Kadima Rehabilitation & Nursing At Latrobe
Inspection history, citations, penalties and survey trends for this long-term care facility in Latrobe, Pennsylvania.
- Location
- 576 Fred Rogers Drive, Latrobe, Pennsylvania 15650
- CMS Provider Number
- 395892
- Inspections on file
- 41
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Latrobe during CMS and state inspections, most recent first.
Nursing staff failed to document administration of controlled medications after signing them out for three cognitively intact residents with pain-related conditions. Facility policy required immediate recording of each administered dose on the MAR. For one resident with chronic back pain, Percocet doses were signed out on two occasions without any MAR or clinical record entries. For another resident on hospice with spinal stenosis and diabetic neuropathy, multiple Morphine doses were signed out with no corresponding documentation of administration. For a third resident with occasional pain on PRN opioids, Percocet doses were also signed out on two occasions without any MAR or clinical record entries. The DON confirmed that there was no documentation showing these signed-out narcotic doses were actually administered.
Two residents requiring colostomy care did not receive proper services as required. One resident with paraplegia had no documented evidence of colostomy care being provided despite care plan instructions. Another resident had orders for ostomy care every shift, but there were no specific orders or care plan for changing or emptying the colostomy appliance, and staff only emptied the bag after being prompted by the resident. The DON confirmed the lack of necessary orders and care planning.
A resident receiving IV antibiotics via a PICC line was found with a dressing that had not been changed according to facility policy, which requires weekly changes. The dressing remained in place for eight days, and the DON confirmed it was overdue, demonstrating a lapse in required PICC line care.
A resident with end-stage renal disease who required hemodialysis did not have documented communication between the facility and the dialysis center regarding their health status before and after dialysis sessions, as required by facility policy and physician orders. The DON confirmed the absence of this documentation.
The facility did not maintain sanitary conditions for ice storage, as the ice machine drain was directly connected to a PVC pipe leading to a bucket of stagnant water without the required air gap. The Maintenance Director confirmed the absence of the air gap and noted that a malfunctioning sump pump caused the bucket to fill with stagnant water.
The facility did not obtain or document reference checks for five newly hired staff members, including nurse aides, an LPN, an RN, and the Maintenance Director, as required by facility policy. This was confirmed through review of personnel files and staff interviews.
A resident was discharged to a senior living community, but the required physician discharge summary was not completed. Review of the clinical record and staff interviews confirmed the absence of this documentation at the time of survey.
A resident with diabetes and orders for blood pressure medications did not have required blood pressure or heart rate checks documented prior to administration of amlodipine, clonidine, or metoprolol. Facility policy and physician's orders required these assessments, but review of the E-MAR and confirmation from the DON showed they were not performed or documented.
A resident with diabetes returned from the hospital with physician orders for specific insulin administration and blood glucose monitoring. Facility staff failed to check the resident's blood glucose and did not administer the ordered insulin doses. The resident reported symptoms and a high glucose reading, and the DON confirmed the required care was not provided.
Three opened bottles of Aplisol solution in a medication room refrigerator were found without labels indicating the date they were opened, contrary to facility policy and manufacturer instructions. The ADON confirmed that these bottles should have been dated upon opening.
A resident receiving hospice care, who was cognitively impaired and dependent on staff, did not have updated hospice nurse aide or RN charting in their clinical record as required by facility policy. The DON confirmed the absence of this documentation, despite an active hospice care plan and physician order.
The QAPI committee did not effectively implement plans of correction for previously cited deficiencies, resulting in repeated failures to comply with regulations on abuse policies, quality of care, medication storage, and food sanitation. Despite conducting audits and reviewing results, the committee was ineffective in ensuring ongoing compliance in these areas.
Surveyors identified multiple lapses in infection prevention and control, including an LPN failing to perform hand hygiene after glove removal, lack of Enhanced Barrier Precautions for a resident with an indwelling catheter, and improper handwashing technique by another LPN after obtaining a blood sugar reading.
A resident with diabetes and other medical conditions did not have blood sugar monitoring documented as required by physician orders, despite orders for scheduled and as-needed insulin administration. The DON confirmed the absence of documentation for blood sugar monitoring.
The facility did not update care plans to reflect changes in care needs for several residents, including the discontinuation of foley catheters, antibiotics, and anticoagulant medications. Care plans continued to list outdated interventions or therapies, as confirmed by review of clinical records and interviews with the DON.
Staff did not document obtaining blood pressure and heart rate before administering Metoprolol to two residents with hypertension, as required by physician orders. The medication was given over multiple days without evidence that the necessary vital signs were checked prior to administration, as confirmed by the DON.
