Kadima Rehabilitation & Nursing At Cheswick
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheswick, Pennsylvania.
- Location
- 3876 Saxonburg Boulevard, Cheswick, Pennsylvania 15024
- CMS Provider Number
- 395538
- Inspections on file
- 39
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Cheswick during CMS and state inspections, most recent first.
Surveyors determined that the facility did not record food holding temperatures at the time of service for breakfast and lunch in the main kitchen. Review of the food temperature log showed no entries confirming that hot or cold foods were maintained at safe internal temperatures during these meals, and the Dietary Manager acknowledged that the temperatures were not documented as required.
Surveyors found that the facility did not develop comprehensive, individualized care plans for two residents receiving methadone for chronic pain. Although physician orders and clinical documentation showed that these residents had chronic pain, anxiety, and other conditions, and that they received methadone either twice daily or through weekly clinic dosing with take-home doses administered by staff, their care plans did not include any information about methadone use or methadone clinic appointments. The DON confirmed during interview that these omissions existed in the residents’ care plans.
A resident with fibromyalgia, adult failure to thrive, and diabetes mellitus had physician orders for showers on specific evening shifts twice weekly, but review of bathing records showed the resident received only two bed baths and missed six ordered showers. Facility policy required care to be provided as needed 24 hours a day to help residents maintain their highest level of functioning, and the DON confirmed the resident did not receive showers as scheduled.
Surveyors found that the facility failed to obtain complete physician orders for two residents receiving methadone at outside clinics. Both residents had chronic pain and other conditions and were on methadone regimens that involved dosing at an external clinic and additional doses administered by facility staff. Although staff reported that a nurse escorted residents to weekly clinic visits and transportation was arranged, the written orders did not include the clinic’s name, address, or phone number, appointment times, transportation details, the need for an escort for all appointments, or instructions for monitoring side effects.
A resident with a history of depression and suicidal ideation was repeatedly found with cords accessible and wrapped around their neck, expressing a desire to self-harm. Despite facility policy and physician orders for close monitoring and removal of hazards, staff failed to provide required supervision, did not secure hazardous items, and did not document or implement ordered safety checks. Staff interviews confirmed lapses in following procedures for residents at risk of self-harm.
A resident with depression and adjustment disorder, identified as a suicide risk, attempted self-harm and expressed suicidal ideation. Facility staff failed to document the incident, did not provide immediate RN assessment, and did not ensure timely psychiatric follow-up as ordered, contrary to facility policy.
The facility did not conduct a required quarterly QAA meeting with all mandated committee members, as attendance records showed the Infection Preventionist, DON, and Medical Director were absent for one meeting, in violation of facility policy and state regulations.
The facility did not provide the required number of nurse aides on several day, evening, and night shifts, as confirmed by staffing records and administrator interview. On multiple occasions, the number of NA hours fell below the regulatory minimums based on the resident census.
Facility staff did not provide the minimum required LPN coverage during a night shift, as staffing records showed fewer LPN hours than mandated for the census. This was confirmed by the administrator after review of schedules and census data.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on multiple days, as confirmed by staffing records and an interview with the Nursing Home Administrator.
Air conditioning units in two resident rooms and two dining areas were found with significant grime and black debris on their air inlet grills and internal areas. These conditions were confirmed by the Director of Maintenance and indicated a failure to maintain a clean, safe, and comfortable environment as required by facility policy.
The facility did not conduct thorough investigations into incidents involving two residents, one of whom was found in a restricted area and another who exited the building without proper supervision. Despite facility policy requiring investigation and reporting of such events, these incidents were not properly investigated as confirmed by the administrator.
The facility did not provide evidence that its Registered Dietician reviewed or approved the four week Spring Summer cycle menu before it was implemented, and failed to follow the menu during a lunch meal by not providing the correct dessert to residents on mechanical soft and pureed diets. The Food Service Director confirmed the lack of documentation and menu adherence.
Surveyors observed that the facility did not provide a safe and homelike environment, with a missing door jamb at the elevator exposing unfinished plaster, torn and missing wallpaper in a first floor lounge, and a resident room with peeling paint and wall damage. These issues were confirmed by maintenance and nursing leadership.
Food service staff did not follow manufacturer instructions when preparing sugar free pudding, including incorrect measurement of milk, use of the wrong milk type, and failure to allow the pudding to set properly before meal service. The Food Service Director confirmed these errors, which resulted in the potential for serving non-palatable and inaccurately prepared food products.
During a lunch meal service, all residents prescribed mechanical soft and puree diets did not receive the correct form of lemon blueberry tart dessert as indicated on their tray cards and menu extension sheets. Staff and the Food Service Director confirmed that the required mechanical soft and pureed desserts were not prepared or served, contrary to facility policy and residents' dietary prescriptions.
Kadima Rehabilitation and Nursing at Cheswick failed to complete initial social service assessments for three residents with complex medical conditions, resulting in incomplete medical records. This deficiency was confirmed by the Nursing Home Administrator during a survey following a complaint.
The facility did not meet the required nurse aide staffing levels on several shifts over a week. Specifically, there were insufficient NAs during the day, evening, and night shifts on multiple days. This was confirmed through staffing documents and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 3.20 hours of direct resident care per patient daily on five days within a week. Staffing documents showed that the facility provided less than the required hours on several days, with the lowest being 2.38 PPD. This was confirmed by the Nursing Home Administrator.
The facility failed to secure a surety bond that adequately protected the personal funds of residents deposited with the facility for three months. The bond value was $193,915.84, insufficient compared to the $252,107.96 in resident funds held by the facility. The Nursing Home Administrator confirmed the inadequacy of the bond amount in protecting all resident financial funds as required.
Kadima Rehabilitation & Nursing at Cheswick failed to maintain sufficient petty cash for residents over three days, leading to denied withdrawals of personal funds. A resident confirmed issues accessing funds, and the Nursing Home Administrator acknowledged the deficiency.
The facility failed to ensure proper supervision for a provisional SLP, who worked without daily oversight from a licensed SLP after the previous supervisor left. A new licensed SLP was hired but only supervised every two to three weeks, not meeting the required daily supervision.
The facility did not meet the required LPN staffing levels during the night shift on two occasions, with a census of 91 residents requiring 2.28 FTE LPNs, but only 2.19 and 2.06 FTEs were present. The Assistant Director of Nursing confirmed the staffing shortfall.
The facility failed to meet the required staffing levels for nurse aides on multiple occasions, with insufficient coverage during daylight, evening, and night shifts over a period of several days. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 PPD hours of direct resident care on ten days between mid-December 2024 and early January 2025. The lowest recorded was 2.53 PPD, confirmed by the Nursing Home Administrator.
The facility did not meet the required staffing levels for nurse aides on both daylight and evening shifts over several days. On two days, the daylight shift lacked the mandated one NA per 10 residents, and on three days, the evening shift did not meet the one NA per 11 residents requirement. The Nursing Home Administrator confirmed these staffing shortfalls.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care over five consecutive days. Staffing documents showed PPD hours ranging from 2.93 to 3.19, and the Nursing Home Administrator confirmed the deficiency.
The facility failed to maintain acceptable temperature levels in 32 resident rooms across three floors, with temperatures falling below the required range due to a circulatory pump failure on the main boiler. Observations showed temperatures as low as 67 degrees Fahrenheit in dining rooms, and residents expressed discomfort due to the cold. The Nursing Home Administrator confirmed the deficiency.
The facility's main kitchen had unsanitary conditions due to a build-up of dust, grime, and debris on the cold air condenser fan covers in the walk-in cooler. This was confirmed by the FSD, violating the facility's sanitation policy and creating potential for cross-contamination.
