incomplete programs, leading to the residents not maintaining or improving their abilities.
The facility's main kitchen was found to have multiple sanitation issues, including limescale buildup on dish machines, damaged meal trays, and food debris in various areas. Staff reported inconsistent water softener performance, and several kitchen appliances and surfaces were observed with dust, debris, and food splatter. These findings were discussed with the Nursing Home Administrator and DON.
A facility failed to ensure accurate MDS assessments for a resident, incorrectly documenting an active pneumonia infection in December 2023 and March 2024, despite the resident not having the infection since October 2023. This error was confirmed by facility documentation and staff interviews.
A facility failed to provide an integrated hospice care plan for a resident with a terminal cerebrovascular disease diagnosis. The care plan lacked details on hospice services, including the hospice entity, disciplines involved, and service frequency. This deficiency was confirmed through interviews with facility staff, who acknowledged the absence of necessary documentation.
A resident with moisture-associated skin damage on the buttocks did not receive recommended Multivitamin and Vitamin C supplements as advised by a wound specialist. Despite weekly follow-ups and noted exacerbation of the condition, the facility failed to order the supplements or consult the resident's primary care physician. The Director of Nursing confirmed the oversight.
The facility failed to implement restorative nursing programs for two residents as recommended by therapy, leading to deficiencies in maintaining their range of motion. One resident received sporadic ambulation therapy, while another did not receive the prescribed passive range of motion program. These findings were confirmed by the DON.
A resident was self-administering her tube feeding without a proper assessment to ensure her capability to do so safely. The facility's assessment and care plan did not address the self-administration of enteral feeding, as confirmed by the DON.
The facility failed to create and implement individualized care plans for two residents diagnosed with dementia. Despite assessments indicating the need for such plans, there was no evidence of person-centered care plans addressing dementia and cognitive loss for these residents. This deficiency was confirmed through staff interviews and record reviews.
A resident was found chewing on a piece of her own tooth, but the facility failed to document follow-up actions or inform the resident's spouse about the incident. The spouse initially declined dental services without knowledge of the broken tooth, and it wasn't until later that they were informed and agreed to a dental visit. This communication lapse led to a deficiency in addressing the resident's dental care needs.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides as per the Commonwealth of Pennsylvania Long Term Care Licensure Regulations. Specifically, during the day shift, the facility did not provide the minimum required number of nurse aides for four out of the 21 days reviewed. On September 1, 2024, there were 4.17 nurse aides for a census of 51 residents, requiring 5.10 nurse aides. On November 24, 2024, there were 4.20 nurse aides for a census of 50 residents, requiring 5.00 nurse aides. On November 29, 2024, there were 4.67 nurse aides for a census of 50 residents, requiring 5.00 nurse aides. On January 18, 2025, there were 5.10 nurse aides for a census of 53 residents, requiring 5.30 nurse aides. Additionally, during the night shift on January 19, 2025, the facility provided 3.20 nurse aides for a census of 53 residents, requiring 3.53 nurse aides. These staffing deficiencies were identified through a review of nursing staff care hours and confirmed through staff interviews.
Plan Of Correction
- Residents were not found to be affected by deficient practice. - The Director of Wellness conducted initial Quality Improvement (QI) monitoring of schedules for the past week to review NA staffing ratios. - The Director of Wellness and Scheduler will meet daily to review the schedule to ensure ratios and hours meet regulation. The Executive Director will reeducate the wellness team on efforts to improve recruitment and retention of direct care staff and the scheduling process, including critical shift incentives. - The Director of Wellness will conduct Quality Improvement (QI) monitoring of the nursing schedule related to NA staffing ratios 5 times a week for 2 weeks, then weekly for 2 weeks, and finally monthly for 2 months. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI).
LPN Staffing Deficiency on Day Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift. This deficiency was identified during a review of nursing staffing hours for specific dates. On January 18 and 19, 2025, the facility scheduled only 2.00 LPNs for a resident census of 53, which required 2.12 LPNs to meet the mandated staffing levels. This shortfall in staffing was noted during a review of the facility's nursing staff care hours for the periods of September 1-7, 2024, November 24-30, 2024, and January 15-25, 2025. The Director of Nursing was informed of these findings on January 24, 2025.