The facility did not maintain sanitary conditions for the ice machine near the kitchen, as the drain pipe was found submerged in stagnant water within a bath basin and lacked the required air gap, contrary to manufacturer instructions.
A resident who was cognitively intact and able to communicate was not kept informed about his discharge plans. Although staff communicated with the resident's family regarding discharge arrangements, they did not provide the resident with updates or document these communications in the medical record.
A registered nurse was allowed to begin employment before the required license check was completed, contrary to facility policy that mandates background and license verification prior to hire. This was confirmed by review of the nurse's personnel file and staff interview.
The facility did not accurately complete MDS assessments for five residents, failing to document the administration of anti-platelet, anti-anxiety, and antibiotic medications as indicated in physician orders and medication records. These discrepancies were confirmed by review of clinical documentation and staff interviews.
The facility did not complete required safety assessments for a resident using siderails and two residents using air mattresses. One cognitively intact resident with a knee prosthesis infection was observed using bilateral siderails without a fully completed assessment. Two other residents, one with chronic DVT and another with cerebral palsy and cognitive impairment, were using air mattresses without documented safety assessments. The DON confirmed that these assessments were not completed.
Two residents with indwelling urinary catheters did not have their urinary output consistently documented as required by physician orders and care plans. Record reviews showed multiple missed entries across several shifts, and the DON confirmed the lack of documentation.
The facility did not keep the posted nurse staffing information up to date, as the information displayed at the main entrance was not current and was confirmed by the administrator.
A controlled medication, Ativan, was found stored in a medication refrigerator with other non-controlled medications, rather than in a separately locked, permanently affixed container as required by facility policy. An LPN and the DON confirmed that the Ativan was not properly secured according to double-lock security protocols.
The facility did not ensure clinical records were accurately maintained for two residents, including missing documentation of pain assessment and dental referral for a resident with dental issues, lack of psychiatric follow-up records for a resident with schizophrenia, and absence of discharge planning notes for a cognitively intact resident. These omissions resulted in incomplete medical records as required by professional standards.
The QAPI committee did not effectively implement or follow through on plans of correction for previously identified deficiencies, resulting in repeated issues with pharmaceutical services, MDS accuracy, care plan timing, quality of care, safety hazards, medication storage, and medical records. Despite audit and reporting processes being outlined, these actions were not successfully executed, leading to ongoing noncompliance.
The facility did not maintain sanitary conditions in three utility rooms, which were filled with soiled linen bags due to non-functional laundry equipment. A laundry attendant confirmed the backlog, and the Regional Clinical Consultant acknowledged the unsanitary state and delayed laundry return to residents.
A resident was injured during transport to dialysis when their wheelchair was not properly secured in the facility's van, leading to a fall and a sternal fracture. The van driver was distracted and failed to lock the wheelchair, resulting in the resident's knees striking their chest. The incident was confirmed by the facility's investigation and the Director of Nursing.
A resident using a wheelchair was injured during transport in a facility van due to improper securing of the wheelchair. The van driver was distracted and failed to lock the wheelchair properly, causing it to tip over. The resident suffered a sternal fracture and required transfer to a trauma center for treatment.
The facility failed to maintain a clean and homelike environment for several residents. A resident's privacy curtain was stained, and multiple rooms had food debris on the floor. Staff interviews confirmed that cleaning schedules were not adhered to, as privacy curtains are washed monthly or during deep cleaning. The Nursing Home Administrator acknowledged the need for cleaning in the affected rooms.
The facility failed to follow physician's orders for medications and treatments for five residents. A resident with a hydrocele did not have a scheduled urology consult. Two residents with hypertension received medication despite blood pressure readings below the ordered threshold, and another resident's blood pressure was not recorded as ordered. Additionally, wound care treatments for two residents were not documented as administered. The DON and wound care staff confirmed these deficiencies.
The facility failed to maintain accountability for controlled medications for three residents. A resident's Oxycodone was signed out but not documented as administered, another resident's entire card of Oxycodone went missing, and a third resident's medications were destroyed without a second nurse present, violating policy.
The facility failed to ensure complete and accurate documentation of care for two residents. One resident's foley catheter care and output were not consistently recorded in the TARs, despite nurse aide documentation indicating completion. Another resident with a Stage 4 pressure ulcer had missing documentation of wound care, although it was confirmed to have been completed. The DON and Infection Control/Wound Care RN acknowledged the documentation errors.
The facility failed to follow proper infection control practices, including not disinfecting a glucometer between residents, inadequate hand hygiene during wound care, lack of Enhanced Barrier Precautions for a resident with an indwelling catheter, and improper handling of oxygen tubing for a resident with respiratory issues. These actions were contrary to facility policies and CDC guidelines.
