Kadima Rehabilitation & Nursing At Greenville
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Pennsylvania.
- Location
- 110 Fredonia Road, Greenville, Pennsylvania 16125
- CMS Provider Number
- 395158
- Inspections on file
- 26
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Greenville during CMS and state inspections, most recent first.
The facility failed to administer insulin according to manufacturer guidelines and appropriate meal timing for three residents with diabetes. In one case, a resident with multiple comorbidities received insulin lispro well before receiving a meal tray and subsequently experienced a hypoglycemic episode requiring Glucagon. In two other cases, residents received Novolin R or insulin lispro based on sliding scale orders tied to meals, but insulin was administered about an hour or more before meals were actually served. An LPN reported routinely giving insulin one hour before meals, and the NHA acknowledged that insulin should be administered within a short time frame before or after meals per manufacturer instructions.
The facility failed to provide sufficient nursing staff and timely call light response, resulting in multiple residents waiting 30 minutes to several hours for assistance despite policies requiring prompt response and frequent checks on those unable to call for help. Resident council minutes and grievance logs documented ongoing concerns about delayed call bell response, especially on afternoon and night shifts. Several residents reported they no longer used their call bells because no one responded, with one resident instead propelling in a wheelchair to the nurses’ station for help. In one case, a resident with a Foley catheter who had activated the call bell for bleeding waited so long that they called 911 and were later found by the DON to have bleeding with large blood clots before being transferred to the hospital.
The facility failed to maintain a functional call bell system on one hall, where the installed system relied on a small digital display at the nurse's station that only briefly beeped, lacked overhead lights, and could show only a limited number of active calls. Staff had to go to the nurse's station and cross-reference a list to determine which room was calling and had no way to know if multiple calls were active without checking the display. Testing showed that one room’s call bell did not register on the digital unit on two separate days. A resident and family member reported that call bells had not been working adequately for months and resorted to using a tap bell and a cow bell so staff could hear them, while another resident’s representative reported that the call bell was not working for that resident.
A resident with paranoid schizophrenia, diabetes, and HTN eloped from the facility and was later identified as being at risk for elopement through an Elopement Risk Assessment. Despite facility policies requiring individualized care plans and specific revisions following any successful elopement, the resident’s comprehensive care plan did not include interventions for elopement risk or the actual elopement, a deficiency confirmed by the RN Assessment Coordinator during surveyor interview.
A resident with paranoid schizophrenia, diabetes, and hypertension eloped from the facility, but the clinical record contained no documentation of the elopement, the resident’s safe return, or notification of the physician or resident representative, contrary to the facility’s documentation policy. Review of the record also showed that elopement risk assessments were not completed on a quarterly basis as required, and interviews with the DON, RNAC, and NHA revealed uncertainty about the required frequency of these assessments and confirmed the absence of timely documentation.
A resident with an indwelling urinary catheter and multiple diagnoses, including bronchitis, hypertension, and diabetes, was receiving antibiotics for a UTI when surveyors observed the resident’s catheter drainage bag lying uncovered on the floor under the bed. Facility policy required catheter bags to be covered, properly positioned, and kept off the floor. An LPN and the Nursing Home Administrator both confirmed that the bag should have been covered and not in contact with an unclean surface, demonstrating a failure to provide essential catheter care and infection prevention measures.
A resident reported that their mail was being opened by facility staff before delivery, which was confirmed by the Nursing Home Administrator. This action violated the resident's right to privacy in written communications as outlined in facility policy.
The facility did not clarify a physician's order for surgical dressing care for a resident, resulting in the dressing remaining in place beyond the ordered removal date. Additionally, a physician's order for a UA C&S for another resident was not carried out in a timely manner, with the urine sample collected several days after the order was given.
A resident with end stage renal disease did not have required dialysis communication forms completed for several treatments, and multiple prescribed medications were not administered on dialysis days as ordered, with no evidence that the physician was notified of these omissions. Facility leadership confirmed these documentation and medication administration failures.
A multi-dose vial of Tirzepatide was found in a medication storage room without labeling to indicate the resident's name, date opened, or use by date. Facility policy requires such labeling for all medications in use. Both a registered nurse and nursing leadership confirmed the vial was in use and not properly labeled.
