Kadima Rehabilitation & Nursing At Harmony
Inspection history, citations, penalties and survey trends for this long-term care facility in Harmony, Pennsylvania.
- Location
- 191 Evergreen Mill Road, Harmony, Pennsylvania 16037
- CMS Provider Number
- 395758
- Inspections on file
- 32
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Harmony during CMS and state inspections, most recent first.
Surveyors determined that the facility failed to provide ADL assistance with bathing and showers as assessed and scheduled for three residents with conditions including anemia, hypertension, BPH, malnutrition, paraplegia, chronic pain syndrome, heart failure, PVD, and thyroid disorder. Each resident’s MDS and task card showed a need for substantial to dependent assistance with bathing and scheduled showers on specific days and shifts, yet shower documentation over multiple months showed numerous missed showers or baths. Residents reported that they did not receive showers consistently, had to request them, sometimes received only bed baths, or were offered showers at times that did not match their preferences. The DON was informed that required baths and showers were not offered on the identified dates, constituting a failure to provide ADL care as required by facility policy and state nursing services regulations.
A resident with anxiety, depression, and psychotic disorder, who was cognitively intact but functionally dependent, was involuntarily secluded when a nurse aide closed their door against their wishes while the resident was yelling for it to be opened. The aide admitted to closing the door due to the resident's behavior, and this action was confirmed by an LPN and facility leadership, in violation of facility policy prohibiting involuntary seclusion.
Two residents with cognitive impairment and exit-seeking behaviors were not adequately supervised or properly identified as elopement risks. One resident exited the facility unsupervised during a smoking break when staff were distracted, while another resident's risk status was not maintained or communicated, despite ongoing exit-seeking behavior. Staff relied on informal knowledge rather than documented procedures, leading to lapses in supervision and resident safety.
For one week, meal trays were served without tray tickets, and dietary staff relied on handwritten information that did not include residents' food allergies or preferences. This resulted in a failure to ensure that residents' daily nutritional and special dietary needs were met.
Surveyors found that food items in the kitchen were not labeled or dated, refrigeration and freezer temperatures were not consistently recorded, and kitchen equipment such as the meat slicer and stand mixer were left uncovered and unclean, as confirmed by the Dietary Manager.
The NHA and DON failed to manage the facility to prevent the elopement of a resident and did not properly identify another resident's risk for elopement, resulting in Immediate Jeopardy for two residents. Both leaders confirmed these failures, which occurred despite their job responsibilities to ensure regulatory compliance and resident safety.
Surveyors found that MDS assessments did not accurately reflect the status of four residents. Two residents with serious mental illness were not properly identified in the PASRR section, one resident's tobacco use was not correctly documented despite evidence of daily smoking, and two residents were marked as receiving anticoagulants without supporting physician orders. These inaccuracies were confirmed by staff and clinical record review.
The facility did not provide timely and sufficient social services to assist two residents with severe cognitive impairment in obtaining guardians, resulting in delays in necessary care and incomplete admission documentation. Staff and administrator interviews confirmed that both residents remained without guardians for an extended period, impacting their ability to access needed services.
Surveyors found that medication carts were left unlocked and unattended, and that medications such as albuterol nebulizers, timolol eye drops, and inhalers were not dated upon opening or were expired. These issues were confirmed by LPNs, an RN, and the DON, indicating a failure to follow facility policy for medication security and storage.
A nurse aide entered the rooms of two residents without knocking or requesting permission, contrary to facility policy requiring staff to protect resident privacy and dignity. The aide confirmed this lapse during an interview.
A medication cart was left unattended with its computer screen displaying residents' personal and medical information, allowing unauthorized individuals to view confidential data. A registered nurse confirmed the breach of confidentiality, which violated facility policy limiting access to such records.
Surveyors observed that three residents were living in rooms with dirty walls, built-up grime, cracked floor tiles, soiled floor mats, and, in one case, gnats flying around an old meal tray left on a bedside table. An air conditioning unit was also left on the floor in one room. These environmental deficiencies were confirmed by the NHA.
A resident with chronic pain and multiple medical conditions was threatened by a CRNP with a reduction in pain medication if verbally aggressive behavior continued. This was documented in the clinical record and confirmed by facility leadership as inappropriate intimidation and a threat of deprivation, violating the resident's right to be free from mental abuse.
A resident with multiple medical conditions, including dementia and anxiety disorder, reported feeling taunted and mistreated by staff and exhibited significant behavioral disturbances that led to police and EMS involvement. Despite these events and corroborating accounts from other residents, the facility did not submit a timely report of the emotional abuse allegation to the State field office, as required by policy and regulation.
The facility did not ensure that necessary information, including care plan goals and advanced directives, was communicated to the receiving health care provider for two residents transferred to the hospital. This deficiency was confirmed by both the DON and ADON, and involved residents with complex medical conditions.
Two residents with multiple diagnoses received controlled medications that were not immediately documented on the narcotic accountability record by an LPN, resulting in discrepancies between the actual pill count and the accountability log. The DON confirmed that this failure did not meet professional standards of clinical practice.
A resident with a history of hypertension, stroke, and seizure disorder was observed on multiple occasions without a physician-ordered right-hand edema glove, despite orders and care plan instructions for its use. Nurse aides were unaware of the order, and an LPN and the DON confirmed the resident was not provided the required edema glove.
A resident with Alzheimer's disease, stroke, and depression was not provided with needed glasses or cataract surgery despite documented visual impairment and recommendations for corrective lenses. Staff confirmed the resident had not received assistive devices to maintain visual ability, resulting in the resident's inability to read menus and access visual information.
A resident with limited mobility and a physician's order for bilateral palm roll splints was repeatedly observed without the required splints in place. An LPN confirmed the resident was not receiving the ordered services and equipment to maintain or improve mobility, resulting in a deficiency related to resident care and nursing services.
Two residents with multiple medical conditions were observed with enabler bars on their beds, but their clinical records lacked ongoing assessments and care plan interventions related to bedrail use. Facility staff confirmed that accurate care plans and assessments were not maintained as required by policy.
Two residents with indwelling medical devices did not have enhanced barrier precautions (EBP) signage or required infection control supplies, such as gowns and gloves, at their room entrances as mandated by facility policy and physician orders. Staff confirmed the absence of signage and supplies, and one resident's catheter bag was observed on the floor. These lapses in following EBP protocols created the potential for cross-contamination.
A resident who reported smoking multiple times daily was not properly assessed for smoking safety according to facility policy, with documentation and physician orders failing to reflect the resident's actual smoking status. Facility leadership confirmed that the required smoking evaluation and orders were not completed, resulting in noncompliance with established policies.
Required postings for State Agency contacts, complaint procedures, Adult Protective Services, and complete Ombudsman information were missing or incomplete in multiple accessible areas. An administrator confirmed the absence of these postings throughout the facility.
The facility failed to meet required staffing levels for nurse aides on multiple shifts over a seven-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. This was confirmed through staffing documents and an interview with the Assistant Director of Nursing.
The facility failed to meet the required LPN staffing levels, with shortages noted on specific days for both day and night shifts. For example, on one day, the facility provided 31.14 actual LPN hours against the required 32.64 hours for a census of 102 residents during the day shift. This deficiency was confirmed by the Assistant Director of Nursing.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care on five days. The PPD hours ranged from 2.73 to 3.07 on these days. This was confirmed by the Assistant Director of Nursing during an interview.
The facility failed to meet required staffing levels for nurse aides on multiple shifts over an eight-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift, one NA per 11 residents during the evening shift, and one NA per 15 residents on the night shift. These deficiencies were confirmed through staffing documents and an interview with the Assistant Director of Nursing.