A resident with impaired cognition and an indwelling urinary catheter was observed with their urinary drainage bag visible from the door and without a privacy cover. Staff interviews confirmed the lack of a privacy cover, which compromised the resident's dignity.
The facility did not complete comprehensive MDS assessments within the required timeframe for three residents. An annual MDS assessment must be completed no later than 14 days after the ARD. One resident's assessment was completed 16 days after the ARD, another's 19 days after, and a third's 15 days after. These delays were confirmed by the DON.
The facility failed to complete Quarterly MDS assessments within the required timeframe for 17 residents. According to the RAI User's Manual, assessments are due every 92 days, but several were completed between two to 51 days late. The DON confirmed the non-compliance, indicating a systemic issue in adhering to the mandated schedule.
The facility failed to submit MDS assessments to the CMS QIES ASAP System within the required 14-day timeframe for several residents. Despite varying completion dates, all delayed submissions occurred on the same date, indicating a systemic issue. The DON confirmed these delays during an interview.
The facility failed to accurately complete MDS assessments for two residents. One resident's hospice services were not correctly documented, and another resident's injection and insulin administration days were inaccurately recorded. These discrepancies were confirmed by the DON.
The facility failed to develop and implement individualized care plans for three residents, including one with high blood pressure, another requiring oxygen therapy, and a third with PTSD. The absence of care plans for these residents' specific needs was confirmed by the DON.
A facility failed to update a resident's care plan to include current physician's orders for feeding tube management. The care plan, last updated in January, did not reflect December orders for checking residuals every shift and administering a 25 ml water flush before and after medications. This was confirmed by the DON during an interview.
A facility failed to clarify a physician's order for a resident's Osmolite 1.5 feeding, resulting in conflicting administration instructions. Despite inconsistent orders, there was no evidence of physician contact for clarification. Staff documented the administration according to all conflicting orders, confirmed by interviews with a nurse and the DON.
A facility failed to provide a restorative nursing program for a resident who required assistance with walking due to medical conditions. Despite the facility's policy to assess residents quarterly for such programs, there was no evidence of implementation for this resident, who expressed a desire to improve mobility for discharge. Interviews confirmed the absence of a program, violating facility policy and regulatory standards.
A facility failed to provide ordered pressure ulcer treatments for a resident with an unstageable pressure injury on the abdomen. Despite physician's orders for daily wound care, records showed that the care was not documented on multiple occasions. An interview with the Infection Control/Wound Care RN confirmed the absence of documentation for these treatments.
A resident, who was severely cognitively impaired and required extensive assistance, did not have a perimeter mattress on their bed as required by their care plan and physician orders. Observations during a survey confirmed the absence of the mattress, and interviews with staff corroborated this deficiency.
A resident with heart failure and respiratory failure was prescribed oxygen at 2 liters per minute via nasal cannula. However, the resident was observed receiving 5 liters per minute, contrary to the physician's order. This was confirmed by both a registered nurse and the DON, highlighting a failure to follow the prescribed oxygen therapy.
A facility failed to obtain physician's orders and monitor a resident's dialysis site, as well as ensure communication with the dialysis provider. The resident, requiring dialysis for kidney failure, had no documented evidence of site monitoring or collaboration between the facility and dialysis center, confirmed by the DON.
A facility failed to attempt non-pharmacological interventions before administering as-needed antipsychotic medication to a resident with cognitive impairments and multiple diagnoses, including Alzheimer's and bipolar disorder. The resident received quetiapine fumarate multiple times without documented evidence of prior behavioral interventions, contrary to facility policy. The DON confirmed that such interventions should have been attempted.
The facility failed to label multi-dose insulin and Tuberculin vials as required. Two residents' insulin vials and several Tuberculin vials in medication refrigerators were found opened and undated, contrary to facility policy and manufacturer's instructions. This was confirmed by staff interviews.
A facility failed to obtain the required physician's certification of terminal illness from a contracted hospice provider for a resident receiving hospice services. Despite an agreement with Bridges Hospice, there was no documented evidence of the certification in the resident's or hospice provider's clinical records. This was confirmed by the DON.