Plan Of Correction
- Residents were not found to be affected by deficient practice. - The Director of Wellness conducted initial Quality Improvement (QI) monitoring of schedules for the past week to review LPN staffing ratios. - The Director of Wellness and Scheduler will meet daily to review the schedule to ensure ratios and hours meet regulation. The Executive Director will reeducate the wellness team on efforts to improve recruitment and retention of direct care staff and the scheduling process, including critical shift incentives. - The Director of Wellness will conduct Quality Improvement (QI) monitoring of the nursing schedule related to LPN staffing ratios 5 times a week for 2 weeks, then weekly for 2 weeks, and finally monthly for 2 months. Further recommendations will be reported to Quality Assurance Performance Improvement (QAPI).
Failure to Maintain Residents' Ambulation and Strength
Penalty
Summary
The facility failed to maintain the ambulation status and strength of two residents, identified as Residents 34 and 36, as per their restorative nursing programs. Resident 34 was on a restorative nursing program for ambulation, which required her to be walked 50-150 feet, 1-2 times daily with assistance. However, her program was not completed on numerous occasions in April and May 2024, with staff documenting 'not applicable' without a clear reason. The Nursing Home Administrator and Director of Nursing confirmed the program was not completed as ordered. Resident 36 was also on a restorative nursing program following discharge from skilled occupational and physical therapy services. The program aimed to maintain her upper and lower extremity strength and activity tolerance. However, documentation showed multiple instances of 'not applicable' entries and refusals for the program in April and May 2024. Despite being referred back to physical and occupational therapy in May 2024 due to decreased endurance and functional mobility, there was no evidence of refusal for these services. Interviews with staff revealed that the restorative programs were not completed due to staffing issues, such as the lack of available personnel to assist with ambulation programs. The restorative coordinator acknowledged the multiple 'not applicable' entries and was unsure why Resident 36 refused the restorative program but not the therapy services. The facility's failure to provide the necessary restorative services resulted in the residents not maintaining or improving their abilities as required.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed during a survey. The dish machine and several utility carts were found with a white buildup, attributed to limescale from the water. Staff indicated that the water softeners were inconsistent in their performance, and although a limescale remover was used weekly, the issue persisted. Additionally, a ceiling light cover in the dish room was covered with dried food and liquid splatter, and a stack of resident meal serving trays was found to be discolored, stained, and damaged with cracks and broken edges. Further observations revealed an uncovered industrial floor mixer with dust and debris inside the mixing bowl, and a panini press with dried food buildup on a preparation counter. The surrounding wall was also splattered with dried food. The lower shelf of a preparation table was dusty and debris-laden, and a nearby garbage can was soiled with dried food and liquid. In the dry storage area, shelf liners were dusty, and the flooring under shelving units in the walk-in cooler and freezer had food debris. A soiled glove, coffee filter, and dried food were found under the ice machine. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident. A review of the resident's clinical record revealed discrepancies in the MDS assessments dated December 21, 2023, and March 18, 2024, which incorrectly indicated that the resident had an active pneumonia infection. However, the resident had not experienced an active pneumonia infection since October 1, 2023. This error was confirmed by documentation provided by the facility and through interviews with the Administrator and Director of Nursing.
Failure to Implement Integrated Hospice Care Plan
Penalty
Summary
The facility failed to provide the highest practicable care for a resident admitted to hospice care due to a terminal diagnosis related to cerebrovascular disease. The clinical record review revealed that the facility did not implement an integrated plan of care with hospice services for the resident. The care plan lacked evidence of all services that hospice would provide for managing the resident's terminal illness. Additionally, the care plan did not identify the hospice entity providing services, the hospice disciplines involved, or the frequency of care and services. These findings were confirmed during interviews with the Nursing Home Administrator, Director of Nursing, and a social services employee, who acknowledged the absence of further documentation related to the resident's hospice services and plan of care.