The facility failed to communicate necessary information to receiving health care providers for four residents transferred to the hospital. The residents' records lacked documentation of care plan goals, advanced directives, and specific care instructions. This deficiency was confirmed by the ADON, highlighting a systemic issue in handling transfers.
The facility failed to notify three residents or their representatives of the bed-hold policy during hospital transfers. The clinical records lacked documentation of written information about the policy for residents with various diagnoses, including neurocognitive disorders and atrial fibrillation. The ADON confirmed this deficiency.
The facility failed to provide trauma-informed care for five residents with PTSD by not identifying or managing triggers that could cause re-traumatization. Despite having a policy in place, the Social Service History assessments did not assess or identify potential stressors, and care plans lacked strategies to mitigate these triggers. This deficiency was confirmed by the Social Service Director.
The facility failed to obtain physician orders and ensure coordination of hospice services for three residents with serious medical conditions requiring end-of-life care. The physician orders lacked qualifying diagnoses, and care plans did not include hospice contact information, as confirmed by the Social Service Director.
The facility did not implement enhanced barrier precautions for residents with catheters, as required by their policy. Observations showed no signage or PPE outside the rooms of residents needing catheter care. The Infection Preventionist confirmed the oversight, indicating a failure in the facility's infection prevention program.
The facility failed to maintain a clean, safe, and homelike environment on the Second and Third floors. Observations included missing floor tiles, improperly stored equipment in dining rooms, and a resident's Broda chair with a sticky substance. The Nursing Home Administrator confirmed these deficiencies.
A resident with anxiety, depression, and high blood pressure experienced neglect when a nurse aide refused to assist with changing a soiled brief during the night. Despite the resident's request for help, the aide instructed her to change it herself and left the room. This incident was confirmed by the resident, her roommate, and the Director of Nursing.
A facility failed to investigate an incident involving a resident with chronic atrial fibrillation and mental health disorders, who was found near the basement elevator. Despite the facility's policy requiring investigation and reporting of such incidents, no investigation was conducted, as confirmed by the ADON.
The facility failed to maintain proper admission documentation for two residents with cognitive impairments. One resident, with severe impairment, had no admission packet, while another, with moderate impairment, lacked a necessary POA signature. The Nursing Home Administrator confirmed these deficiencies.
A resident with chronic atrial fibrillation, bipolar disorder, and major depressive disorder eloped to an unsupervised basement area due to inadequate supervision. The facility's policy requires a secure environment to prevent such incidents, but the resident was found confused and unable to explain their presence in the basement. The DON confirmed the supervision failure.
The facility failed to provide appropriate respiratory care for three residents, as their oxygen concentrators had filters covered with a gray/white fuzzy substance, and one resident had outdated oxygen tubing. These deficiencies were confirmed by LPNs and acknowledged by the Nursing Home Administrator.
A resident with diabetes was sent to the ER after a nurse, untrained on a new retractable needle system, mistakenly believed a needle was dislodged during insulin administration. The facility failed to ensure nurses had the necessary competencies for subcutaneous injections.
A facility failed to report abnormal lab results to the ordering physician in a timely manner for a resident. The resident had a physician's order for a urine culture, and the lab report with abnormal values was finalized. However, the clinical record showed no evidence of physician notification. The Infection Preventionist indicated that lab results are signed off after physician review, and the Nursing Home Administrator confirmed the failure to report the results promptly.
A facility failed to provide adaptive feeding devices for a resident with Parkinson's Disorder and dysphagia, despite an active physician order for weighted utensils and a divided plate. Observations confirmed the absence of these devices on the resident's lunch tray, which was acknowledged by both a nurse aide and the Food Service Director.
The facility failed to notify the LTC Ombudsman of hospital transfers for four residents with various medical conditions, including neurocognitive disorders and atrial fibrillation. The Assistant DON confirmed the lack of documented evidence for these notifications.
The facility failed to follow physician orders and notify a physician of abnormal glucose readings for a resident with diabetes, renal failure, and hemiplegia. Despite multiple instances of low blood glucose levels over a month, there was no documentation of physician notification, as confirmed by the ADON.
The facility failed to ensure that weights were monitored as ordered for a resident with renal failure, diabetes, and hemiplegia. The resident had a physician's order for weekly weights, but the Medication Administration Record showed missing documentation for three specified dates. Interviews confirmed the lack of documented weights, indicating a failure to follow the physician's order.
Failure to Document Food Holding Temperatures at Time of Service
Penalty
Summary
Surveyors found that the facility failed to document food holding temperatures at the time of service in the main kitchen. On review of the facility’s food temperature log at 12:15 p.m. on 3/4/26, there was no documented evidence that temperatures were obtained during service for breakfast and lunch to verify that food was maintained at safe internal temperatures. During this review period, the Dietary Manager (Employee E7) confirmed that there were no recorded temperatures for breakfast or lunch and acknowledged that these temperatures should have been recorded. The deficiency was cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(b)(3) regarding management, based on the lack of required temperature documentation for meals served from the main kitchen.
Failure to Include Methadone Therapy and Clinic Visits in Resident Care Plans
Penalty
Summary
Surveyors determined that the facility failed to develop comprehensive, individualized care plans that addressed all identified care needs for two residents. Facility policy on MDS/RAI/Care Planning, last reviewed on 11/1/25, stated that the care planning process is an interdisciplinary tool and that care plans are to be assessed at least quarterly and reviewed by the interdisciplinary team. For one resident admitted on an unspecified date, the MDS dated 1/21/26 documented diagnoses of diabetes, anxiety, and chronic pain. Physician orders dated 1/14/26 showed Methadone HCl Oral Concentrate 10 mg/mL, 8 mL by mouth twice daily for chronic back pain, and the physician’s initial comprehensive visit on 1/16/26 documented that the resident went to an outpatient methadone clinic for prescriptions. Review of this resident’s care plan, initiated on 1/19/26, showed a problem for pain related to chronic pain but did not include any information about the resident’s methadone use or methadone clinic appointments. For a second resident admitted on an unspecified date, the MDS dated 12/13/25 documented arthritis, anxiety, and chronic pain. A nursing progress note dated 12/8/25 indicated the resident left via wheelchair with a nurse escort in baseline condition to an appointment, and a physician order dated 12/8/25 directed the resident to dose every Monday at a clinic and to receive six take-home methadone doses in a lunchbox to be administered by facility staff. The resident’s care plan, initiated on 12/8/25, failed to include any information regarding methadone use or methadone clinic appointments. In an interview on 4/4/26, the DON confirmed that the care plans for both residents did not include information concerning methadone or clinic appointments.