Lack of Documentation for Signed-Out Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accountability and documentation for controlled medications for three cognitively intact residents with pain-related conditions. Facility policy dated May 14, 2025, required nursing staff to record and sign the medication, dosage, and time of administration on each resident’s medication record immediately after administration. For one resident with chronic back pain related to spinal stenosis and discitis, physician orders dated October 20, 2025, prescribed Percocet 5-325 mg every six hours as needed. The controlled drug record for October 2025 showed Percocet tablets signed out on October 24 at 3:30 p.m. and October 25 at 9:00 a.m., but there was no corresponding documentation on the MAR or elsewhere in the clinical record that these doses were administered. A second resident, cognitively intact with spinal stenosis, diabetic neuropathy, recent hospice admission, and an opioid regimen, had a physician’s order dated January 10, 2026, for Morphine 10 mg sublingual every two hours as needed for pain or respiratory distress. The January 2026 controlled drug record showed Morphine 10 mg doses signed out on January 10 at 8:00 a.m., 12:00 p.m., and 4:00 p.m., with no documented evidence on the MAR or in the clinical record that these doses were given. A third cognitively intact resident with occasional pain and on routine and PRN pain medications, including an opioid, had an order dated December 29, 2025, for Percocet 5-325 mg every 12 hours as needed. The controlled drug record for late December 2025 and January 2026 showed Percocet tablets signed out on December 28 at 6:15 p.m. and January 5 at 10:30 a.m., again without documentation in the MAR or clinical record that the doses were administered. In an interview on January 14, 2026, at 3:57 p.m., the DON confirmed there was no documented evidence in the three residents’ records that the signed-out narcotic doses were administered at the recorded dates and times.
Failure to Provide and Document Colostomy Care for Two Residents
Penalty
Summary
The facility failed to provide proper colostomy care for two residents as required. For one resident with paraplegia and a colostomy, the care plan specified that staff were to change the colostomy appliance as necessary. However, a review of the clinical records, physician's orders, and treatment administration records revealed no documented evidence that colostomy care was being provided. This was confirmed by the Nursing Home Administrator during an interview. For another resident with a colostomy, physician's orders indicated that ostomy care was to be provided every shift. Observations confirmed the presence of a colostomy bag, and the resident reported that staff usually emptied the bag at least once per shift, but sometimes only after prompting. There were no physician's orders for changing or emptying the colostomy appliance, and no care plan was in place for the resident's colostomy. The DON confirmed the absence of both physician's orders and a care plan for colostomy care.
Failure to Timely Change PICC Line Dressing
Penalty
Summary
The facility failed to provide adequate care and maintenance for a peripherally inserted central catheter (PICC) for one resident. According to facility policy, PICC dressings are to be changed 24 hours after insertion and then weekly or as needed. A resident with moderate cognitive impairment, requiring staff assistance for daily care, and receiving IV antibiotics for MRSA, was observed with a PICC line dressing that had not been changed for eight days. The dressing was dated October 29, 2025, despite the requirement for a change by November 5, 2025. The Director of Nursing confirmed that the dressing change was overdue, indicating non-compliance with established protocols for PICC line care.
Failure to Document and Communicate Resident Status Before and After Dialysis
Penalty
Summary
The facility failed to ensure proper communication regarding a resident's health status or changes in condition before and after dialysis treatments. According to facility policy, residents receiving dialysis are to be monitored, and relevant medical information from the dialysis provider must be maintained in the resident's medical record. If such information is not received upon the resident's return, the facility is required to contact the dialysis provider to obtain it. For one resident with end-stage renal disease who was cognitively intact and dependent on hemodialysis, physician orders and the care plan specified that vital signs and weight were to be recorded before dialysis and that open communication with the dialysis center was necessary. However, review of the resident's clinical record and dialysis binder revealed no documented evidence of communication between the facility and the dialysis center regarding the resident's health status before and after dialysis on multiple occasions. Nursing notes and the medication administration record confirmed that the resident attended dialysis on several dates, but there was no documentation of the required communication. The Director of Nursing confirmed that such documentation was missing and acknowledged that it should have been present.
Ice Machine Lacked Required Air Gap, Resulting in Unsanitary Storage Conditions
Penalty
Summary
The facility failed to ensure that ice was stored under sanitary conditions in the main dining room. According to the facility's policy, there should be an air gap between the ice machine drain and the drainage pipe. However, observations revealed that the ice machine drain was inserted directly into a PVC pipe, which led to a bucket under the sink that was full of stagnant water. There was no air gap between the ice machine drain pipe and the PVC pipe, nor between the opposite end of the PVC pipe and the bucket. The Maintenance Director confirmed that the sump pump was not functioning properly, resulting in the accumulation of stagnant water in the bucket and the absence of the required air gap.
Failure to Obtain Reference Checks for New Hires
Penalty
Summary
The facility failed to obtain and document reference checks for five newly hired employees, including two nurse aides, an LPN, an RN, and the Maintenance Director. According to the facility's policy dated May 14, 2025, all new hires are required to have verified references documented in their personnel files prior to starting employment. However, a review of the personnel files for these five staff members revealed no evidence that reference checks from previous employers were obtained before their start dates. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of documented reference checks for the identified staff members. The lack of compliance with the facility's own policy and state regulations regarding pre-employment screening was identified through review of facility policies, personnel records, and staff interviews.