The facility did not meet the required LPN staffing levels on a night shift, providing only 16.15 hours instead of the required 20.80 hours for 104 residents. This deficiency was confirmed by the Assistant Director of Nursing.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care on three days, providing 3.08, 3.19, and 3.07 PPD on those days. This was confirmed by the Assistant DON through a review of nursing schedules and staff interviews.
A resident with diabetes, hyperlipidemia, and hypertension did not receive scheduled showers during a specific week due to staffing shortages in the evenings. The facility's policy requires continuous care to maintain residents' highest level of functioning, but documentation showed no record of the resident receiving or refusing a shower. The DON confirmed the deficiency in providing ADL assistance.
The facility did not meet state-required nurse aide staffing levels over a three-week period, with shortages on daylight, evening, and overnight shifts. Residents reported staff shortages, particularly in the evenings, and the DON confirmed the facility's failure to meet staffing requirements.
The facility did not meet state-mandated LPN staffing levels during both day and overnight shifts over a three-week period. The facility failed to provide the required number of LPNs per residents on multiple occasions, as confirmed by schedule reviews and resident interviews. The DON acknowledged the staffing shortfall.
The facility did not provide the required minimum of 3.20 PPD hours of direct care for residents on 15 out of 21 days reviewed. The PPD ranged from 2.83 to 3.19 on these days, as confirmed by the DON.
The facility failed to notify a physician of a resident's missed medication and increased behaviors, and did not inform another resident's responsible party of an increased medication dosage. Both residents had severe cognitive impairments, and the facility's policies on notification were not followed, as confirmed by the Director and Assistant Director of Nursing.
A facility failed to provide adequate supervision for residents at risk of elopement, leading to an incident where a resident exited the premises without authorization. The facility's policy requires monitoring of cognitively impaired residents, but a resident with dementia was found missing, with evidence of elopement. Additionally, the facility did not consistently document post-incident responses for two residents involved in elopement incidents, with missing documentation in their progress notes.
A resident was transferred to an inpatient rehabilitation center without a physician's discharge order, and the facility failed to communicate necessary information to the receiving provider. The Social Worker admitted to faxing the information without documentation, and the DON confirmed these deficiencies.
Two residents in an LTC facility reported unresolved grievances related to inadequate care. One resident, with anxiety and osteoarthritis, complained about not receiving care, and the facility's attempt to resolve it with a whiteboard was ineffective. Another resident, with neuromuscular dysfunction and depression, reported being denied assistance with eating and incontinence care. Both residents confirmed their concerns were unresolved, and the Nursing Home Administrator acknowledged the facility's failure to address these grievances.
A resident with multiple diagnoses did not receive prescribed medications, including Ferrous Gluconate, Protonix, and LiquaCel, on several occasions due to unavailability and reordering issues. The DON confirmed the medications were not administered as ordered.
The facility failed to monitor the cooling of foods and improperly stored utensils, creating the potential for foodborne illness. The Food Service Director confirmed that meat served over multiple days was not properly temperature-monitored, and an ice scoop was improperly stored, risking contamination. A resident was served unappetizing leftovers, and the facility's cooling logs lacked required documentation.
The facility failed to document or provide the opportunity for advanced directives for eight residents with various medical conditions. This deficiency was confirmed through staff interviews and a review of clinical records, revealing a significant oversight in respecting residents' rights to self-determination.
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five residents during facility-initiated transfers. The clinical records lacked documented evidence of communication of essential information such as care plan goals, advanced directives, and specific instructions for ongoing care. This deficiency was confirmed by the DON during interviews.
The facility failed to notify residents, their representatives, and the Office of the State Long-Term Care Ombudsman in writing before transferring or discharging residents. This deficiency affected five out of seven residents reviewed, who were transferred to the hospital and returned without the required written notifications.
The facility failed to ensure that MDS assessments accurately reflected the status of three residents. One resident's weight was not updated within the required 30-day period, another resident was not weighed monthly, and a third resident's hospice care status was not documented in the MDS assessment despite being on hospice. These discrepancies were confirmed by the LPNAC.
The facility failed to adhere to standards of practice related to interdisciplinary meetings and timely Nutrition Assessments. A resident experienced significant weight loss that was not addressed, and another resident did not have a documented nutritional assessment. The RD, present only one day per week, confirmed these deficiencies.
The facility failed to ensure that showers were consistently provided and adequate hygienic care was maintained for eight out of 12 sampled residents. Several residents did not receive the required number of showers, and observations revealed issues such as untrimmed facial hair and long, discolored fingernails. The Director of Nursing confirmed the lack of documentation and adherence to the facility's policy.
The facility failed to monitor and address the nutritional needs of several residents, leading to significant weight loss and inadequate nutritional interventions. Staff interviews and clinical record reviews confirmed that the facility did not adhere to its policies on resident weights and nutrition management.
The facility failed to provide appropriate respiratory care and maintain equipment for three residents. Observations revealed issues such as incorrect oxygen flow rates, undated nebulizer tubing, improperly stored masks, and empty humidifier bottles. These deficiencies were confirmed by staff interviews and clinical record reviews.
The facility failed to employ a full-time qualified Food Service Director for six months. The current FSD lacks the required certification and formal education, and the facility's Registered Dietitian only visits one day per week. The Nursing Home Administrator confirmed the FSD's lack of qualifications.
The facility failed to have sufficient dietary staff, resulting in missed nutritional evaluations for residents. One resident experienced significant weight loss that was not addressed, and another resident with multiple diagnoses did not have a documented nutritional assessment. The RD confirmed that her limited availability and the increased census made it impossible to complete all necessary evaluations and participate in essential meetings.
The facility failed to maintain an effective training program for six staff members, as their records lacked annual in-service training on critical topics such as resident rights, QAPI, and compliance and ethics. The last recorded training for these employees was in early 2023, and the facility's staff educator confirmed the deficiency.
Failure to Provide Scheduled Bathing Assistance per Residents’ Needs and Preferences
Penalty
Summary
Surveyors found that the facility failed to provide assistance with activities of daily living (ADLs), specifically bathing and showers, in accordance with residents’ assessed needs, preferences, and scheduled care. Facility policy dated 1/19/26 stated that, based on the comprehensive assessment and resident choices, the facility would ensure residents’ abilities in ADLs do not deteriorate unless unavoidable and that care and services would be provided for bathing, dressing, grooming, and oral care. For one resident with anemia, hypertension, and BPH, the MDS showed a need for substantial/maximal assistance with bathing, and the task card scheduled showers on Wednesdays and Saturdays during day shift. However, December 2025 and January–February 2026 shower documentation showed multiple dates on which no shower or bath was provided, and the resident reported not receiving showers consistently, having to ask for them, and sometimes only being offered showers at night, which was not his preference. A second resident, with malnutrition, paraplegia, and chronic pain syndrome, was assessed as dependent for bathing, with showers scheduled on Fridays and Tuesdays. Review of December 2025 through February 2026 shower records showed numerous missed showers or baths, and the resident stated a preference for showers over bed baths and that showers were not provided consistently. A third resident, with heart failure, PVD, and a thyroid disorder, required partial/moderate assistance with bathing and was scheduled for Wednesday and Saturday day-shift showers. Documentation for December 2025 and January 2026 again showed multiple dates with no shower or bath provided. During an interview, the DON was informed that baths and/or showers had not been offered on the identified dates and that the facility failed to provide ADL services for these three residents, in violation of 28 Pa. Code 211.10(d) and 211.12(c)(d)(1)(3)(5).