Failure to Provide Ordered Showers and Maintain Resident Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for one of four residents reviewed, identified as Resident R5. Facility policy titled "Flow of Care" dated 11/1/25 stated that care would be provided as needed 24 hours a day to help residents attain and maintain the highest level of functioning. Clinical records showed that Resident R5 was admitted with diagnoses including fibromyalgia, adult failure to thrive, and diabetes mellitus. Physician orders dated 1/2/26 directed that the resident was to receive showers on the evening shift on Tuesdays and Fridays. Review of the resident’s January 2026 bathing records revealed that instead of the ordered showers, the resident received only two bed baths on 1/6/26 and 1/16/26, resulting in six missed showers during that month. In an interview on March 4, 2026, at 2:30 p.m., the Director of Nursing confirmed that the resident missed six showers and did not receive showers as scheduled. The deficiency was cited under 28 Pa. Code 211.5(f) Clinical records and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Incomplete Physician Orders for Residents Receiving Methadone at Outside Clinics
Penalty
Summary
The facility failed to obtain complete physician orders for residents receiving methadone treatment at outside clinics. For one resident with diabetes, anxiety, and chronic pain, the clinical record showed methadone orders for chronic back pain, including a schedule that split doses between the facility and an outpatient methadone clinic. However, these orders did not include the name, address, or phone number of the methadone clinic, the time of the clinic appointments, transportation service information, the need for an escort for all appointments, or instructions for monitoring for side effects. The facility’s policy for transfers to outside appointments required verification of a physician order for the appointment/consult and arrangements for transportation and escort as appropriate. A second resident with arthritis, anxiety, and chronic pain also had incomplete methadone-related orders. Nursing documentation indicated the resident left via wheelchair with a nurse escort to an appointment, and physician orders directed that the resident dose every Monday at a clinic and receive six take-home doses to be administered by facility staff, with additional orders specifying daily methadone dosing at the facility on non-clinic days. These orders likewise omitted the methadone clinic’s name, address, and contact phone number, the appointment time, transportation service information, the need for an escort for all appointments, and monitoring for side effects. During interviews, nursing staff and the DON described a process in which residents go to the clinic weekly with a nurse escort and transportation arranged by a scheduler, but the DON later acknowledged that the existing orders for the residents going to the methadone clinic were incomplete.
Failure to Supervise and Protect Resident with Suicidal Ideation
Penalty
Summary
The facility failed to keep a resident with known suicidal ideation and a history of suicide attempt free from hazards and did not provide the necessary monitoring and supervision as required by facility policy and physician orders. The resident, who had diagnoses of depression and adjustment disorder, was found on multiple occasions with a cord wrapped around their neck and expressing suicidal ideation. Despite these incidents, there was no evidence that the required 1:1 supervision or every 15-minute checks were implemented or documented as ordered by the physician and outlined in facility policy. Facility policy required that any suicide threats be taken seriously, with immediate reporting to the nurse supervisor or charge nurse, and that a staff member remain with the resident until further assessment. The policy also required removal or securing of items that could be used for self-harm, such as cords and plastic liners. However, observations revealed that cords in the resident's room, including bed control cords, call bell cords, and telephone cords, were not secured and remained accessible. Additionally, the resident's roommate also had unsecured cords in the shared room. Interviews with staff confirmed that after the resident was found with a cord around their neck and expressing suicidal ideation, appropriate assessments and monitoring were not performed. Staff were unclear about documentation procedures and did not consistently implement or record the required supervision. The DON and NHA acknowledged the lack of evidence for required monitoring and supervision, and staff interviews further confirmed that facility policies were not followed in response to the resident's suicidal behavior.
Removal Plan
- Resident R96 will be provided with a safe environment by securing bed control cord, call bell cord, and telephone cord so cords are not accessible to resident to harm self. Roommate's cords have also been secured. The room has also been checked for any other hazardous items to ensure a safe environment.
- Physician orders for monitoring resident BP will be completed by nursing staff every 15 minutes to ensure resident safety.
- Residents will be evaluated by psychiatric services for safety.
- Care plan will be reviewed and updated.
- The Director of Nursing or designee will complete a house audit of all residents for suicidal ideations. A resident questionnaire on suicidal ideation will be used for all residents with a BIMS of 9 or above. Residents with a BIMS of 8 or below, a resident skin check and review of risk management to determine resident's safety.
- Care plans will be updated to reflect the residents' current condition by Licensed Practical Nurse Assessment Coordinator (LNAC) or designee.
- A house audit of environment will be completed by Environmental Services Supervisor or designee to validate no hazards are identified for residents with suicidal ideations.
- The NHA, DON and Regional Clinical Consultant will review and update the facility policy and procedures for Suicidal Threats and Supervision of Residents with suicidal ideations.
- All staff will be re-educated on the facility policy and procedures for Suicidal Threats, Care Plans and Supervision of residents identified with suicidal ideations.
- All incidents and accidents will be reviewed and results reported to the Quality Assurance and Process Improvement Committee for review and frequency of audits.
Failure to Provide Appropriate Mental Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with mental or psychosocial adjustment difficulties. The resident, who had diagnoses of depression and adjustment disorder with depressed mood, was identified as a suicide risk and had expressed suicidal ideation. On one occasion, a nurse aide found the resident attempting self-harm by wrapping a telephone cord around their neck and expressing a desire to die. Despite facility policy requiring immediate reporting, assessment, and supervision of residents expressing suicidal ideation, there was no documentation that the resident displayed suicidal ideations or behavioral issues on the day of the incident. Additionally, a registered nurse did not assess the resident immediately after the suicide attempt, contrary to facility policy. Further review revealed that although the resident was instructed to follow up with psychiatry after a hospital visit and a physician ordered a psychiatric consult, there was no evidence in the clinical record that the resident was seen by psychiatry as ordered. Interviews with facility staff, including the DON and Nursing Home Administrator, confirmed that the required assessments, monitoring, and psychiatric consultation were not completed as per policy for a resident displaying mental health difficulties and suicidal ideation.
Failure to Hold Required QAA Meeting with All Committee Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of four quarterly meetings in 2025. According to the facility's Quality Assurance/Performance Improvement policy, meetings are to be held at least quarterly to identify non-compliant service areas or those with potential for improvement. Review of sign-in sheets and attendance records for the third quarter of 2025 showed that the Infection Preventionist, Director of Nursing, and Medical Director were not present. This was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the required QAA meeting did not occur with all mandated members present as stipulated by facility policy and state regulations. No information regarding specific residents, their medical history, or condition at the time of the deficiency was provided in the report.
Failure to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing levels on multiple occasions, as evidenced by a review of staffing documents and staff interviews. Specifically, on two separate day shifts, the number of NA hours provided was less than what was required for the census present. Similarly, on two evening shifts and one night shift, the facility did not provide the mandated NA coverage based on the resident census. The Nursing Home Administrator confirmed during an interview that the facility did not have the required number of NAs on these shifts, as outlined by the regulation effective July 1, 2024. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1. The facility cannot correct that the facility failed to provide one nurse assistant (NA) per 10 residents on the daylight shift on 8-4-25 & 8-11-25 and one nursing assistant per 11 residents on the evening shift on 8-3-25 & 8-10-25 and one nursing assistant per 15 residents on the night shift on 8-11-25 as required. 2. The facility will ensure that nurse aide staffing ratios of 1:10 on day shift, 1:11 on evening shift, and 1:15 on night shift. Open positions will continue to be posted on various platforms. We will continue with a weekly retention and recruitment meeting. We have help wanted signs on our property. We posted an ad in our local township summer 2025 newsletter that gets distributed to over 3000 homes and businesses in our township. We have reached out to the union to inquire about financial benefits for the members to pursue CNA training and CCAC to explore CNA class options to partner with CCAC and to post help wanted ads on the college bulletin boards. We offer a sign-on bonus and bonuses as incentives to our staff to pick up shifts. We offer "Refer a Friend" bonus to our staff. We utilize staffing agencies to fill needed shifts. We will continue to review referrals to ensure we can meet their needs prior to accepting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler, and RN Supervisors on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facility's projections to meet ratios fall below required ratios due to call-offs, No Call No Shows, etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call our off-duty personnel, and/or call extra support staff via staffing agencies to assist as necessary. 4. The HR Director/designee will audit staffing sheets daily for three months to ensure nurse aide staffing ratios are being met. The audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 9-16-2025
Failure to Meet Minimum LPN Staffing Requirements on Night Shift
Penalty
Summary
Facility administrative staff failed to provide the required minimum number of licensed practical nurses (LPNs) during the night shift on one of ten reviewed days. Specifically, on the night in question, the facility census was 104 residents, which required 20.80 LPN hours, but only 16.00 LPN hours were provided. This deficiency was identified through a review of nursing time schedules and census data, and was confirmed by the Nursing Home Administrator during an interview. No information regarding the medical history or condition of specific residents was provided in the report.