A resident's personal refrigerator was found without a thermometer and lacked any evidence of temperature monitoring or documentation, despite facility policy requiring regular checks and recording on the EMAR. Interviews with the ADON and an LPN confirmed the monitoring process was not followed, and the administrator acknowledged the deficiency.
A resident with dementia and age-related disability was found to have an acute hip fracture of unknown origin. The facility did not report this serious injury to the State Survey Agency within the required timeframe, as confirmed by the DON, despite regulations mandating immediate reporting of such incidents.
The facility did not meet the required NA staffing ratios on multiple occasions, failing to provide adequate care for its residents. The deficiency was confirmed through a review of staffing documents and staff interviews, revealing consistent shortages in NA coverage across day, evening, and overnight shifts.
The facility did not meet the required LPN staffing ratios on four occasions, failing to provide the mandated number of LPNs per resident during the day shift. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. A review of staffing documents revealed that the care hours were below the mandated minimum on several days, with the lowest being 2.72 hours per patient per day. This deficiency was confirmed by the Nursing Home Administrator.
Failure to Administer Insulin in Accordance With Manufacturer Guidelines and Meal Timing
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin in accordance with manufacturer guidelines and good nursing principles for three residents with diabetes. Facility policy required medications to be administered as prescribed and in accordance with good nursing practices. Manufacturer instructions for Humalog (insulin lispro) specified administration within 15 minutes before or immediately after a meal, and for Novolin Regular within 30 minutes before or immediately after a meal. For one resident with diabetes, CHF, and COPD, the record showed a blood sugar of 336 at 5:00 p.m. on 2/26/26, and 10 units of insulin lispro were administered per sliding scale by an LPN. At approximately 5:45 p.m., the resident had not yet received a meal tray and subsequently experienced a hypoglycemic episode requiring administration of Glucagon at 5:50 p.m. and again at 6:10 p.m. Another resident with diabetes, altered mental status, hypertension, and coronary artery disease had an order for Novolin R sliding scale with meals. On 3/05/26, the blood sugar at 11:30 a.m. was 315, and 5 units of Novolin R were administered by an LPN, but the lunch meal was not delivered until 1:25 p.m. That same day, the resident’s evening blood sugar at 4:00 p.m. was 276, and 4 units of Novolin R were given, while dinner was not served until 6:50 p.m. A third resident with diabetes, COPD, gastrointestinal hemorrhage, and hypovolemic shock had an order for insulin lispro sliding scale with meals; on 3/05/26, a blood sugar of 236 at 4:00 p.m. led to administration of 3 units of insulin lispro, while dinner was not served until 6:49 p.m. During interview, the LPN who administered the insulin to the latter two residents stated that insulin was typically given one hour before meals, and the Nursing Home Administrator confirmed insulin should be administered within a short time span before or after meals per manufacturer guidelines.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and timely call light response to meet residents’ needs, as required by facility policy and job descriptions. The facility’s call light policy and CNA/RN job descriptions state that staff must respond to call lights and resident needs promptly, check frequently on residents unable to call for help, and that all employees must answer call lights regardless of department. Resident Council minutes over a three‑month period documented repeated concerns that call bells were not answered as timely as residents preferred, particularly on afternoon and midnight shifts. Grievance logs from the same period showed multiple complaints of residents waiting from 30 minutes up to two to three hours for assistance after activating their call bells. Interviews conducted with multiple residents and a resident representative confirmed ongoing delays of 30 minutes or more in call bell response, with some residents reporting they had stopped using their call bells because staff did not respond. One resident reported waiting two hours for assistance on a specific evening. Another resident stated they had to self‑propel in a wheelchair to the nurses’ station to obtain help. During an observation, a resident with a Foley catheter was found in bed, upset and calling out for a nurse, and reported having activated the call bell approximately 1 hour and 45 minutes earlier due to bleeding; this resident ultimately called 911 and was found by the DON to have bleeding with large blood clots before being transferred to the hospital. The DON acknowledged that all residents should have their call bells answered in a timely manner and that waiting 30 minutes or more for staff response was unacceptable.