Physician Discharge Summary Not Completed for Discharged Resident
Penalty
Summary
The facility failed to ensure that a physician completed a discharge summary for one resident who was discharged to a senior living community. Clinical record review showed that the resident was admitted to the facility and later discharged, as documented in a nursing note. However, at the time of the survey, there was no evidence in the clinical record that a physician discharge summary had been completed for this resident. This was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the required discharge summary was not completed by the physician.
Failure to Assess and Document Vital Signs Prior to Medication Administration
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for one resident. According to the facility's medication administration policy, medications must be given in accordance with written physician orders, and documentation in the electronic medication administration record (E-MAR) should include vital signs such as blood pressure or heart rate when appropriate. For a resident who was cognitively intact, independent with personal care, and had a diagnosis of diabetes, physician's orders specified that amlodipine should be held for a systolic blood pressure (SBP) less than 120, clonidine should be held for SBP less than 120 or heart rate less than 55, and metoprolol should be held for SBP less than 100 or heart rate less than 55. Review of the resident's E-MAR for the relevant months showed no documented evidence that blood pressure or heart rate was checked prior to administering amlodipine, clonidine, or metoprolol as ordered. The Director of Nursing confirmed that these assessments should have been performed and documented prior to medication administration, but they were not. This failure to assess and document vital signs prior to administering these medications constituted a deficiency in following physician's orders and facility policy.
Failure to Administer Insulin and Monitor Blood Glucose as Ordered
Penalty
Summary
A review of facility policy, clinical records, and staff interviews revealed that the facility failed to administer medications as ordered by the physician for one resident. The resident, who was cognitively intact, independent with personal care, and had a diagnosis of diabetes, returned to the facility from the hospital with specific physician orders for insulin aspart (using a sliding scale and fixed doses before meals) and insulin glargine. On the day of return, there was no documented evidence that the resident's blood glucose was checked or that the prescribed insulin doses were administered. The resident reported not having their blood sugar checked and experiencing a headache, with their glucose monitor reading "HI." The physician was notified of the omitted insulin doses and blood glucose checks. The Director of Nursing confirmed that the resident's blood glucose should have been monitored and insulin administered as ordered, but this did not occur upon the resident's return from the hospital.
Failure to Label Opened Multi-Dose Medication Containers
Penalty
Summary
The facility failed to properly label multi-dose containers of medications with the date they were opened in one of the medication rooms. During an observation of the East 1 medication room, three opened and undated bottles of Aplisol solution were found in the medication refrigerator. Facility policy required medications to be stored in accordance with federal and state regulations, including labeling requirements, and the manufacturer's instructions for Aplisol specified that vials in use for more than 30 days should be discarded. The Assistant Director of Nursing confirmed at the time of observation that the opened bottles should have been labeled with the date they were opened.
Failure to Maintain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained and maintained the required hospice documentation for a resident receiving hospice services. According to facility policy, all hospice assessments, plans of care, progress notes, and services provided must be integrated into the resident's medical record, and nursing staff are responsible for ensuring that current physician orders, progress notes, and hospice documentation are available. For one resident who was cognitively impaired, dependent on staff for daily care, and diagnosed with dementia, there was an active physician's order and care plan for hospice services. However, as of the date of review, there was no documented evidence in either the resident's clinical record or the hospice provider's record that updated hospice nurse aide or registered nurse charting had been obtained or maintained. This was confirmed by the DON, who acknowledged that the required hospice documentation was missing from both records, despite the resident's ongoing hospice care.
QAPI Committee Failed to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and did not ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Despite developing plans of correction for previously cited deficiencies, including those related to abuse policies, quality of care, proper storage of medications, and food procurement and sanitation, the QAPI committee did not successfully implement these plans. The current survey identified repeated deficiencies in these same areas, indicating that the committee's actions were ineffective in correcting the issues. Specifically, the facility's plans of correction included conducting audits and reporting the results to the QAPI committee for review. However, the results of the current survey showed that the committee failed to ensure ongoing compliance with regulations regarding abuse policies (F607), quality of care (F684), labeling and storing drugs and biologicals (F761), and food procurement, storage, preparation, and serving under sanitary conditions (F812). The repeated nature of these deficiencies demonstrates that the QAPI committee did not adequately address or resolve the cited issues.