Plan Of Correction
The facility will ensure state-required LPN ratios are met during the overnight shift. The facility cannot correct that LPN staffing ratios of 1:40 were not met on the overnight shift on 8-10-25. The facility will ensure that the LPN staffing ratio of 1:40 is met during the overnight shift. Open positions will continue to be posted on various platforms. We will continue with a weekly retention and recruitment meeting. We have help wanted signs on our property. We posted an ad in our local township summer 2025 newsletter that gets distributed to over 3000 homes and businesses in our township. We offer a sign-on bonus and bonuses as incentives to pick up shifts. We offer a "Refer a Friend" bonus to our staff. We utilize staffing agencies to fill needed shifts. We will continue to review referrals to ensure we can meet their needs prior to accepting. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler, and RN Supervisors on regulation P5530 and ensuring LPN staffing ratios are met during the overnight shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facility's projections to meet LPN ratios on the overnight shift fall below required ratios due to call-offs, no call no-shows, etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off-duty personnel, and/or call extra support staff via staffing agencies to assist as necessary. The HR Director/designee will audit staffing sheets daily for three months to ensure LPN staffing ratios are being met during the overnight shift. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. Date of compliance: 9-16-2025
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum of 3.2 hours of direct nursing care per resident per day on six out of ten days reviewed. Specifically, staffing documents and nursing schedules from the period of 8/2/25 through 8/11/25 showed that on 8/3/25, 8/4/25, 8/5/25, 8/9/25, 8/10/25, and 8/11/25, the provided per patient daily (PPD) hours ranged from 2.82 to 3.19, all below the required threshold. These findings were based on a review of the facility's staffing records and were confirmed during an interview with the Nursing Home Administrator. No information was provided regarding the specific residents affected, their medical histories, or their conditions at the time of the deficiency. The deficiency was identified solely through documentation review and staff interview, with no additional details about the impact on resident care or outcomes included in the report.
Plan Of Correction
1. The facility will ensure state-required general nursing care hours in each 24 hr period will be a minimum of 3.2 hrs of direct resident care for each resident. The facility cannot correct that we did not meet the minimum PPD of 3.2 hrs on August 3, 4, 5, 9, 10 & 11, 2025. 2. The facility will ensure that the 3.2 state minimum direct resident care hours in each 24hr period is met. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler, and RN Supervisors on regulation P5640 ensuring a minimum of 3.2 direct resident care hrs are met in each 24hr period. Resident care hrs will be reviewed at our daily staffing meeting to ensure a minimum PPD of 3.2 is scheduled to be met. The RN Nursing Supervisors will continue to review direct resident care hrs on evenings and weekends. If the facility's projection to meet the state minimum falls below a 3.2 due to call offs, No Call No Shows, etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off-duty personnel, and/or call extra support staff via staffing agencies to assist as necessary. 4. The HR Director/designee will audit staffing sheets daily for three months to ensure the minimum 3.2 hrs of direct resident care for each resident is met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 9-16-2025
Failure to Maintain Clean and Safe Environment in Resident Rooms and Dining Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents in specific resident rooms and dining areas. Observations conducted on 7/2/25 revealed that air conditioning units in two resident rooms, the second floor dining room, and the third floor dining room had a build-up of grime and black debris on the air inlet grills and the internal areas immediately behind them. These findings were confirmed by the Director of Maintenance during interviews at the time of observation. A review of the facility's Environmental Services policy, dated 3/21/25, indicated that both the interior and exterior of the facility should be maintained in a clean, safe, and orderly manner, with proper housekeeping, laundry, and maintenance services to prevent infection and cross-contamination. Despite this policy, the presence of grime and debris on multiple air conditioning units demonstrated a failure to adhere to these standards. The Nursing Home Administrator also confirmed that the facility did not provide a safe, clean, and comfortable environment as required.
Failure to Investigate Resident Incidents and Elopement
Penalty
Summary
The facility failed to initiate thorough investigations into incidents or accidents involving two residents, as required by its own Accident and Incident-Investigating and Reporting policy. For one resident with anxiety, diabetes mellitus, and bipolar disorder, clinical records showed that the resident was found in the basement near the kitchen after seeking out kitchen staff regarding her dinner menu. Despite this incident, there was no evidence of a comprehensive investigation being conducted. Another resident, with a history of seizures, hypertension, and alcohol dependence, was observed ambulating to the first floor, exiting the building through a side door, and being spotted by staff outside the facility. The facility administrator confirmed during an interview that no thorough elopement investigation was conducted for either resident, as required by facility policy and state regulations.
Failure to Review, Approve, and Follow Preplanned Cycle Menu
Penalty
Summary
The facility failed to ensure that its four week Spring Summer cycle menu was reviewed, dated, and approved by the Registered Dietician (RD) prior to implementation, as required by facility policy. Documentation provided did not show evidence of RD review or approval for the menu. Additionally, during a lunch meal service, the facility did not follow the preplanned cycle menu by failing to provide the correct dessert to residents prescribed mechanical soft and pureed diets. These deficiencies were confirmed by the Food Service Director, who stated that the menu was implemented before his hiring and that there was no documentation of RD approval.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents as required by its policies. Observations revealed that the door jamb at the elevator on the second floor nursing unit was missing on the right side, exposing rough and unfinished plaster, which created an unsafe environment. Additionally, the lounge area on the first floor had torn and missing wallpaper, and a resident room contained peeling and chipping paint on the ledge at the heating unit, as well as gouge marks and missing paint on the walls. These deficiencies were confirmed by the Assistant Maintenance Director and the Assistant Director of Nursing during interviews.
Failure to Follow Manufacturer Instructions for Sugar Free Pudding Preparation
Penalty
Summary
The facility failed to follow manufacturer instructions for preparing sugar free pudding for the lunch meal service. Food service staff did not prepare the required number of servings in advance and did not use the correct measurements or type of milk as specified by the manufacturer. Specifically, staff mixed two quarts of 2% milk with two packets of sugar free vanilla pudding mix, found the mixture too thin, and added an additional packet. When more servings were needed, staff incorrectly measured milk, initially using two cups instead of two quarts, and then added more milk to compensate. Additionally, a packet of sugar free butterscotch pudding mix was added to the vanilla mixture. The pudding was not prepared in advance to allow proper setting time as required by the manufacturer’s instructions. A review of the facility’s standardized recipes policy confirmed that standardized recipes are to be used in food production. The Food Service Director confirmed that the staff did not follow manufacturer instructions, used the wrong type of milk, and did not allow the pudding to set properly before service. This failure created the potential for inaccurate nutrient content and non-palatable food products to be served to residents.
Failure to Provide Prescribed Diet-Appropriate Desserts
Penalty
Summary
The facility failed to provide the appropriate dessert forms for all residents prescribed mechanical soft and puree diets during a lunch meal service. Specifically, 23 residents on a mechanical soft diet did not receive the mechanical soft lemon blueberry tart, and nine residents on a puree diet did not receive the pureed lemon blueberry tart, as indicated on their tray cards and the facility's menu extension sheets. The facility's policies require that standardized menus, reviewed and approved by the Registered Dietician, fulfill residents' nutritional and therapeutic needs, including providing food in the correct consistency for those with chewing or swallowing difficulties. Observations and staff interviews confirmed that the required mechanical soft and pureed desserts were not prepared or served to the affected residents. Both a staff member and the Food Service Director acknowledged the failure to produce and serve the approved desserts as required by the facility's policies and the residents' prescribed diets. This deficiency was identified during a review of meal service documentation and direct observation of the lunch meal.