Failure to Maintain Functional Call Bell System on 500 Hall
Penalty
Summary
The facility failed to ensure that the call bell system was adequately working on one of six halls (500 hall/Unit 1), as required by its policy that mandates a call bell or alternative device be within reach of each resident in their room, toilet, or bathing area, with staff alerted by visual and audible signals. The installed call system used an oblong digital unit at the nurse's station that displayed two-digit numbers corresponding to room and bathroom call bells and emitted three beeps when the first call was activated. However, the system did not provide ongoing audible alerts, did not illuminate overhead lights down the hall or outside resident rooms, and could only display up to eight active calls at a time. When more than one call bell was activated, subsequent calls displaced earlier numbers on the display without additional sound or visual alerts, and any calls beyond eight were not displayed until earlier calls were cleared. Staff reported that to identify which resident was calling, they had to go to the nurse's station, view the two-digit number on the unit, and then cross-reference a separate list to match the number to a resident room. On the 500 hall, testing and observation revealed that call bell number 47, associated with a specific room, did not display on the digital unit when activated on two consecutive days, a problem confirmed by a CNA and the DON. A resident and family member reported that call bells had not been working adequately for several months, and that the resident had been provided a tap bell by the facility while the daughter purchased a cow bell so staff could hear it. Another resident representative reported that the call bell was not working for that resident. Staff interviews confirmed they had no way to know if more than one call bell was activated unless they physically went to the nurse's station to look at the digital unit, and that the system’s limited display and lack of continuous audible or visible alerts impeded their awareness of active calls. These observations and interviews demonstrated that the call system on the 500 hall was not reliably functioning as intended by facility policy.
Failure to Care Plan for Resident Elopement Risk After Actual Elopement
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive, individualized plan of care addressing elopement risk for one resident. Facility policies on MDS/RAI/care planning, Resident Elopement, and Resident Elopement Follow-Up Procedure required that each resident have a written, individualized care plan and that any resident with a successful elopement be reassessed, with additional interventions identified and incorporated into the plan of care, including modifications for increased elopement risk and monitoring as needed. Review of the resident’s clinical record showed that an Elopement Risk Assessment was completed on 2/26/26 and identified the resident as being at risk for elopement. The resident, admitted on 11/7/14, had diagnoses including paranoid schizophrenia, diabetes, and high blood pressure. Information submitted by the facility showed that the resident eloped from the facility on 2/26/26. Despite this event and the completed Elopement Risk Assessment, review of the comprehensive plan of care did not reveal any care plan addressing the resident’s risk for elopement or the actual elopement. During an interview on 3/6/26, the RN Assessment Coordinator confirmed that the resident’s comprehensive plan of care did not include a care plan for elopement risk or the actual elopement, in contrast to the facility’s stated policies.
Failure to Document Elopement Incident and Complete Quarterly Elopement Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and timely documentation related to an elopement incident and to follow its own policies for elopement risk assessment. Facility policy on documentation required nursing documentation to be concise, clear, pertinent, accurate, and to communicate the resident’s status and provide an accurate accounting of care and monitoring. A separate policy on resident elopement required that residents be reassessed at least quarterly for elopement risk. One resident, admitted with diagnoses including paranoid schizophrenia, diabetes, and hypertension, eloped from the facility on 2/26/26. However, the clinical record progress notes contained no documentation of the elopement event, the resident’s safe return, or notification of the physician and/or resident representative. Review of the resident’s elopement risk assessments showed they were completed on 1/14/25, 4/17/25, and 2/26/26, with no evidence that these assessments were performed on a quarterly basis as required by policy. During interviews, the DON confirmed that the clinical record lacked documentation of the elopement, the resident’s return, and required notifications, and stated that a risk management entry and/or progress note should have been completed. The DON and RNAC reported they were unsure how often elopement risk assessments were to be completed, and the NHA was also unable to verify the required frequency at the time of interview. The NHA confirmed that the resident’s record lacked evidence of quarterly elopement risk assessments, resulting in noncompliance with state regulations governing medical records and nursing services.