Failure to Prevent Involuntary Seclusion of a Resident
Penalty
Summary
The facility failed to prevent involuntary seclusion for one resident, as evidenced by staff actions and resident reports. According to the clinical record, the resident had diagnoses including anxiety, depression, and psychotic disorder, and was assessed as cognitively intact but functionally dependent. During an observation, the resident was found with their door closed, repeatedly yelling to have it opened. A nurse aide admitted to closing the door because the resident was yelling and instructing her, and this was confirmed by a licensed practical nurse who instructed not to shut the resident's door. The resident reported that the door was shut for about five minutes, and that the nurse aide closed it while on the phone and passing lunch trays. Facility policy prohibits involuntary seclusion, defined as separating a resident from others or confining them to their room against their will. Interviews with the resident, the nurse aide, and facility leadership confirmed that the door was closed against the resident's wishes, constituting involuntary seclusion. The incident was corroborated by direct observation and staff statements, and the facility's failure to prevent this action was acknowledged by the nursing home administrator and director of nursing.
Failure to Prevent Elopement and Identify At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent accidents, specifically elopement, for two residents. One resident, who was assessed as being at risk for elopement due to cognitive impairment, poor decision-making skills, and exit-seeking behavior, was able to leave the facility unsupervised. This resident exited the building when a CNA was assisting other residents to a smoking area, and the door was opened using a code that temporarily disabled the Wanderguard alarm system. The resident was not identified as a smoker and was not being directly supervised at the time, allowing him to leave unnoticed until another resident alerted staff. Another resident, also with cognitive impairment and a history of exit-seeking behavior, was not properly identified as an elopement risk. Although this resident had previously been assessed as at risk and had a Wanderguard device ordered, the device was discontinued after one week without documented evidence of ongoing risk assessment or justification. Staff interviews revealed that this resident had managed to exit the building with visitors and had to be redirected frequently due to continued exit-seeking behaviors. However, the resident was not included in the facility's elopement risk binder, and key staff, including the NHA, were unaware of her risk status or previous incidents. Observations and staff interviews indicated a lack of consistent documentation and communication regarding which residents were at risk for elopement and who required supervision during high-risk activities such as smoking breaks. Staff relied on informal knowledge rather than documented lists, and there was insufficient supervision during these times. The facility's failure to identify and supervise residents at risk for elopement resulted in one resident leaving the premises without staff knowledge and another resident's risk not being properly managed or communicated.
Removal Plan
- The facility reviewed and revised the elopement policy.
- The Director of Nursing or designee will complete assessments on all residents to identify their risk for elopement, and care plans will be updated to reflect the residents' current condition, risk for elopement and resident centered interventions.
- A list of residents at risk for elopement will be placed at each nursing station to inform staff of residents at risk.
- The Nursing Home Administrator or Designee will educate all staff, including agency staff, on elopement policies and procedures, documenting residents with exit seeking behaviors, reporting exit seeking behaviors to administration and implementing proper interventions for these residents prior to staff's next scheduled shift.
- The facility will allocate additional staff members to supervise smokers to ensure appropriate supervision is available to meet residents.
- The facility will have one staff member for every eight residents who smoke.
- The Facility will complete a head count of all residents each shift to ensure residents are safe and provided adequate supervision.
- The Director of Nursing of Designee will review progress notes daily to identify any residents with new exit seeking behaviors to ensure appropriate interventions are in place.
- The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for frequency of audits.
Failure to Communicate Resident Dietary Needs Due to Missing Tray Tickets
Penalty
Summary
The facility failed to ensure that residents' daily nutritional and special dietary needs were met for one of four weeks, specifically due to the absence of tray tickets on meal trays. During an observation, lunch trays were found without tray tickets, which are used to identify the resident, their diet, and specific food items. Instead, dietary staff hand-wrote residents' last names, room numbers, and diet orders on the placemats. This practice was implemented because the facility's printer was broken for approximately one week. The information provided to dietary staff for this workaround only included residents' names, room numbers, and diet orders, but did not include critical details such as food allergies or preferences. The Dietary Manager confirmed that this omission meant that proper information regarding resident preferences and food allergies was not communicated or provided during this period. The administrator also confirmed that the facility failed to ensure that daily nutritional and special dietary needs for residents were met.
Failure to Label Food, Monitor Temperatures, and Maintain Kitchen Sanitation
Penalty
Summary
The facility failed to properly label and date multiple food items stored in the main kitchen, including cooked beef patties, pickles, diced potatoes, sauerkraut, Jello, coleslaw mix, and a container of Cheerios. These items were observed in the walk-in refrigerator and cook's area without any labels or dates. Additionally, the facility did not consistently monitor or record refrigeration and freezer temperatures for several days, as evidenced by missing entries on temperature logs for both the tray line refrigerator and the walk-in refrigerator and freezer. Further observations revealed that kitchen equipment was not maintained in a sanitary condition. The meat slicer and stand mixer were found without covers to protect them from contamination, and the stand mixer contained a thick layer of dried food particles. The Dietary Manager confirmed these failures, acknowledging the lack of proper labeling, temperature monitoring, and equipment cleanliness in the main kitchen.
Failure to Prevent and Identify Resident Elopement Risk
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of a resident and the failure to properly identify another resident's risk for elopement. The job descriptions for both the NHA and DON require them to ensure compliance with federal, state, and local regulations and to maintain the highest degree of quality care for residents. Despite these responsibilities, the facility did not prevent a resident from eloping and did not adequately assess another resident's risk for elopement. These failures were confirmed during staff interviews, where both the NHA and DON acknowledged their inability to manage the facility effectively in these instances. The deficiencies created an Immediate Jeopardy situation for two residents, as the facility did not follow established guidelines and regulations to protect residents from harm related to elopement.
Inaccurate MDS Assessments for PASRR, Tobacco Use, and Anticoagulant Documentation
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of four residents, as required by facility policy and the Resident Assessment Instrument (RAI) User's Manual. For two residents with documented diagnoses of serious mental illness and positive Level II PASRR screenings, the MDS assessments incorrectly indicated that they were not considered by the state Level II PASRR process to have a serious mental illness or related condition. This was confirmed by both clinical documentation and staff interviews, which established that the residents did meet the criteria for serious mental illness according to state review. Additionally, one resident's MDS assessment failed to accurately reflect current tobacco use. Despite clinical records, physician orders, and a smoking safety screening indicating that the resident smoked 5-10 cigarettes daily and was permitted to smoke under supervision, the MDS was coded as 'No' for current tobacco use. Nursing progress notes further documented the resident's participation in smoking activities and related behavioral incidents during smoking times. For two other residents, the MDS assessments indicated that they had received anticoagulant medications during the 7-day look-back period. However, a review of their clinical records did not reveal any physician orders for anticoagulant medications, suggesting that the MDS entries were inaccurate. These discrepancies were acknowledged by the facility's LPN Assessment Coordinator during staff interviews.
Failure to Provide Timely Social Services for Guardianship
Penalty
Summary
The facility failed to provide sufficient and timely social services to assist in obtaining guardians for two residents with severe cognitive impairment. One resident, diagnosed with Alzheimer's disease, stroke, and depression, had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. Staff interviews confirmed that this resident had not received necessary interventions such as cataract surgery or glasses due to issues involving a family member and the lack of a guardian. The Nursing Home Administrator acknowledged delays in securing a guardian, citing a lapse in attorney services due to a change in contracted providers. Another resident, with diagnoses including manic depression, psychotic disorder, and borderline intellectual functioning, also had a BIMS score indicating severe cognitive impairment. Upon review, it was found that this resident's admission agreement had not been completed for an extended period, as the resident was unable to sign and required a guardian. Documentation showed ongoing efforts to address medical assistance and guardianship, but the process was delayed. The Nursing Home Administrator confirmed that both residents had not received timely assistance in obtaining guardians, resulting in unmet social service needs.