Incomplete Medical Records for Three Residents
Penalty
Summary
Kadima Rehabilitation and Nursing at Cheswick was found to be non-compliant with federal and state regulations regarding the maintenance and documentation of resident medical records. Specifically, the facility failed to ensure that medical records were complete and accurately documented for three residents. The deficiency was identified during an abbreviated survey conducted in response to a complaint. The survey revealed that the facility did not complete the required initial admission assessments by social services for three residents who were admitted in late January 2025. The residents involved had significant medical conditions, including alcoholic cirrhosis of the liver, chronic kidney disease, hepatic encephalopathy, orthopedic aftercare, absence of a limb, alcohol-induced chronic pancreatitis, fracture of the tibia, protein-calorie malnutrition, and polyosteoarthritis. Despite these complex medical needs, the facility's failure to conduct initial social service assessments meant that crucial aspects of their care planning and documentation were incomplete. This oversight was confirmed by the Nursing Home Administrator during an interview with surveyors.
Plan Of Correction
1. The facility will correct that Social Services did not complete initial admission assessments for 3 of 7 residents. Social Service will complete an initial admission assessment for R1, R2, and R3. 2. The facility will ensure that Social Services completes an initial admission assessment on new admissions timely. The Social Service Director will look back at every new admission since January 1st to confirm if they have an initial assessment completed. If any are found to not have one completed, one will be completed if the resident is still a current resident. 3. The NHA will educate the Social Service Director on F-842 with emphasis on completing an initial admission assessment on every new admission timely. 4. The NHA/Designee will audit every new admission for 3 months to ensure a Social Service admission assessment was completed timely. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance 2-10-25
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple shifts over a seven-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on three days, one NA per 11 residents during the evening shift on four days, and one NA per 15 residents during the night shift on three days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to meet the staffing requirements on the specified shifts.
Plan Of Correction
1. The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the daylight shift on three of seven days (1/20/25 through 1/23/25), one NA per 11 residents on the second shift on four of seven days (1/20/25, 1/21/25, 1/22/25, and 1/24/25), and one NA per 15 residents on the night shift on three of seven days (1/20/25 through 1/23/25) as required. 2. The facility will ensure that nurse aide staffing ratios of 1:10 on day shift, 1:11 on the evening shift, and 1:15 on night shift are met. Open positions will continue to be posted on various platforms including CCAC to attract new hires. We will continue with a weekly retention and recruitment meeting. We have help wanted signs on our property. We increased bonuses as incentive to pick up shifts. We utilize agency to fill needed shifts. We added a $2.00/hr shift differential for Nurse Aides on the evening shift. We will continue to review referrals to ensure we can meet their needs prior to accepting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler, and RN Supervisors on regulation P5510 and ensuring nurse aide staffing ratios are met each shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facility's projections to meet ratios fall below required ratios due to call offs, No Call No Shows, etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call our off-duty personnel, and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 2/24/2025
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on five out of seven days during the period from January 20, 2025, to January 26, 2025. A review of staffing documents and nursing staff schedules revealed that the facility provided only 2.38 PPD on January 20, 2.81 PPD on January 21, 2.70 PPD on January 22, 3.05 PPD on January 23, and 3.15 PPD on January 26. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 28, 2025, at 10:05 a.m., who acknowledged the failure to provide the required minimum hours of direct care on the specified dates.
Plan Of Correction
1. The facility will ensure state-required general nursing care hours in each 24 hr period will be a minimum of 3.2 hrs of direct resident care for each resident. The facility cannot correct that we did not meet the minimum PPD of 3.2 hrs on the following dates: (1/20/25 through 1/23/25 and 1/26/25). 2. The facility will ensure that the 3.2 state minimum direct resident care hours in each 24hr period is met. Open positions will continue to be posted on various platforms including CCAC to attract new hires. We will continue with a weekly retention and recruitment meeting. We have help wanted signs on our property. We increased bonuses as incentive to pick up shifts. We utilize agency to fill needed shifts. We added a $2.00/hr shift differential for Nurse Aides on the evening shift and increased hourly rates for every LPN who was hired under our "No Benefits" rate. We will continue to review referrals to ensure we can meet their needs prior to accepting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5640 ensuring a minimum of 3.2 direct resident care hrs are met in each 24hr period. Resident care hrs will be reviewed at our daily staffing meeting to ensure a minimum PPD of 3.2 is scheduled to be met. The RN Nursing Supervisors will continue to review direct resident care hrs on evenings and weekends. If the facilities projection to meet the state minimum fall below a 3.2 due to call offs, No Call No Shows etc, the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure the minimum 3.2 hrs of direct resident care for each resident is met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 2/24/2025
Inadequate Surety Bond for Resident Funds
Penalty
Summary
The facility failed to secure a surety bond that adequately protected the personal funds of residents deposited with the facility for three consecutive months. The facility's policy, dated 7/1/24, mandates the purchase of a surety bond to safeguard residents' financial security, with an annual evaluation to ensure sufficient coverage. However, a review of the Resident Trust Surety Bond effective 11/1/24 revealed a bond value of $193,915.84, which was insufficient compared to the $252,107.96 in resident funds held by the facility as of 1/7/25. During an interview on 1/7/25, the Nursing Home Administrator confirmed the inadequacy of the bond amount in protecting all resident financial funds as required by PA Code: 201.18(e)(1) Management.
Plan Of Correction
1. The facilities Resident Trust Surety Bond was increased to $252,200.00 on 1/7/25 to protect the residents financial funds deposited in the facility Resident Trust Accounts. 2. The facility will ensure the value of the facilities Surety Bond protects the balance of resident's financial funds that are deposited in the facility Resident Trust Fund. 3. The NHA will educate the new BOM on the requirement to protect the total amount of resident's financial funds that are deposited in the facilities Resident Trust Fund by ensuring the resident Surety Bond value meets or exceeds the value of funds identified in the Facility Trial Balance. 4. The NHA/designee will complete a Facility Trial Balance monthly x 3 and compare the amt to the value of the resident Surety Bond to ensure the resident funds are protected. If the Surety Bond is found to be not enough to protect the residents funds, the Surety Bond will be increased immediately. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance 2-10-25
Non-Compliance in Management of Residents' Personal Funds
Penalty
Summary
Kadima Rehabilitation & Nursing at Cheswick was found to be non-compliant with federal and state regulations regarding the management of residents' personal funds. The facility failed to maintain sufficient petty cash on hand to meet the residents' needs for three consecutive days. This deficiency was identified during an abbreviated survey conducted in response to five complaints. The facility's policy, dated July 1, 2024, stated that it would maintain adequate petty cash funds to meet residents' needs, but this was not adhered to during the period in question. Interviews conducted during the survey revealed that residents experienced difficulties in accessing their personal funds when requested. A resident confirmed that there were concerns about obtaining personal funds, and the facility was denying withdrawals due to insufficient funds. The Nursing Home Administrator acknowledged the issue, confirming that the facility did not maintain enough petty cash for the specified days, resulting in residents being unable to withdraw cash from their personal funds as needed.