Failure to Adhere to Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain professional infection prevention and control practices for three residents. For one resident with moderate cognitive impairment and a PICC line, an LPN entered the room, performed care involving the resident's antibiotic and PICC, removed gloves, and then touched multiple surfaces in the facility without performing hand hygiene. Both the LPN and the Nursing Home Administrator confirmed that hand hygiene should have been performed after glove removal, as required by facility policy. Another resident, who was cognitively impaired and had an indwelling urinary catheter, did not have Enhanced Barrier Precautions (EBP) in place as required. Observations over several days showed that there was no signage or PPE station indicating EBP in or near the resident's room, despite the care plan stating that EBP was in effect. Staff interviews confirmed that EBP should have been implemented for this resident due to the presence of the indwelling catheter, but it was not. A third resident was observed during a medication pass when an LPN obtained a blood sugar reading while wearing gloves. After removing the gloves and washing hands, the LPN turned off the faucet with her clean hand instead of using a paper towel, contrary to facility policy. Both the LPN and the Director of Nursing acknowledged that the correct procedure was not followed. These findings demonstrate lapses in adherence to established infection prevention and control protocols.
Failure to Monitor Blood Sugar per Physician Orders
Penalty
Summary
The facility failed to follow physician's orders for a resident who was cognitively intact and required staff assistance for daily care, with diagnoses including joint prosthesis infection and diabetes mellitus. Physician's orders specified that the resident should receive 15 units of Glargine insulin subcutaneously at bedtime and as needed if blood sugar exceeded 300 mg/dl. However, a review of the Medication Administration Record for June and July 2025 showed no documented evidence that the resident's blood sugar was being monitored as ordered. This was confirmed by the Director of Nursing, who acknowledged the lack of documentation for blood sugar monitoring per physician's orders.
Failure to Update Care Plans Following Changes in Resident Care Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for five residents. In several cases, care plans continued to list interventions or medications that had been discontinued, such as foley catheters and anticoagulant or antibiotic therapies. For example, one resident's care plan still indicated the presence of a foley catheter after it had been removed and was not re-inserted per physician orders. Another resident's care plan continued to reference anticoagulant therapy even after the medication had been discontinued, and similar discrepancies were found for residents who were no longer receiving antibiotics or anticoagulants, as confirmed by review of physician orders and medication administration records. These deficiencies were confirmed through interviews with the Director of Nursing, who acknowledged that the care plans had not been updated as required. The facility's policy required quarterly reassessment and interdisciplinary review of care plans, but documentation did not show that care plans were revised to reflect significant changes in residents' treatments or conditions. The lack of timely updates to care plans was identified through review of clinical records, policies, and staff interviews.
Failure to Document Required Vital Signs Before Administering Antihypertensive Medication
Penalty
Summary
Staff failed to follow physician's orders for two residents who had diagnoses of hypertension and were prescribed Metoprolol. For both residents, the orders specified that staff were to administer 25 mg of Metoprolol twice daily, but only if the systolic blood pressure was at least 90 mmHg and the heart rate was at least 60 beats per minute. The orders also required staff to hold the medication if these parameters were not met. Review of the Medication Administration Records for both residents showed that Metoprolol was administered twice daily over an 11-day period without documented evidence that blood pressure and heart rate were checked prior to administration. This lack of documentation was confirmed by the Director of Nursing, who acknowledged that there was no evidence staff obtained the required vital signs before giving the medication as ordered.
Ice Machine Drainage Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to ensure that ice was stored under sanitary conditions for the ice machine located next to the kitchen. Manufacturer's instructions for the ice machine specified that the drain line must have a 1.5-inch drop per 5 feet of run, must not create traps, and that the floor drain must be large enough to accommodate all drainage, with an air gap required between the drain pipe and the basin. However, observations revealed that the ice machine's drain was discharging into a bath basin, with the drain pipe submerged in stagnant water and a small pump moving some water into a nearby sink. There was no air gap present between the drain pipe and the basin, contrary to the manufacturer's instructions.
Failure to Inform Resident of Discharge Plans
Penalty
Summary
The facility failed to ensure that a resident was fully informed and able to participate in decisions regarding his discharge plan. Clinical record review showed that the resident was cognitively intact and able to communicate effectively. Despite this, the resident reported confusion and lack of information about his discharge, stating that he believed he was supposed to go home weeks earlier and that no one had explained the situation to him. The Nursing Home Administrator confirmed that while the Social Worker had communicated with the resident's brother about discharge arrangements, this information was not relayed to the resident nor documented in the medical record.