Failure to Secure and Properly Store Medications on Medication Carts
Penalty
Summary
Surveyors identified that the facility failed to properly secure and store medications on multiple medication carts. Specifically, one medication cart was found unlocked and unattended outside a resident's room, which was confirmed by both a registered nurse and the director of nursing. Additionally, medications on three separate carts were observed to be either not dated upon opening or expired, including albuterol nebulizers, timolol eye drops, and albuterol inhalers for several residents. These findings were confirmed by interviews with licensed practical nurses responsible for the carts. Facility policy requires that all medications be stored in a safe, secure, and orderly manner, with compartments locked when not in use. The surveyors' observations and staff confirmations demonstrated that these policies were not followed, resulting in medications being improperly stored and unsecured. The deficiencies were cited under relevant state codes for pharmacy and nursing services, as well as the responsibility of the licensee.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
Staff failed to protect and value the private space of two residents in the South Wing when a nurse aide entered their rooms without knocking or requesting permission, as observed during facility rounds. The facility's confidentiality policy, dated 4/25/25, requires staff to knock before entering a resident's room except in emergencies, in order to maintain privacy and dignity. During interviews, the nurse aide acknowledged not knocking prior to entering the rooms of the two residents, which did not uphold the residents' rights to privacy and a dignified existence.
Failure to Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information when a medication cart was left unattended at the nurses station with the computer screen open, displaying identifiable resident information. This allowed any passerby to view personal and confidential details. The incident was observed during a survey, and a registered nurse confirmed that the computer screen was left open and unattended, in violation of the facility's confidentiality policy, which restricts access to resident medical records to only staff and consultants providing services to the resident.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for three residents as observed during a survey. In one room, the wall near the entrance and under the heating element was dirty with built-up grime, the floor mat was soiled with white and gray markings, and the bathroom had five visibly cracked floor tiles. Another resident's bathroom had three cracked floor tiles around the base of the commode. In a third room, gnats were observed flying around a bedside table that still had an old meal tray from breakfast, the wall under the heating element was corroded with grime, and an air conditioning unit was left sitting on the floor. These conditions were confirmed by the Nursing Home Administrator during a tour and interview.
Mental Abuse and Threat of Deprivation Related to Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from mental abuse and threats of punishment or deprivation. A cognitively intact resident with chronic pain and multiple medical conditions, including osteoarthritis, lymphedema, and chronic osteomyelitis, was observed to be receiving pain medications as prescribed. However, during a palliative care consultation, a Certified Registered Nurse Practitioner (CRNP) discussed with the resident that if his verbally aggressive behavior towards staff persisted, his pain medications would be reduced in the future. This statement was documented in the resident's clinical record and was acknowledged by facility leadership as a form of intimidation and a threat to deprive the resident of necessary pain management. The incident was identified through review of facility policies, clinical records, and staff interviews. The facility's policy clearly states that residents have the right to be free from abuse, including mental abuse and threats of punishment or deprivation. The Nursing Home Administrator confirmed that the CRNP's statement constituted inappropriate intimidation and a threat to withhold pain medication, which is not permitted under facility policy and regulatory requirements.
Failure to Timely Report Allegation of Emotional Abuse
Penalty
Summary
The facility failed to submit a timely report of an allegation of emotional abuse involving a resident to the local State field office, as required by facility policy and state regulations. The resident in question had a history of hypertension, anxiety disorder, COPD, and dementia, and was care planned to be gently redirected during inappropriate actions. On one occasion, the resident expressed concerns about staff being mean and reported feeling taunted and picked on by staff. Documentation showed that the resident had significant behavioral episodes, including yelling profanities, making threats, and requiring police and EMS intervention for psychological evaluation. Despite these incidents and the resident's statements about mistreatment, there was no evidence that the facility reported the allegation of emotional abuse to the State field office within the required timeframe. Interviews with other residents and staff corroborated the occurrence of the incident, including a staff member refusing to clean a soiled bathroom and a verbal altercation between the resident and staff. The resident council also raised concerns about staff intimidation. Review of facility records and reports submitted to the State field office confirmed that no report related to the resident's allegation of emotional abuse was made. The Nursing Home Administrator and Director of Nursing acknowledged the failure to report the allegation as required by policy and regulation.
Failure to Communicate Required Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two of three sampled residents. For one resident with diagnoses including high blood pressure, anemia, and hyperlipidemia, there was no documented evidence that the facility provided the receiving hospital with required information such as care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs. This lack of documentation was confirmed by the Director of Nursing. Similarly, another resident with diagnoses of high blood pressure, delirium due to a known physiological condition, and altered mental status was transferred to the hospital without documented evidence that the required information was communicated to the receiving provider. The Assistant Director of Nursing confirmed that the facility did not ensure the necessary resident information was provided for these two residents as required by regulation.
Failure to Immediately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality regarding the administration and documentation of controlled medications for two residents. According to facility policy, licensed nurses are required to immediately document the administration of controlled drugs on the narcotic accountability record, including the date, time, amount administered, and the nurse's signature, after the dose is given. However, during an observation of the North Medication Cart, discrepancies were found in the narcotic counts for two residents. The LPN responsible acknowledged that medications had been administered and signed off on the medication administration record (MAR), but had not yet documented them on the narcotic accountability record as required. For one resident with diagnoses of high blood pressure, anxiety, and depression, the clonazepam count was off by one pill, and for another resident with heart failure, high blood pressure, and anxiety, the lorazepam count was also off by one pill. In both cases, the narcotic accountability log did not match the actual number of pills present due to the LPN's failure to immediately document the administration. The Director of Nursing confirmed that the facility did not meet accepted standards of clinical practice for these two residents.
Failure to Follow Physician Order for Edema Glove
Penalty
Summary
The facility failed to follow a physician's order for a resident requiring a right-hand edema glove. According to the clinical record, the resident had diagnoses including high blood pressure, stroke, and seizure disorder, and both the physician order and care plan specified that the resident should wear a right edema glove during the day, to be put on with morning care and removed with evening care. However, during two separate observations, the resident was seen out of bed and dressed for the day without the edema glove on the right hand as ordered. Interviews with nurse aides assigned to the resident's hall revealed that they were unaware of any residents requiring an edema glove for swelling. An LPN confirmed via the computer system that the order for the edema glove was in place and acknowledged that the resident was not wearing it as required. The Director of Nursing also confirmed that the facility did not follow the physician's order for the edema glove for this resident.
Failure to Provide Proper Vision Services and Assistive Devices
Penalty
Summary
A deficiency was identified when a resident with a history of Alzheimer's disease, stroke, and depression was not provided with proper treatment and assistive devices to maintain visual ability. The resident, who previously had glasses, reported being unable to read the lunch menu and stated he had not had glasses for a long time. Clinical records showed that the resident had been evaluated for cataracts in both eyes, with recommendations for new glasses pending insurance approval and a referral for cataract surgery. However, subsequent documentation indicated that the resident did not receive cataract surgery, did not have glasses, and had a cancelled optometry visit. Staff interviews confirmed that the resident had not received glasses or cataract surgery, and the facility failed to ensure the resident received necessary visual aids as outlined in their own policy. The deficiency was substantiated by the lack of follow-through on recommendations for corrective lenses and surgical intervention, as well as the resident's ongoing inability to access visual information independently.
Failure to Provide Ordered Splint Devices for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received the appropriate services, equipment, and assistance to maintain or improve mobility. According to the facility's Splint/Brace Management policy, residents are to be assessed and provided with splint or brace devices as needed to prevent decline in joint mobility. The clinical record for the resident indicated a physician's order for bilateral palm roll splints to be worn at all times, except during hygiene, with skin checks every shift. The resident had diagnoses including high blood pressure, schizophrenia, and muscle weakness. Despite these orders, multiple observations over two days showed the resident without the required palm roll splints applied. During an interview, an LPN confirmed that the resident did not have the splints on and acknowledged the facility's failure to provide the necessary services and equipment as ordered. This deficiency was cited under several Pennsylvania state codes related to licensee responsibility, management, resident care policies, and nursing services.