Plan Of Correction
1. The facility cannot correct that we did not maintain a sufficient amount of petty cash for 3 days (January 1, 2 & 3, 2025) to provide residents the amount they wanted to withdraw from their personal funds. 2. The facility will increase the dollar amount of petty cash to have on hand to ensure residents are not denied requested cash withdrawals from their RFMS accounts. 3. The NHA will educate the new BOM on the RFMS process to include maintaining a sufficient amount of cash to meet residents' requests for withdrawals from their accounts. 4. The Social Service Director/Designee will interview 5 residents with RFMS accounts weekly x 4 weeks, then 5 residents a month x 2, to determine if they received requested withdrawals from personal funds. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance 2-10-25
Failure to Provide Proper Supervision for Provisional SLP
Penalty
Summary
The facility failed to ensure that a Speech Therapist providing care to residents was properly licensed. A Speech Language Pathologist (SLP) with a provisional license, Employee E2, was required to practice under the supervision of a licensed SLP. However, this supervision ceased on November 10, 2024, when the supervising licensed SLP left the facility. From that date until December 12, 2024, Employee E2 worked without the required daily supervision. A new licensed SLP, Employee E3, was hired but only provided supervision every two to three weeks, which did not meet the requirement for daily supervision. This lack of proper supervision was confirmed by both the provisional SLP and the Nursing Home Administrator, as well as the Supervisor for the State Licensing Board.
Plan Of Correction
1. The facility cannot correct that E2 had no SLP supervision from 11-10-24 to 12/12/24. 2. The facility will ensure the SLP on a provisional license will receive supervision from a licensed SLP. 3. The Regional Clinical Consultant will re-educate the Nursing Home Administrator on Federal regulation 0826, detailing ensuring if a Speech Language Pathologist (SLP) is currently working on a provisional license, is provided supervision from a Licensed SLP. 4. The NHA/designee will audit weekly x 4 weeks then monthly x 2 to ensure that a SLP on a provisional license who provides care is supervised by a licensed SLP. 5. Date of compliance 2-10-25
LPN Staffing Shortage During Night Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one licensed practical nurse (LPN) per 40 residents during the night shift on two specific days. A review of the nursing time schedules and facility census data from December 8, 2024, through December 28, 2024, revealed that on December 10 and December 15, 2024, the facility did not have the required number of LPNs on duty during the night shift. Specifically, the facility had a census of 91 residents, necessitating 2.28 full-time equivalent (FTE) LPNs, but only 2.19 and 2.06 FTEs were present on the respective days. The Assistant Director of Nursing confirmed this staffing shortfall during an interview on January 7, 2025, acknowledging the failure to provide the required LPN coverage without any additional higher-level staff to compensate for the deficiency.
Plan Of Correction
1. The facility will ensure state-required LPN ratios are met during the overnight shift. The facility cannot correct that LPN staffing ratios were not met on the overnight shift on 12/10/24 & 12/15/24. 2. The facility will ensure that the LPN staffing ratio of 1:40 are met during the overnight shift. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5530 and ensuring LPN staffing ratios are met during the overnight shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facilities projections to meet LPN ratios on the overnight shift fall below required ratios due to call offs, No Call No Shows etc., the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure LPN staffing ratios are being met during the overnight shift. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance 2-10-25.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions between December 16, 2024, and January 1, 2025. Specifically, the facility did not provide the mandated number of NAs per resident during the daylight, evening, and night shifts on several days. For the daylight shift, the facility was short on seven days, with actual hours worked falling below the required hours. Similarly, the evening shift was understaffed on seven days, and the night shift on eight days, with actual hours consistently below the required staffing levels. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 3, 2025.
Plan Of Correction
1. The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the following dates: Daylight shift on (12/25/24 through 12/30/24 and 1/1/25), evening shift on (12/22/24 and 12/26/24 through 12/31/24), and night shift on (12/16/24, 12/18/24, 12/21/24, 12/22/24, and 12/26/24 through 12/29/24). 2. The facility will ensure that nurse aide staffing ratios of 1:10 on day shift, 1:11 on the evening shift and 1:15 on night shift are met. Open positions will continue to be posted on platforms to attract new hires. We will continue with a weekly retention and recruitment meeting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5510 and ensuring nurse aide staffing ratios are met each shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facilities projections to meet ratios fall below required ratios due to call offs, No Call No Shows etc, the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 1/20/2025.
Facility Fails to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-mandated requirement of providing a minimum of 3.2 hours of direct resident care per patient daily (PPD) on ten out of seventeen days between December 16, 2024, and January 1, 2025. A review of nursing time schedules and staff interviews revealed that the facility's PPD hours fell short on specific dates, with the lowest being 2.53 PPD on December 26, 2024. The Nursing Home Administrator confirmed the deficiency during an interview on January 3, 2025, acknowledging the failure to meet the required PPD hours on the specified dates.
Plan Of Correction
1. The facility will ensure state-required general nursing care hours in each 24 hr period will be a minimum of 3.2 hrs of direct resident care for each resident. The facility cannot correct that we did not meet the minimum PPD of 3.2 hrs on the following dates: 12/16/24, 12/21/24, 12/22/24, 12/25/24 through 12/28/24, and 12/30/24 through 1/1/25. 2. The facility will ensure that the 3.2 state minimum direct resident care hours in each 24hr period is met. Open positions will continue to be posted on platforms to attract new hires. We will continue with a weekly retention and recruitment meeting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5640 ensuring a minimum of 3.2 direct resident care hrs are met in each 24hr period. Resident care hrs will be reviewed at our daily staffing meeting to ensure a minimum PPD of 3.2 is scheduled to be met. The RN Nursing Supervisors will continue to review direct resident care hrs on evenings and weekends. If the facilities projection to meet the state minimum fall below a 3.2 due to call offs, No Call No Shows etc, the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure the minimum 3.2 hrs of direct resident care for each resident is met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 1/20/2025
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on both the daylight and evening shifts over a specified period. On two days, the facility did not provide the mandated one nurse aide per 10 residents during the daylight shift, and on three days, it did not meet the requirement of one nurse aide per 11 residents during the evening shift. Specifically, on 11/29/24 and 12/2/24, the daylight shift was understaffed, with actual hours worked falling short of the required hours. Similarly, on 11/29/24, 12/2/24, and 12/3/24, the evening shift also experienced a shortfall in staffing hours. The Nursing Home Administrator confirmed these deficiencies during an interview.
Plan Of Correction
1. The facility will ensure state-required nurse aide ratios are met for all shifts. The facility cannot correct that nurse aide staffing ratios were not met on the following dates: 11/29/24, 12/2/24 & 12/3/24. 2. The facility will ensure that nurse aide staffing ratios of 1:10 on day shift, 1:11 on the evening shift and 1:15 on night shift are met. Open positions will continue to be posted on platforms to attract new hires. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5510 and ensuring nurse aide staffing ratios are met each shift. Staffing ratios will be reviewed at our daily staffing meeting to ensure ratios are scheduled to be met. The RN Nursing Supervisors will continue to review shift staffing ratios on evenings and weekends. If the facilities projections to meet ratios fall below required ratios due to call offs, No Call No Shows etc, the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure nurse aide staffing ratios are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 12/16/2024
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on five consecutive days from November 29, 2024, to December 3, 2024. A review of staffing documents and nursing staff schedules revealed that the facility provided 3.00 PPD on November 29, 3.17 PPD on November 30, 3.19 PPD on December 1, 2.93 PPD on December 2, and 3.09 PPD on December 3. During an interview on December 4, 2024, the Nursing Home Administrator confirmed the facility's failure to meet the required PPD hours on these dates.