Failure to Complete License Check Prior to RN Hire
Penalty
Summary
The facility failed to ensure that a license check was obtained prior to the hire of a registered nurse. Review of the personnel file for the registered nurse showed that the individual began employment on March 9, 2025, but the license check was not completed until March 10, 2025, after the start date. The facility's policy required that employment background checks, including license verification, be conducted before an employee's start date to prevent abuse, neglect, or mistreatment of residents. This lapse was confirmed during an interview with the Regional Human Resources Director, who acknowledged that the license check should have been completed prior to the nurse's start date.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For several residents, the MDS assessments did not accurately reflect medications administered during the seven-day look-back period. Specifically, residents who received daily doses of aspirin, an anti-platelet medication, were incorrectly coded as not having received anti-platelet therapy. Additionally, a resident who received Clobazam, an anti-anxiety medication, was not coded as having received such medication, and another resident who received triple antibiotic ointment for a wound was not coded as having received an antibiotic medication. These inaccuracies were confirmed through reviews of physician orders, Medication Administration Records (MAR), Treatment Administration Records (TAR), and staff interviews. The discrepancies were identified for residents who had clear documentation of medication administration during the assessment periods, but whose MDS assessments did not reflect this information. The Director of Nursing and the Nursing Home Administrator confirmed the inaccuracies during interviews.
Failure to Complete Safety Assessments for Siderails and Air Mattresses
Penalty
Summary
The facility failed to complete required safety assessments for residents using siderails and air mattresses. For one resident who was cognitively intact and required assistance with daily care due to an infection of a right knee prosthesis, the facility's siderail/assist bar evaluation was not fully completed, specifically omitting the section to determine if siderails or assist bars were indicated. Despite this incomplete assessment, observations confirmed that the resident was using bilateral upper siderails during multiple surveyor visits. The Director of Nursing confirmed that the last two assessments for this resident were not fully completed to identify the need for siderails. Additionally, two other residents who were dependent on staff for personal care and had orders and care plans for the use of air mattresses did not have documented safety assessments for the air mattresses prior to their use. One of these residents was cognitively intact with a diagnosis of chronic deep vein thrombosis, and the other was cognitively impaired with cerebral palsy and at risk for pressure sores. Observations confirmed that both residents were using air mattresses, but there was no evidence of safety assessments being completed. The Director of Nursing acknowledged that air mattress safety assessments were not completed for residents using air mattresses at the time of the survey.
Failure to Document Urinary Catheter Output as Ordered
Penalty
Summary
The facility failed to ensure that urinary output was consistently monitored and documented for two residents with indwelling urinary catheters. For one resident with cognitive impairment and a diagnosis of benign prostatic hyperplasia, the care plan and physician's orders required staff to measure and document urinary catheter output every shift. However, clinical record reviews revealed multiple instances across various shifts where there was no documented evidence of urinary output being recorded, as confirmed by the Director of Nursing. Similarly, another resident with a neurogenic bladder and an indwelling catheter had physician's orders and a care plan directing staff to document urinary output every shift. Review of this resident's records also showed missing documentation of catheter output on several shifts, which was acknowledged by the Director of Nursing. These findings indicate that the facility did not follow physician orders and care plan interventions for monitoring and documenting urinary output for residents with indwelling catheters.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information posted at the main entrance was current. On May 17, 2025, an observation revealed that the posted staffing information was dated May 15, 2025, and had not been updated as required. This was confirmed in an interview with the Nursing Home Administrator, who acknowledged that the information displayed was not current.
Controlled Substance Not Properly Secured in Medication Room
Penalty
Summary
A review of facility policies, observations, and staff interviews revealed that a controlled medication, Ativan, was not stored according to the facility's policy and regulatory requirements. The policy required controlled substances to be kept under double-lock security, with access keys for controlled medications being different from those for other medications. During an observation of the East Side medication room, an opened vial of Ativan was found stored in the medication refrigerator alongside non-controlled medications, without being placed in a separately locked, permanently affixed container. An LPN confirmed the absence of a separately locked container for the Ativan, and the DON also confirmed that the medication was not stored as required.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for multiple residents. For one resident with confusion, a nursing note documented dental pain and a missing tooth, but there was no evidence in the clinical record that the resident's pain was assessed or that a dental referral was made, despite the DON later providing a dentist's consult report that should have been included in the record. Another resident with paranoid schizophrenia exhibited ongoing hallucinations and paranoia, but there was no documentation that the psychiatrist was informed of these symptoms or that follow-up psychiatric visits occurred, even though the administrator stated that such visits had taken place. Additionally, a cognitively intact resident was scheduled for discharge, but there was no documentation in the clinical record regarding communication with the resident or his family about discharge plans. The resident expressed confusion about his discharge status, and the administrator confirmed that the social worker had communicated with the resident's brother but had not documented it. These omissions demonstrate a failure to maintain clinical records in accordance with accepted professional standards.