Failure to Maintain Accurate Care Plans and Assessments for Bedrail Use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing assessments regarding the use of bedrails for two residents. Facility policy required an assessment to determine the need for side rails, including a review of the resident's bed mobility and transfer abilities, and mandated that the use of side rails as assistive devices be addressed in the resident's care plan. However, for both residents observed, the clinical records did not include ongoing assessments for enabler bar usage, nor did they contain the development of goals and interventions related to this usage in the care plans. One resident had diagnoses including high blood pressure, hyponatremia, and depression, while the other had hyperkalemia, dementia, and depression. Observations confirmed that both residents had two top enabler bars present on their beds. Staff interviews further confirmed that the facility did not maintain accurate care plans or conduct ongoing assessments to ensure that bedrails were used appropriately and that associated risks were addressed, as required by facility policy and state regulations.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement and follow its own infection prevention and control program, specifically regarding enhanced barrier precautions (EBP) for residents with indwelling medical devices. For one resident with a Foley catheter, multiple observations revealed the absence of EBP signage and the lack of required infection control supplies such as gowns and gloves at the room entrance. Additionally, the resident's catheter bag was observed on the floor during several visits. Staff interviews confirmed that the necessary signage and supplies were not present as required by facility policy and physician orders. Another resident with a nephrostomy tube also did not have EBP signage at the doorway, despite physician orders and care plans indicating the need for enhanced barrier precautions. The infection preventionist confirmed the lack of appropriate signage, and the assistant director of nursing described a process for communicating EBP status that was not reflected in practice for these residents. These failures created the potential for cross-contamination and did not comply with the facility's infection control policies.
Failure to Follow Smoking Assessment and Policy for Resident
Penalty
Summary
The facility failed to follow its established smoking policy in the assessment and management of one resident's smoking status. According to the facility's policy, residents who smoke are to be reviewed for safety upon admission, with licensed staff responsible for completing a smoking review, and all smokers capable of understanding the rules are to sign a smoking agreement. The policy also requires that smokers be reviewed on admission, quarterly, and as needed based on changes in condition. However, for one resident, the admission record and Minimum Data Set indicated no current tobacco use, and there were no physician orders related to smoking. The resident's smoking evaluation was completed incorrectly, failing to reflect the resident's actual smoking status. Despite documentation indicating the resident was not a smoker, the care plan identified the resident as at risk for side effects from smoking and recommended the use of a smoking apron. The resident reported smoking multiple times daily, which was confirmed during an interview. Facility leadership, including the Assistant Director of Nursing and the Director of Nursing, acknowledged that the required physician order and accurate smoking evaluation were not completed, resulting in noncompliance with the facility's smoking policy and regulatory requirements.
Failure to Post Required State Agency and Advocacy Group Information
Penalty
Summary
The facility failed to post required information regarding State Agency contacts, complaint filing procedures, Adult Protective Services, and complete contact details for the State Long-Term Care Ombudsman program in areas accessible to all residents. Observations revealed that in the [NAME] Hallway, only the Ombudsman phone number was posted, lacking the name, address, and email address. Additional observations at the nursing station between the South and North Hallways, as well as in the Northwest Hallway, showed missing information on the State Agency, complaint procedures, and Adult Protective Services. The Nursing Home Administrator confirmed that the required postings were not present throughout the facility as mandated.
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 from February 3, 2025, to February 9, 2025. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on six out of seven days, one NA per 11 residents during the evening shift on four out of seven days, and one NA per 15 residents during the night shift on three out of seven days. This deficiency was confirmed through a review of staffing documents and an interview with the Assistant Director of Nursing, who acknowledged the shortfall in staffing on the specified shifts.
Plan Of Correction
The facility cannot correct that nurse aide staffing ratios were not met on 2/3/25, 2/4/25, 2/5/25, 2/6/25, 2/7/25, 2/8/25, and 2/9/25. The facility will ensure that nurse aide staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly 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.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as per the regulation effective July 1, 2023. Specifically, the facility did not provide the minimum of one LPN per 25 residents during the day shift on February 8, 2025, and one LPN per 40 residents during the night shift on five separate days: February 3, 4, 6, 8, and 9, 2025. A review of the facility's census data and nursing time schedules revealed that on these dates, the actual LPN hours were below the required hours. For instance, on February 8, 2025, during the day shift, the facility had 31.14 actual LPN hours against the required 32.64 hours for a census of 102 residents. Similarly, on the night shift of February 3, 2025, the facility provided only 15.60 actual LPN hours against the required 21.40 hours for a census of 107 residents. This deficiency was confirmed by the Assistant Director of Nursing during an interview on February 11, 2025.
Plan Of Correction
The facility cannot correct that LPN staffing ratios were not met on 2/3/25, 2/4/25, 2/6/25, 2/8/25, 2/9/25. The facility will ensure that LPN staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN 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.
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 reviewed. Specifically, the facility provided only 2.73 PPD on 2/3/25, 2.95 PPD on 2/4/25, 3.07 PPD on 2/5/25, 2.85 PPD on 2/8/25, and 2.82 PPD on 2/9/25. This deficiency was identified through a review of nursing time schedules and staff interviews. The Assistant Director of Nursing confirmed the failure to meet the required PPD hours during an interview conducted on 2/11/25 at 10:30 a.m.
Plan Of Correction
The facility cannot correct that the PPD was below a 3.20 staffing level on 2/3/25, 2/4/25, 2/5/25, 2/8/25, 2/9/25. The facility will ensure that PPD is met for every day. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and making sure that PPDs are met. Daily schedules will be reviewed to monitor the projected PPD and the IDT will adjust if needed to ensure PPDs are met. The Nursing Supervisors will review staffing sheets on the weekends. If the facility projects to not meet PPD on any given day, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure PPDs 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.
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 an eight-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on January 18 and 19, 2025. Additionally, the facility did not meet the requirement of one NA per 11 residents during the evening shift on seven of the eight days from January 13 to January 20, 2025. Furthermore, the facility fell short of the required one NA per 15 residents on the night shift on January 18 and 19, 2025. These deficiencies were confirmed through a review of staffing documents and an interview with the Assistant Director of Nursing, who acknowledged the failure to provide the necessary number of NAs during the specified shifts.
Plan Of Correction
The facility cannot correct that nurse aide staffing ratios were not met on 1/13/25, 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25. The facility will ensure that nurse aide staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly 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.
LPN Staffing Shortage on 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 January 19, 2025. A review of the nursing time schedules and facility census data from January 13 to January 20, 2025, revealed that on the night of January 19, the facility had a census of 104 residents but only provided 16.15 actual LPN hours, whereas 20.80 hours were required. This staffing shortage was confirmed during an interview with the Assistant Director of Nursing on January 23, 2025.
Plan Of Correction
The facility cannot correct that LPN staffing ratios were not met on 1/19/25. The facility will ensure that LPN staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN 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.
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 three specific days within the review period. On January 18, 2025, the facility provided 3.08 PPD, on January 19, 2025, it provided 3.19 PPD, and on January 20, 2025, it provided 3.07 PPD. This deficiency was identified through a review of nursing time schedules and staff interviews. The Assistant Director of Nursing confirmed the shortfall in meeting the required PPD hours during an interview conducted on January 23, 2025.