Plan Of Correction
1. The facility will ensure state-required general nursing care hours in each 24 hr period will be a minimum of 3.2 hrs of direct resident care for each resident. The facility cannot correct that we did not meet the minimum PPD of 3.2 hrs on the following dates: 11/29/24, 11/30/24, 12/1/24, 12/2/24 & 12/3/24. 2. The facility will ensure that the 3.2 state minimum direct resident care hours in each 24hr period is met. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5640 ensuring a minimum of 3.2 direct resident care hrs are met in each 24hr period. Resident care hrs will be reviewed at our daily staffing meeting to ensure a minimum PPD of 3.2 is scheduled to be met. The RN Nursing Supervisors will continue to review direct resident care hrs on evenings and weekends. If the facilities projection to meet the state minimum fall below a 3.2 due to call offs, No Call No Shows etc, the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure the minimum 3.2 hrs of direct resident care for each resident is met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 12/16/2024
Failure to Maintain Acceptable Temperature Levels
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring acceptable temperature levels in 32 resident rooms across three floors. The facility's policy requires maintaining temperatures between 70 and 82 degrees Fahrenheit, but a review of the temperature log revealed that the temperatures in these rooms were below the minimum acceptable range. This issue was attributed to a failure in the circulatory pump on the main boiler, which was leaking and ultimately failed, as confirmed by the Maintenance Director. During a facility tour, it was observed that the temperatures in the first and third-floor dining rooms were 67 degrees Fahrenheit, and one resident room was at 70 degrees Fahrenheit. Interviews with residents indicated discomfort due to the cold temperatures, with residents expressing a desire for the heat to be turned on. The Nursing Home Administrator confirmed the facility's failure to maintain the required temperature range, impacting the residents' environment and comfort.
Unsanitary Kitchen Equipment in Main Kitchen
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition, specifically within the walk-in cooler of the main kitchen. During an observation, it was noted that the cold air condenser fan covers had accumulated dust, grime, and dark-colored debris. This observation was confirmed by the Food Service Director (FSD) Employee E3, who acknowledged the unsanitary condition of the equipment. The facility's policy on sanitation, dated 7/1/24, mandates that all food service areas and equipment be kept clean and in good repair, free from breaks, corrosions, open seams, cracks, and chipped areas. The failure to adhere to this policy created the potential for cross-contamination in the main kitchen.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for four residents who were transferred to the hospital and expected to return. The clinical records of these residents, who had various diagnoses including neurocognitive disorders, high blood pressure, insomnia, anxiety, dementia, parkinsonism, bipolar disorder, major depressive disorder, and atrial fibrillation, lacked documented evidence of communication of essential information. This information included the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs at the receiving facility. The deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the facility did not provide the necessary information for the residents involved. The lack of communication was identified for residents transferred on multiple occasions, indicating a systemic issue in the facility's process for handling transfers and discharges. This failure to communicate critical information could potentially impact the continuity and quality of care provided to the residents upon their transfer to another health care provider.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers for three out of five residents reviewed. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. Specifically, the clinical records of Residents R58, R69, and R70 did not contain documented evidence that they or their representatives were provided with written information about the facility's bed-hold policy at the time of their respective hospital transfers. Resident R58, who was admitted with diagnoses including neurocognitive disorder with anxiety, high blood pressure, and dementia, was transferred to the hospital on 9/23/24. Resident R69, with diagnoses including neurocognitive disorder with Lewy bodies and parkinsonism, was transferred on 4/23/24. Resident R70, diagnosed with bipolar disorder, major depressive disorder, and atrial fibrillation, was transferred on two occasions, 3/27/24 and 6/29/24. In each case, there was no documented evidence of notification regarding the bed-hold policy. The Assistant Director of Nursing confirmed this failure during an interview.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to five residents diagnosed with PTSD, as evidenced by the lack of identification and management of triggers that could lead to re-traumatization. The facility's policy on Trauma Informed Care, dated 7/1/24, mandates individualized care and the identification of trauma triggers upon admission by the social worker. However, the Social Service History assessments for these residents did not assess or identify potential stressors or triggers related to their PTSD. This oversight was confirmed during interviews with the Social Service Director, who acknowledged the failure to incorporate this critical information into the residents' care plans. Each of the five residents had documented diagnoses of PTSD, along with other conditions such as insomnia, anxiety, depression, and various physical health issues. Despite these diagnoses, their care plans did not include specific strategies to avoid or mitigate known triggers, which is a crucial component of trauma-informed care. The deficiency was highlighted by the facility's inability to adhere to its own policy, as confirmed by the Social Service Director, who admitted that the facility did not adequately identify or address PTSD triggers for these residents.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to obtain a physician order for hospice services and ensure the coordination of hospice services with facility services for three residents receiving end-of-life care. The facility's policy on hospice care, dated 7/1/24, requires that all hospice assessments, plans of care, progress notes, and services be maintained on the medical record and integrated with the facility's plan of care. However, the review of the clinical records for three residents revealed that the physician orders for hospice services did not include the diagnoses qualifying the residents for hospice care. Additionally, the care plans for these residents did not provide contact information for the hospice services. The residents involved had serious medical conditions, including Parkinson's Disease, Alzheimer's Disease, stroke, atrial fibrillation, and non-Alzheimer's dementia, which necessitated hospice care. Despite the residents receiving hospice care, the facility did not have the necessary physician orders or coordination with hospice services documented in their care plans. This lack of documentation and coordination was confirmed by the Social Service Director during an interview, highlighting the facility's failure to meet the needs of residents for end-of-life care.
Failure to Implement Enhanced Barrier Precautions for Residents with Catheters
Penalty
Summary
The facility failed to implement enhanced barrier precautions for four residents who had active orders for catheter use. The facility's policy on enhanced barrier precautions, dated 7/1/24, requires the use of gowns and gloves during high-contact resident care activities, such as catheter care. However, the physician orders for Residents R26, R41, R44, and R65 did not include orders for enhanced barrier precautions, despite their need for catheter care. Observations confirmed the absence of enhanced barrier isolation signage and personal protective equipment (PPE) outside the rooms of these residents. The Infection Preventionist confirmed the facility's failure to ensure enhanced barrier precautions were ordered and implemented for these residents. The deficiency was identified through clinical record reviews, observations, and staff interviews, revealing a lack of compliance with the facility's infection prevention and control program. This oversight was noted in the context of Pennsylvania code requirements for resident care policies and nursing services.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for residents on the Second and Third floors. Observations revealed that Resident R44 had two square floor tiles missing from the right side of the bed, and Resident R56 had multiple divots in the floor tiles to the right side of the bed. Additionally, the Second-floor dining room had seven trays stacked with old dishes from breakfast, and mechanical lifts and unused wheelchairs were stored inappropriately in the dining room. Similar storage issues were observed in the Third-floor dining room, where four mechanical lifts and unused wheelchairs were stored in corners. Furthermore, Resident R16 was found outside the dining room in a Broda chair that had a dried, sticky substance on the wheels, brakes, armrests, and frame. This was confirmed by Nurse Aide Employee E1. The Nursing Home Administrator acknowledged the facility's failure to maintain a clean, safe, comfortable, and homelike environment for the affected units. These observations and interviews indicate a breach of the facility's policy on maintaining a homelike environment and compliance with state regulations.
Neglect of Resident Needing Assistance with Incontinence
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by the incident involving a resident who required assistance during the night. The resident, who had a history of anxiety, depression, and high blood pressure, experienced diarrhea and needed help changing her brief. Despite pulling the call bell for assistance, the nurse aide who responded refused to help, instructing the resident to change it herself before leaving the room. This neglectful behavior was corroborated by the resident's roommate, who witnessed the interaction. The incident was further confirmed during an interview with the resident, who reiterated her need for assistance and the nurse aide's refusal to provide help. The Director of Nursing acknowledged the facility's failure to protect the resident from neglect. The deficiency was identified under several Pennsylvania Code regulations, highlighting the facility's responsibility to ensure proper resident care and management.