Failure to Maintain Indwelling Catheter Bag Off Floor and Covered
Penalty
Summary
The facility failed to follow its own catheter care policy for a resident with an indwelling urinary catheter. The policy dated 11/2024 required that residents with indwelling catheters receive appropriate care, including maintaining catheter drainage bags off the floor, ensuring the catheter is anchored, and keeping the drainage bag covered and properly positioned. Resident R1, admitted on 12/24/25 with diagnoses including bronchitis, hypertension, and diabetes, was identified in the clinical record as currently receiving a seven-day course of antibiotics for a urinary tract infection. During an observation on 1/27/26 at 11:44 a.m., Resident R1’s urinary catheter drainage bag was seen lying uncovered on the floor under the bed, without any covering over the bag. In an interview at 11:50 a.m., an LPN (Employee E3) confirmed that the catheter bag was on the floor and acknowledged that the bag should be covered and maintained off the floor for infection control. In a separate interview at 12:40 p.m., the Nursing Home Administrator also confirmed that the catheter bag should be covered and not touch an unclean surface due to the risk of infection. These observations and interviews established that the facility did not ensure essential catheter care and infection prevention measures for this resident.
Failure to Ensure Resident Mail Privacy
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened, as required by facility policy and resident rights regulations. Review of the facility's policies confirmed that residents have the right to privacy in written communications, including the right to send and promptly receive unopened mail. During an interview, a cognitively intact resident reported that the facility was opening their mail prior to delivery, which the resident identified as an invasion of privacy. The Nursing Home Administrator confirmed that some of the resident's mail was being opened before being given to the resident.
Failure to Clarify and Follow Physician Orders for Wound Care and Urine Testing
Penalty
Summary
The facility failed to clarify a physician's order regarding surgical dressing care for one resident. The resident was admitted with an order stating that an Aquacel dressing should have been removed on a specific date and the incision left open to air. However, upon arrival at the facility several days later, the Aquacel dressing was still intact, indicating that the order was not followed or clarified as required by facility policy. The Director of Nursing confirmed that the conflicting orders should have been clarified with the physician. Additionally, the facility did not follow a physician's order to obtain a urinalysis and culture & sensitivity (UA C&S) in a timely manner for another resident. The order was written for the test to be performed due to symptoms of dysuria and frequency, but the urine sample was not collected until several days after the order was given. The clinical record lacked evidence that the test was collected promptly, as required by the physician's instructions.
Failure to Document Dialysis Communication and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate records of dialysis communication and did not ensure that medications were administered according to physician's orders for a resident receiving dialysis. A review of the Memorandum of Agreement between the facility and the dialysis provider required the exchange of relevant information regarding the resident's condition and treatment, and facility policy mandated documentation of dialysis care in the medical record. However, the clinical record for a resident with diagnoses including diabetes, end stage renal disease, and respiratory failure lacked evidence of completed dialysis communication forms for multiple scheduled dialysis treatments. Additionally, the resident's care plan included an intervention to ensure medication administration times did not conflict with the dialysis schedule. Despite this, the Medication Administration Records showed that several prescribed medications were not administered on dialysis days, with the reason documented as Leave of Absence. There was no documentation that the physician was notified about the missed or altered medication administration times on these days. Interviews with facility leadership confirmed the absence of required dialysis communication documentation and the failure to administer medications as ordered, as well as the lack of physician notification regarding these omissions. These findings were cited under multiple state regulations related to licensee responsibility, management, medical records, and nursing services.