Plan Of Correction
The facility cannot correct that the PPD was below a 3.20 staffing level on 1/18/25, 1/19/25, 1/20/25. The facility will ensure that PPD is met for every day. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and making sure that PPDs are met. Daily schedules will be reviewed to monitor the projected PPD and the IDT will adjust if needed to ensure PPDs are met. The Nursing Supervisors will review staffing sheets on the weekends. If the facility projects to not meet PPD on any given day, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure PPDs 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.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to provide Activity of Daily Living (ADL) assistance for Resident R1, specifically in the provision of scheduled showers. According to the facility's policy, care should be provided 24 hours a day to maintain the highest level of functioning for residents, with specific tasks assigned to different shifts. Resident R1 was scheduled to receive showers on Tuesdays and Fridays during the 3 p.m. to 11 p.m. shift. However, documentation revealed that Resident R1 did not receive a shower during the week of December 1 to December 7, 2024, and there was no record of a shower being provided or refused during this period. Resident R1, who has diagnoses including diabetes, hyperlipidemia, and hypertension, was identified as being at risk for functional decline in ADLs and required monitoring of skin integrity during baths/showers. During an interview, Resident R1 mentioned that the facility was short-staffed in the evenings, which led to missing a shower. The Director of Nursing confirmed the failure to provide the required ADL assistance, acknowledging the deficiency in care provided to Resident R1.
Plan Of Correction
Resident R1 has been provided a bed bath per resident request and continues to be offered showers as per shower schedule. The facility will ensure that nursing staff follow shower schedules as per plan of care. The Director of Nursing or designee will educate all nursing staff on proper shower schedules and appropriate documentation of care. The Director of Nursing or designee will perform 10 shower audits weekly for 4 weeks, then monthly for 3 months, to ensure residents are receiving appropriate hygienic care per their plan of care. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
Failure to Meet State-Mandated Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the state-required minimum staffing levels for nurse aides across multiple shifts over a three-week period. Specifically, the facility did not provide the required number of nurse aides during daylight shifts on 11 out of 21 days, evening shifts on 15 out of 21 days, and overnight shifts on 4 out of 21 days. This deficiency was identified through a review of nurse staffing schedules and was corroborated by interviews with residents and the Director of Nursing (DON). Residents reported experiencing a shortage of staff, particularly during the evening shifts. The DON confirmed the facility's failure to meet the staffing requirements, acknowledging the specific dates on which the staffing levels fell below the state-mandated minimums. The deficiency was documented based on the review of staffing schedules and resident feedback, highlighting the facility's inability to maintain adequate staffing levels as required by state regulations.
Plan Of Correction
The facility cannot correct that nurse aide staffing ratios were not met on 11/22/24, 11/23/24, 11/25/24, 11/27/24, 11/28/24, 11/29/24, 11/30/24, 12/1/24, 12/2/24, 12/3/24, 12/4/24, 12/5/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24, 12/10/24. The facility will ensure that nurse aide staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5520 and ensuring nurse aide staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly 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.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the state-mandated staffing requirements for Licensed Practical Nurses (LPNs) during both daylight and overnight shifts over a three-week period. Specifically, the facility did not provide the required minimum of one LPN per 25 residents during the day shift on two occasions and failed to provide one LPN per 40 residents during the overnight shift on 14 occasions. This deficiency was identified through a review of the nursing time schedules and was corroborated by interviews with residents and the Director of Nursing (DON). Residents expressed concerns about staffing shortages, with one resident noting that the facility was "a little short on staff in the evenings," and another resident confirming that staff shortages occurred at times. The DON acknowledged the failure to meet the staffing requirements, confirming the specific dates when the facility did not have the mandated number of LPNs on duty. These findings highlight the facility's non-compliance with the staffing regulations effective from July 1, 2023.
Plan Of Correction
The facility cannot correct that LPN staffing ratios were not met on 11/21/24, 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/26/24, 11/28/24, 12/1/24, 12/2/24, 12/3/24, 12/4/24, 12/6/24, 12/8/24, 12/9/24, 12/10/24. The facility will ensure that LPN staffing ratios are met every shift. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5530 and ensuring LPN staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at daily staffing meetings. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects to not meet staffing ratios on a given shift, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure LPN 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.
Failure to Meet Minimum Nursing 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) for 15 out of 21 days reviewed. The deficiency was identified through a review of nursing time schedules and staff interviews. Specific days where the PPD fell short include 11/22/24 with 3.07 PPD, 11/23/24 with 3.13 PPD, and several other days where the PPD ranged from 2.83 to 3.19. The Director of Nursing confirmed the failure to meet the required PPD on these days during an interview on 12/12/24.
Plan Of Correction
The facility cannot correct that the PPD was below a 3.20 staffing level on 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/28/24, 11/29/24, 11/30/24, 12/1/24, 12/2/24, 12/3/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24, 12/10/24. The facility will ensure that PPD is met for every day. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation PPDS and making sure that PPDS are met. Daily schedules will be reviewed to monitor the projected PPD and the IDT will adjust if needed to ensure PPDS are met. The Nursing Supervisors will review staffing sheets on the weekends. If the facility projects to not meet PPD on a given day, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator or designee will audit staffing daily for four weeks and monthly for three months to ensure PPDS 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.
Failure to Notify Physician and Responsible Party of Changes
Penalty
Summary
The facility failed to notify the physician of a missed medication and increased behaviors for one resident, and failed to notify a resident's responsible party of an increase in medication dosage for another resident. The facility's policy requires that the responsible party or guardian be notified of changes in condition or occurrences, and that licensed professional nurses provide timely communication to physicians when there is a change in a resident's condition. However, these protocols were not followed in the cases of Resident CRR2 and Resident R1. Resident CRR2, who has severe cognitive impairment and is at risk for elopement, exhibited increased agitation and refused medications on multiple occasions. Despite the resident's agitated state and refusal of medications, the physician was not notified. The Director of Nursing confirmed that the physician was not informed of the resident's refusal of medications and increased behaviors, and the Assistant Director of Nursing acknowledged poor documentation and failure to notify the physician. Resident R1, who also has severe cognitive impairment, had an increase in medication dosage ordered by a Nurse Practitioner. However, the resident's responsible party was not notified of this change. The Assistant Director of Nursing confirmed that the responsible party was not informed of the medication increase, acknowledging the facility's failure to notify the resident's responsible party as required by their policy.
Inadequate Supervision and Documentation in Elopement Incidents
Penalty
Summary
The facility failed to ensure adequate supervision for residents at risk of elopement, resulting in an incident where one resident exited the premises without authorization. The facility's policy on Elopement Prevention, dated 2/1/24, mandates monitoring of cognitively impaired residents to reduce injury risk. However, Resident CRR2, diagnosed with hypertension, hyperlipidemia, and dementia, was found missing from their room, with an open window and a pushed-out screen indicating an elopement. Local authorities were involved in locating and returning the resident. The Director of Nursing acknowledged the lack of supervision. Additionally, the facility did not consistently document post-incident responses in the clinical records for two residents involved in elopement incidents. Resident R1, diagnosed with hypertension, urinary tract infection, and dementia, was found standing at the end of the driveway without prior documentation of the elopement incident in their progress notes. Similarly, Resident CRR2's progress notes lacked documentation of the elopement incident, with only a late entry noting a head-to-toe assessment after the event. The Director of Nursing was unable to explain the lack of documentation for Resident R1.