Failure to Investigate Resident Incident
Penalty
Summary
The facility failed to initiate a thorough investigation for an incident involving one of its residents, identified as Resident R70. According to the facility's Accident and Incident-Investigating and Reporting policy, all accidents or incidents occurring on the premises must be investigated and reported to the administrator. Resident R70, who has diagnoses including chronic atrial fibrillation, bipolar disorder, and major depressive disorder, was found by a nurse aide near the elevator in the basement. The incident occurred between 7:30 and 8:00 pm, and the resident was subsequently returned to her room. Despite the occurrence, the facility did not conduct the required investigation, as confirmed by the Assistant Director of Nursing (ADON) during an interview.
Deficiency in Admission Documentation for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain proper admission documentation for two residents, leading to a deficiency in compliance with admission policies and residents' rights. Resident R11, who was admitted with diagnoses including parkinsonism, adjustment disorder with depressed mood, and convulsions, was found to have a BIMS score of 5, indicating severe cognitive impairment. However, upon review, it was discovered that there was no admission packet available for Resident R11, indicating a lack of required documentation at the time of admission. Similarly, Resident R67, admitted with diagnoses such as hemiplegia and hemiparesis following cerebral infarction, cognitive communication deficit, and hypertension, was assessed with a BIMS score of 10, indicating moderate cognitive impairment. The admission packet for Resident R67 was missing a signature from the Power of Attorney (POA), which is necessary due to the resident's cognitive impairment. The Nursing Home Administrator confirmed that Resident R67 should not have signed the facility paperwork due to their cognitive status, and that Resident R11's admission paperwork was never completed as required.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident, resulting in an elopement incident. The facility's Resident Elopement policy, dated July 1, 2024, mandates a safe and secure environment to prevent resident elopement. However, a resident with chronic atrial fibrillation, bipolar disorder, and major depressive disorder was found unsupervised in the basement by a nurse aide. The incident occurred between 7:30 and 8:00 pm, and the resident was confused and unable to explain why they were there. The Director of Nursing confirmed the lack of adequate supervision for the resident, as required by the facility's policies and state regulations.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care related to oxygen equipment and management for three residents. Resident R33, diagnosed with anemia, COPD, and depression, was observed with an oxygen concentrator whose filters were covered with a gray/white fuzzy substance, indicating they had not been changed as required. Similarly, Resident R44, with diagnoses of anemia, multiple sclerosis, and high blood pressure, was also found with an oxygen concentrator with filters covered in the same gray/white fuzzy substance. Both observations were confirmed by LPNs during interviews. Resident R87, diagnosed with non-Alzheimer's dementia, high blood pressure, and anxiety, was observed with outdated oxygen tubing that had not been changed weekly as ordered. This was confirmed by an LPN during an interview. The Nursing Home Administrator acknowledged the facility's failure to provide appropriate respiratory care for these residents, as required by the facility's policy and physician orders.
Lack of Training on New Needle System Leads to ER Visit
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skill sets to provide care for a resident requiring subcutaneous injections, which resulted in an emergency room visit. Specifically, a resident with diabetes, schizophrenia, and anxiety was prescribed Lantus insulin to be administered subcutaneously twice daily. During an insulin administration, the needle became dislodged into the resident's abdomen, prompting the nurse to send the resident to the emergency room. Upon investigation, it was discovered that the syringe used had a retractable needle, a new system that the staff had not been trained on. The incident highlights a lack of training and competency among the nursing staff regarding the use of new medical equipment. An LPN involved in the incident confirmed that the staff had not received training on the new needle system, which included three different types of needles that appeared similar to the old ones. This lack of training led to confusion and concern when the needle retracted, resulting in the decision to send the resident to the emergency room. The Nursing Home Administrator acknowledged the facility's failure to ensure that licensed nurses had the specific competencies required for administering subcutaneous injections.
Failure to Timely Report Abnormal Lab Results
Penalty
Summary
The facility failed to report abnormal lab results to the ordering physician in a timely manner for one of the three residents reviewed, specifically Resident R58. According to the facility's policy on Notification of Condition Change, any change in a resident's condition, including abnormal lab values, should be reported to the physician promptly. Resident 58 had a physician's order for a urine culture dated 11/3/24, and the laboratory report with abnormal values was finalized and reported on 11/4/24. However, a review of Resident R58's clinical record on 11/6/24 showed no evidence that the physician was notified of these abnormal lab results. An interview with the Infection Preventionist, Employee E8, indicated that lab results are signed off after being reviewed by a physician, and any notifications, lab results, and new orders are documented in the resident's clinical record. The Nursing Home Administrator confirmed the facility's failure to report the abnormal lab results to the ordering physician in a timely manner for Resident R58.
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for Resident R11, who was one of four residents observed. According to the facility's policy on adaptive eating devices, these tools are intended to help patients achieve or maintain their highest level of eating independence. Resident R11, who was admitted to the facility with diagnoses including high blood pressure, Parkinson's Disorder, and dysphagia, had an active physician order dated 6/11/24 for weighted utensils and a divided plate. However, during an observation on 11/4/24, it was noted that Resident R11's lunch tray did not include these adaptive devices. This was confirmed by Nurse Aide, Employee E9. Further observation and interview on 11/6/24 with the Food Service Director, Employee E10, confirmed that the meal tray or ticket for Resident R11 did not indicate the need for weighted utensils and a divided plate, resulting in the failure to provide the necessary adaptive feeding devices.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for four residents. This deficiency was identified through a clinical record review and staff interview. The residents involved were transferred to the hospital on various dates and returned to the facility without documented evidence of a written transportation notification being provided to the Ombudsman. The Assistant Director of Nursing confirmed this failure during an interview. The residents affected had various medical conditions, including neurocognitive disorders, high blood pressure, insomnia, anxiety, dementia, parkinsonism, repeated falls, bipolar disorder, major depressive disorder, and atrial fibrillation. Despite these conditions, the facility did not comply with the requirement to notify the Ombudsman of their hospital transfers, as mandated by 28 Pa. Code 201.29(a)(c.3)(2) regarding resident rights.
Failure to Notify Physician of Abnormal Glucose Levels
Penalty
Summary
The facility failed to follow physician orders and notify a physician of abnormal glucose readings for a resident with diabetes, renal failure, and hemiplegia. The resident had multiple instances of low blood glucose levels, ranging from 58 mg/dl to 69 mg/dl, over a period of approximately one month. Despite the facility's hypoglycemia protocol requiring physician notification for blood glucose levels below 70 mg/dl, there was no documentation indicating that the physician was notified on any of these occasions. The Assistant Director of Nursing (ADON) confirmed during interviews that the facility could not produce documentation to show that the physician was notified of the resident's abnormal blood glucose levels. This failure to follow physician orders and notify the physician as required was identified for one of four residents reviewed. The deficiency was cited under multiple Pennsylvania Code regulations, including management, resident rights, resident care policies, and nursing services.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to ensure that weights were monitored as ordered for one of four residents. According to the facility's policy dated 7/1/23, all residents should be weighed on admission, readmission, and at least monthly, with more frequent weights as needed. Resident R1, who had diagnoses of renal failure, diabetes, and hemiplegia, was admitted to the facility and had a physician's order for weekly weights every Wednesday for four weeks starting from 3/27/24. However, the Medication Administration Record (MAR) showed that weights were not documented for 4/3/24, 4/10/24, and 4/17/24. Interviews with the Registered Dietitian (RD) and the Assistant Director of Nursing confirmed the lack of documented weights for the specified dates, indicating a failure to monitor weights as ordered for Resident R1.
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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