Failure to Implement Wound Specialist Recommendations
Penalty
Summary
The facility failed to implement the recommendations of a wound specialist for a resident with moisture-associated skin damage (MASD) on the buttocks. The resident, who was observed in bed and reported pain from an open area on the buttocks, had been assessed by facility staff and a contracted wound specialist. The specialist recommended a treatment plan that included a Multivitamin once daily and Vitamin C 500 mg twice daily. Despite these recommendations being reiterated in subsequent weekly reports, there was no evidence that the facility ordered these supplements or addressed the recommendations with the resident's primary care physician. The resident's condition showed signs of exacerbation over time, with the MASD areas increasing in size, attributed to the resident's generalized decline, nutritional compromise, and non-compliance with wound care. The wound specialist continued to recommend the same treatment plan, noting some improvement in the condition by May 7, 2024. However, by May 14, 2024, the areas required debridement, and the recommendations for the Multivitamin and Vitamin C remained unaddressed. The Director of Nursing confirmed that the supplements were never ordered, nor were the recommendations discussed with the resident's primary physician.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to implement a restorative nursing program as recommended by therapy for two residents, leading to deficiencies in maintaining their range of motion. Resident 21 was assessed to have range of motion limitations in one side of her lower extremities, as indicated in a Minimum Data Set Assessment dated December 21, 2023. A physical therapy form dated December 19, 2023, recommended an ambulation program for Resident 21 to maintain her lower extremity strength. However, documentation revealed that the resident received the recommended ambulation program only sporadically in February, March, and April 2024, with no consistent adherence to the therapy recommendations. Similarly, Resident 32 was recommended to receive a passive range of motion program to his lower extremities, as per a physical therapy form dated May 7, 2024. The goal was to maintain range of motion and prevent joint contractures. However, there was no documented evidence that Resident 32 received the passive range of motion program since its implementation. An interview with the Director of Nursing confirmed these findings, indicating a failure to provide the necessary restorative nursing care as recommended by therapy.
Failure to Ensure Safe Self-Administration of Tube Feeding
Penalty
Summary
The facility failed to ensure the safe self-administration of tube feeding for a resident, which compromised the resident's nutritional status. The resident, identified as Resident 2, was self-administering her tube feeding and water but not her medications. A clinical record review revealed a physician's order for enteral feeding four times a day, which allowed the resident to self-administer. However, the facility did not have a proper assessment in place to ensure the resident's capability to safely self-administer her tube feeding. Interviews with the Director of Nursing confirmed that the self-administration of medication assessment did not include indicators for safely self-administering tube feeding. Additionally, the resident's care plan did not address the self-administration of her enteral feeding. The Director of Nursing acknowledged that the facility failed to assess the resident's ability to self-administer her tube feeding, which was necessary to maintain acceptable nutritional parameters.
Failure to Develop Person-Centered Care Plans for Dementia
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Resident 8 was admitted on June 27, 2022, with a diagnosis of dementia, as indicated in the Minimum Data Set Assessment dated June 9, 2023. Despite the assessment, there was no evidence that a person-centered care plan addressing dementia and cognitive loss was developed for Resident 8. Similarly, Resident 10, admitted on August 7, 2023, was assessed with dementia according to her admission MDS. However, the facility did not develop or implement a person-centered care plan for her dementia and cognitive loss. These findings were confirmed during interviews with the Nursing Home Administrator, Director of Nursing, and a social services employee, who acknowledged the lack of documentation for individualized care plans for both residents.
Failure to Address Dental Concerns for a Resident
Penalty
Summary
The facility failed to address dental concerns for a resident, identified as Resident 27, who was found chewing on a piece of her own tooth on March 30, 2024. Despite this incident, there was no follow-up documentation in the resident's clinical record. Additionally, a wellness progress note dated May 3, 2024, indicated that the resident's spouse declined dental services, but there was no evidence that the spouse was informed about the broken tooth incident. An interview with the Director of Nursing on May 15, 2024, confirmed that the resident's spouse was not made aware of the dental issue until that day, when they agreed to allow a dental hygienist to see the resident. This lack of communication prevented the spouse from making an informed decision regarding the resident's dental care, leading to a deficiency in the facility's obligation to provide necessary dental services.
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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