Failure to Obtain Physician's Order and Communicate Resident Information
Penalty
Summary
The facility failed to obtain a physician's order for the discharge of a resident and did not ensure that necessary resident information was communicated to the receiving health care provider. This deficiency was identified during a clinical record review and staff interviews. Specifically, Resident R1, who had diagnoses of high blood pressure, muscle spasms, and multiple sclerosis, was transferred to an inpatient rehabilitation center without a documented physician's discharge order. Additionally, there was no evidence that the facility communicated essential information such as the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving facility. During interviews, the Social Worker admitted to faxing the information but failing to document it, and the Director of Nursing confirmed the lack of a physician's order and communication of necessary information. This oversight was noted for one out of five residents sampled with facility-initiated transfers, highlighting a breach in the facility's discharge policy and resident rights as per 28 Pa. Code 201.29.
Unresolved Resident Grievances in LTC Facility
Penalty
Summary
The facility failed to honor the residents' right to voice grievances without discrimination or reprisal, as evidenced by unresolved concerns for two residents. Resident R2, who was admitted with diagnoses including anxiety, osteoarthritis, and difficulty walking, reported a grievance on May 31, 2024, stating she did not receive care. The facility's resolution was to place a whiteboard in her room to display the names of her nurse and nurse aide for the day. However, during an interview on June 27, 2024, Resident R2 stated that the concern was not resolved, as the whiteboard was dated June 25, 2024, and had no staff listed. Similarly, Resident R1, admitted with diagnoses including neuromuscular dysfunction of the bladder, major depressive disorder, and muscle weakness, reported grievances on May 1 and May 19, 2024. He stated he was denied assistance with eating and was not provided proper incontinence care at night. During an interview on June 27, 2024, Resident R1 confirmed that these concerns were unresolved, expressing dissatisfaction with the care received. The Nursing Home Administrator acknowledged the facility's failure to resolve grievances for both residents.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to follow a physician's order for a resident, identified as Resident R1, who was admitted with diagnoses including neuromuscular dysfunction of the bladder, major depressive disorder, and muscle weakness. The resident's physician orders dated 5/17/24 included the administration of Ferrous Gluconate for anemia, Protonix for GERD, and LiquaCel for wound healing. However, a review of the resident's medical administration record (MAR) revealed that these medications were not administered on several occasions: Ferrous Gluconate was missed on 6/15/24, 6/18/24, and 6/22/24; Protonix was missed on 6/6/24, 6/9/24, and 6/17/24; and LiquaCel was missed on 6/22/24 and 6/25/24. Clinical nurse notes indicated that the medications needed to be reordered or were not available on the cart, leading to the resident not receiving them on the specified dates. The Director of Nursing confirmed during an interview that the medications were not available and were not administered as per the physician's order.
Failure to Monitor Food Cooling and Improper Utensil Storage
Penalty
Summary
The facility failed to comply with food safety regulations by not properly monitoring the cooling of foods and improperly storing utensils, creating the potential for foodborne illness. Specifically, the facility did not record the temperatures of un-served/production foods on 4/27/24 and 4/28/24, as required by their Food Temperature Recording Policy. The Food Service Director (FSD) confirmed that the meat served on 4/29/24 had been cooked on 4/27/24, cooled, reheated on 4/28/24, cooled again, and then reheated and served as leftovers on 4/29/24 without proper temperature monitoring. Additionally, an ice scoop was observed sitting on top of the ice machine in the Main Dining Room, which could lead to physical contamination or cross-contamination of the ice. The FSD confirmed these observations and acknowledged the failure to prevent potential contamination and ensure proper cooling of the food. During an observation on 4/29/24, a resident was served a meal that did not match her meal ticket and appeared unappetizing. The resident confirmed that the meat was likely leftovers from the previous day. The FSD verified that the meat was indeed leftovers and appeared very dry and unappetizing. The facility's Food and Leftover Cooling Log for April 2024 did not contain any documentation for the proper cooling of the meat on the specified dates, further confirming the failure to monitor and record food temperatures as required. This deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 28 Pa. Code: 201.18(b)(1) Management, and 28 Pa. Code: 211.6(c) Dietary services.
Failure to Document and Provide Opportunity for Advanced Directives
Penalty
Summary
The facility failed to provide documentation of advanced directives or give the opportunity to formulate an advanced directive for eight residents. The review of clinical records for residents with various diagnoses, including hypertension, heart failure, depression, multiple sclerosis, seizure disorder, dementia, osteoarthritis, peripheral vascular disease, cerebral infarction, malnutrition, dysphagia, diabetes, and osteomyelitis, revealed no evidence of advanced directives or documentation that these residents were given the opportunity to formulate one. This deficiency was confirmed through staff interviews, where both the Social Worker and the Director of Nursing acknowledged the absence of advanced directives in the clinical records. The facility's policy on advanced directives, which was last reviewed on an unspecified date, states that residents should be informed of the policies and procedures regarding advanced directives upon admission or at appropriate times. However, the facility did not adhere to this policy for the eight residents reviewed. The lack of documentation and opportunity to formulate advanced directives was identified during a survey, highlighting a significant oversight in respecting residents' rights to self-determination and their ability to make informed decisions about their care preferences in case of incapacitation.
Failure to Communicate Necessary Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five out of seven residents sampled with facility-initiated transfers. Specifically, the clinical records for Residents R30, R57, R59, R75, and R87 showed no documented evidence that the facility had communicated essential information such as the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. This deficiency was identified through clinical record reviews and staff interviews, which revealed that the facility did not document what information was sent to the receiving health care provider upon transfer of these residents, despite the Director of Nursing stating that information was sent in a packet. The residents involved had various medical conditions, including hypertension, multiple sclerosis, seizure disorder, diabetes, stroke, dysphagia, dementia, cerebral infarction, depression, and heart failure. The lack of documented communication of critical information upon their transfer to the hospital and subsequent return to the facility indicates a failure to comply with regulatory requirements for resident transfers. This deficiency was confirmed by the Director of Nursing during interviews, who acknowledged the absence of evidence that the necessary information was communicated to the receiving health care institution or provider for the sampled residents.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to notify residents, their representatives, and the Office of the State Long-Term Care Ombudsman in writing before transferring or discharging residents. This deficiency was identified through a review of facility policies, clinical records, and staff interviews. Specifically, the facility did not provide written notifications that included the reason for the transfer or discharge, the effective date, the location, a statement of the resident's appeal rights, and the contact information for the Ombudsman for five out of seven residents reviewed. Resident R30, who had diagnoses of hypertension, multiple sclerosis, and seizure disorder, was transferred to the hospital and returned the same day. However, there was no documented evidence that the facility provided the required written transfer notification. Similarly, Resident R57, with diagnoses of diabetes, hypertension, and stroke, was transferred to the hospital and returned two days later without the necessary written notification. Resident R59, diagnosed with diabetes, high blood pressure, and dysphagia, was also transferred to the hospital and returned without the required notification. Additionally, Resident R75, who had hypertension, dementia, and cerebral infarction, and Resident R87, with diagnoses of depression, diabetes, and heart failure, were transferred to the hospital and returned without the facility providing the mandated written notifications. The Director of Nursing confirmed that the facility failed to notify the residents, their representatives, and the Ombudsman in writing for these transfers, as required by federal regulations and state code.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the residents' status for three of six sampled residents. For Resident R3, the MDS assessment dated 4/11/24 indicated a weight of 193 pounds, which was based on a weight recorded on 2/2/24, more than 30 days prior to the Assessment Reference Date (ARD). This discrepancy was confirmed by the LPN Assessment Coordinator (LPNAC) during an interview. Similarly, Resident R21's MDS assessment dated 4/11/24 indicated a weight of 115 pounds, which was also based on a weight recorded on 2/1/24, again more than 30 days prior to the ARD. The LPNAC confirmed that the facility failed to weigh Resident R21 monthly, leading to an inaccurate reflection of the resident's weight status in the MDS assessment. For Resident R37, the MDS assessment dated 3/1/24 failed to indicate that the resident was receiving hospice care, despite documentation in the clinical record and care plans showing that the resident had been on hospice since 12/5/23. The LPNAC confirmed that the facility did not accurately reflect Resident R37's hospice status in the MDS assessment. These deficiencies indicate a failure to conduct comprehensive, accurate, and standardized assessments of each resident's functional capacity as required by the facility's policy and the RAI User's Manual.