Unlabeled Multi-Dose Tirzepatide Vial Found in Medication Room
Penalty
Summary
Surveyors found that a multi-dose vial of Tirzepatide, a prescription medication used for type 2 diabetes and weight loss, was stored in the Unit One medication room without being labeled with the resident's name, the date it was opened, or the date it should be used by. Facility policy requires that all medications be stored in a safe, secure, and orderly manner, and that drug containers must have complete and legible labels, including the resident's name and relevant dates. During the observation, a registered nurse confirmed that the vial was opened and in use but lacked the required labeling. The Director of Nursing and Assistant Director of Nursing also confirmed that the vial was missing this information and acknowledged that it should have been properly labeled.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor the temperature of a resident's personal refrigerator as required by facility policy. The policy stated that personal refrigerators must include a thermometer and be subject to the same regular temperature monitoring as other facility refrigerators, with documentation of temperatures. Observation revealed that a resident had a personal refrigerator in their room without a thermometer and without any visible temperature log sheet. Further inspection of the refrigerator confirmed the absence of a thermometer. Interviews with the Assistant Director of Nursing and an LPN confirmed that temperatures for personal refrigerators were supposed to be documented on the resident's electronic medication administration record (EMAR) every shift. However, review of the resident's EMAR showed no evidence that temperatures had been monitored or recorded. The Nursing Home Administrator also confirmed that the refrigerator lacked a thermometer and that there was no evidence of temperature monitoring for the resident's personal refrigerator.
Failure to Timely Report Serious Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an incident involving a resident who sustained a serious bodily injury of unknown origin. According to facility documentation and staff interviews, a resident with dementia and age-related disability was found to have an acute fracture of the left proximal femur, as confirmed by x-ray. The injury was determined to be of unknown origin, and there was no documentation of any recent falls. The facility's policy and federal regulations require that such incidents, especially those involving serious bodily injury of unknown source, be reported immediately, but not later than two hours after discovery. Despite these requirements, the incident was not reported to the State Survey Agency until several days after the resident's injury was identified. The Director of Nursing confirmed during an interview that the reporting did not occur within the required timeframe. The delay in reporting was in direct violation of both facility policy and federal regulations regarding the timely notification of authorities in cases of suspected abuse, neglect, or injuries of unknown source.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios across multiple shifts over several weeks. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. This deficiency was observed on numerous dates between November 2024 and January 2025, as evidenced by a review of the facility's nursing staffing documents and confirmed through staff interviews. The staffing shortages were significant, with the facility often having fewer NAs than required for the number of residents present. For instance, on several occasions, the facility had a census of over 100 residents but failed to provide the necessary number of NAs to meet the regulatory requirements. The Nursing Home Administrator acknowledged these staffing deficiencies during an interview, confirming the facility's failure to comply with the mandated NA ratios on the specified dates and shifts.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in Nursing Aide ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on staffing ratios for Nurses aides, call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing(DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. Nursing Aid Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews NA ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement(QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation. Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet NA needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly thereafter. QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on the day shift on four specific dates. The regulation mandates a minimum of one LPN per 25 residents during the day. However, on 11/22/24, with a census of 105 residents, only 4.00 LPNs worked when 4.20 were required. On 12/10/24, with 103 residents, 4.00 LPNs worked instead of the required 4.12. On 1/06/25, with 101 residents, 4.00 LPNs worked when 4.04 were needed, and on the same day with 102 residents, 4.00 LPNs worked when 4.06 were required. The Nursing Home Administrator confirmed these staffing shortages during an interview on 1/15/25.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in Licensed Practical Nurse (LPN) ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on staffing ratios for Licensed Professional Nurses (LPN), call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing (DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. LPN Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews LPN ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement (QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation. Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet LPN needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly thereafter. QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on twelve out of fourteen days reviewed. The deficiency was identified through a review of the facility's nursing staffing documents and confirmed during an interview with the Nursing Home Administrator. Specific dates were noted where the hours of direct resident care fell below the required minimum, with the lowest being 2.72 hours per patient per day. This shortfall in staffing levels was acknowledged by the Nursing Home Administrator, indicating a consistent failure to meet the mandated care hours over the specified periods.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in PPD not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on Staffing ratios and PPD, call off policies, and attendance expectations to be completed by DON/designee and human resources. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. Staffing will be monitored daily by DON/Designee as well as NHA at end of stand up meeting. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/DON. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Staffing audits to be completed at monthly QAPI meeting. Audits will consist of PPD and deployment zones for the day which may indicate patterns for intervention. This will include unit, days of any missed PPD if any, and corrective actions pursued or utilized at the time of the event. QAPI has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility. Facility continues to investigate local education centers and community events for recruitment opportunities.
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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