Failure to Adhere to Nutritional Assessment and Interdisciplinary Meeting Standards
Penalty
Summary
The facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings and the completion of Nutrition Assessments by the Registered Dietitian (RD). Specifically, the RD did not participate in interdisciplinary meetings for 12 consecutive months and failed to complete timely Nutrition Assessments for two residents. Resident R21 experienced a significant weight loss of 10.2% over six months, which was not addressed by the RD in a timely manner. Additionally, Resident R59, who had diagnoses of diabetes, high blood pressure, and dysphagia, did not have a documented nutritional assessment addressing her nutritional status and therapeutic diet as required. The RD, who works part-time at the facility and is only present one day per week, confirmed that not all nutritional evaluations are completed as required. The RD also stated that she does not participate in care conferences or interdisciplinary team meetings and sometimes completes admission evaluations remotely without speaking to the residents. The Nursing Home Administrator confirmed these deficiencies, acknowledging the facility's failure to adhere to acceptable standards of practice in these areas.
Failure to Provide Consistent Showers and Adequate Hygienic Care
Penalty
Summary
The facility failed to ensure that showers were consistently provided and adequate hygienic care was maintained for eight out of 12 sampled residents. The facility's policy indicated that residents should receive two baths or showers per week unless otherwise stated by the resident. However, clinical record reviews and resident interviews revealed that several residents did not receive the required number of showers. For instance, Resident R30 did not receive any showers in April 2024, and Resident R50 only received two showers during the same month. Additionally, Resident R63 reported only receiving showers once a week, contrary to the facility's policy. Observations and interviews further highlighted the lack of hygienic care. Resident R50 was observed with facial hair on her chin, and Resident R75 expressed dissatisfaction with her facial hair, which had not been trimmed. Resident R87 was found with long, discolored fingernails and unkempt hair, and she confirmed that she had not received a shower or had her hair washed for a while. Resident R311 and Resident R312 both reported not receiving any showers since their admission to the facility in April 2024. The facility's failure to document and provide the required showers was confirmed by the Director of Nursing. During an interview, an LPN mentioned that shower logs were supposed to be in the shower rooms and documented in the computer, but observations revealed that there were no shower logs in the shower rooms. This lack of documentation and adherence to the facility's policy resulted in inadequate hygienic care for the residents, as confirmed by the Director of Nursing.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to monitor and address the nutritional needs of several residents, leading to significant deficiencies. Resident R21 experienced a significant weight loss of 10.2% over six months, but the facility did not weigh the resident monthly as required, nor did the Registered Dietitian (RD) address the weight loss in a timely manner. Similarly, Resident R50 experienced a weight loss of 7.5% in one month, and although a nutritional supplement was ordered, it was not consistently provided. The resident's weight was also not monitored monthly as per the physician's orders. Additionally, Resident R59's clinical record lacked a timely nutritional assessment despite the resident being on a therapeutic diet for conditions such as diabetes and dysphagia. These failures were confirmed through staff interviews and clinical record reviews, indicating a systemic issue in the facility's nutritional management and monitoring processes. The facility's policies on resident weights and nutrition management were not adhered to, resulting in inadequate monitoring and intervention for residents at risk of significant weight changes. The Registered Dietitian and Licensed Practical Nurse Assessment Coordinator confirmed that the facility did not obtain monthly weights as required, did not complete all nutritional evaluations in a timely manner, and failed to provide nutritional supplements as ordered. These deficiencies highlight a failure in the facility's management and nursing services to ensure residents' nutritional needs were met, as mandated by the facility's policies and state regulations.
Failure to Provide Appropriate Respiratory Care and Maintain Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain respiratory equipment for three residents. Resident R3 was observed receiving oxygen at 3 liters per minute via a nasal cannula, contrary to the physician's order of 2 liters per minute. Additionally, the nebulizer tubing was not dated, and the aerosol face mask was improperly stored. Resident R12 was observed with an empty humidifier bottle dated 4/14/24, despite the requirement to change it weekly. Resident R66's oxygen nasal cannula was improperly positioned, and her humidifier bottle was also empty and dated 4/14/24, with the oxygen line dated 4/21/24. These observations were confirmed by LPN Employee E1 and Nurse Aide Employee E7 during interviews. The Director of Nursing confirmed that the facility did not adhere to the required protocols for respiratory care and equipment maintenance for Residents R3, R12, and R66. The facility's policy mandates regular checks and cleaning of oxygen equipment, including labeling and dating humidifiers, which was not followed. The deficiencies were identified through clinical record reviews, observations, and staff interviews, highlighting a failure to comply with physician orders and facility policies for respiratory care.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to employ a full-time qualified Food Service Director (FSD) for six consecutive months. The job description for the FSD position requires the individual to be a graduate of an accredited dietetic training course, registered as a Food Service Director in Pennsylvania, and to provide documentation of their qualifications. However, during an interview, the current FSD, Employee E9, admitted to not being a Certified Dietary Manager (CDM) and lacking any formal education or certificates in food service management. Employee E9, who was promoted from a cook to FSD, also confirmed that he is not enrolled in any classes to become a CDM. The facility does employ a Registered Dietitian (RD), but the RD only visits the facility one day per week. The Nursing Home Administrator confirmed that Employee E9 did not meet the required qualifications for the FSD position.
Insufficient Dietary Staff Leading to Missed Nutritional Evaluations
Penalty
Summary
The facility failed to have sufficient dietary staff to perform essential clinical duties for six out of 12 months. The Registered Dietitian (RD) was responsible for implementing, coordinating, and evaluating medical nutrition therapy for residents, but due to an increased census and limited availability, the RD could not complete all required nutritional evaluations in a timely manner. Specifically, Resident R21 experienced a significant weight loss of 10.2% over six months, which was not addressed by the RD. Additionally, Resident R59, who had diagnoses of diabetes, high blood pressure, and dysphagia, did not have a documented nutritional assessment addressing her nutritional status and therapeutic diet as required by the Minimum Data Set (MDS). The RD confirmed that she only worked one day per week at the facility and could not keep up with the increased census, leading to missed evaluations and lack of participation in care conferences or interdisciplinary team meetings. During interviews, both the Licensed Practical Nurse Assessment Coordinator (LPNAC) and the Nursing Home Administrator confirmed the facility's failure to address Resident R21's weight loss and to timely assess Resident R59's nutritional status. The RD also acknowledged that her limited availability and the growing census made it impossible to complete all necessary evaluations and participate in essential meetings. This deficiency was corroborated by the facility's policy on resident weights and the RD's job description, which outlined the importance of timely nutritional assessments and interventions.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for six out of eight personnel records reviewed. Specifically, the personnel records of LPN Employee E11, LPN Employee E12, Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15 were found to be lacking in annual in-service training on several critical topics. These topics included resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics. The last recorded in-service training for these employees was in early 2023, and the records did not show any subsequent training on the required topics for the past year. During an interview, the LPN Infection Control Preventionist and staff educator confirmed that the facility did not maintain an effective training program as required. The facility's monthly mandatory education schedule indicated that staff should receive annual training on various topics, but the personnel records reviewed did not reflect compliance with this schedule. This deficiency was identified through a review of facility in-service documentation, personnel records, and staff interviews, highlighting a significant lapse in the facility's staff development and training protocols.
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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