QAPI Committee Failed to Correct Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and did not ensure that plans to improve care and services were effectively implemented. Despite developing plans of correction for deficiencies identified in previous surveys, the committee did not successfully address repeated issues related to pharmaceutical services, inaccurate MDS assessments, care plan timing and revision, quality of care, safety/accident hazards, medication storage, and complete and accurate medical records. The plans of correction included conducting audits and reporting results to the QAPI committee, but these actions were not effectively carried out, as evidenced by the recurrence of the same deficiencies in subsequent surveys. The report specifically notes that deficiencies cited in earlier surveys, such as those ending December 4, 2024, and January 6, 2025, were not resolved, and the same issues were identified again in the most recent survey ending May 20, 2025. The QAPI committee's failure to implement and follow through on their corrective plans resulted in ongoing noncompliance with nursing home regulations across multiple areas of care and facility management.
Failure to Maintain Sanitary Conditions in Utility Rooms
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in three soiled utility rooms, as observed during a survey. The facility's policy on infection control, dated January 2, 2024, emphasizes the importance of preventing healthcare-associated infections and maintaining a sanitary environment. However, observations revealed that the utility rooms were cluttered with soiled linen bags on the floor. An interview with a laundry attendant confirmed that the facility's washer and dryer were not operational, leading to a backlog of laundry. Additionally, the Regional Clinical Consultant acknowledged that the laundry was not being returned to residents in a timely manner and confirmed the unsanitary conditions in the utility rooms.
Neglect During Transportation Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation to dialysis, resulting in neglect. The resident, who was cognitively intact and used a wheelchair due to limited range of motion and renal failure, was being transported in the facility's van. The facility's transportation policy required that all clients in wheelchairs be secured with wheelchair locks and safety belts. However, during the transport, the van driver did not properly secure the resident's wheelchair, leading to the wheelchair tipping over backwards when the van began to move. The incident occurred when the van was pulling out of the driveway, which had a slight upward grade. The resident's wheelchair was not locked into place, causing the resident to be ejected from the wheelchair. As a result, the resident's knees struck her chest, causing significant sternal pain. Despite the resident's initial refusal for further assessment, she was later sent to the hospital by the dialysis center for evaluation and treatment, where a CT scan revealed a sternal fracture. The facility's investigation confirmed that the van driver was distracted and failed to secure the front of the resident's wheelchair properly. This oversight led to the resident's fall and subsequent injury. The Director of Nursing confirmed the findings, acknowledging that the failure to lock the wheelchair properly resulted in the resident's fall and injury. The incident highlights a breach in the facility's responsibility to protect residents from neglect during transportation, as outlined in their policies.
Failure to Secure Wheelchair Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident who used a wheelchair, resulting in an accident during transportation. The resident, who was cognitively intact and required dialysis, was being transported in the facility's van when her wheelchair tipped over backwards. This incident occurred because the van driver did not properly secure the wheelchair, as he was distracted by another passenger's inquiry about a seat belt. The resident reported chest pain after her knees struck her chest during the fall. Following the incident, the resident was sent to a local hospital where a CT scan revealed a sternal fracture. Due to the severity of her condition, she was transferred to a Level 2 trauma center for further treatment, including respiratory support and dialysis. The facility's investigation confirmed that the wheelchair straps were not secured properly, leading to the accident. Interviews with staff corroborated the sequence of events and the oversight in securing the wheelchair.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the rooms of five residents. Observations revealed that Resident 6's privacy curtain had multiple colored stains, and the curtain between the resident and her roommate had a reddish-colored stain. The resident was unable to recall when her room was last cleaned. Additionally, the rooms of Residents 8 and 9, as well as Residents 10 and 11, were found to have multiple food debris on the floor between the beds. In the room of Residents 10 and 11, there was also dried fluid from a spill under the foot of the bed by the door. Interviews with staff confirmed the deficiencies. Housekeeper 1 stated that privacy curtains are washed monthly or when a room is deep cleaned, typically when a resident changes rooms or is discharged. The Nursing Home Administrator acknowledged that Resident 6's privacy curtains needed cleaning and should have been changed over the weekend. The administrator also confirmed that the rooms of Residents 8, 9, 10, and 11 required cleaning, indicating a lapse in maintaining a clean environment as per the facility's standards.
Failure to Follow Physician's Orders for Medications and Treatments
Penalty
Summary
The facility failed to ensure that physician's orders for medications and treatments were followed for five residents. Resident 10, who was cognitively impaired and diagnosed with benign prostatic hyperplasia and obstructive uropathy, was ordered to consult urology for a mild hydrocele in the right testicle. However, there was no documented evidence that the urology consult was scheduled as ordered. The Director of Nursing confirmed the absence of documentation for the urology consult. Resident 36, also cognitively impaired and diagnosed with hypertension, was ordered to receive Lopressor with specific instructions to hold the medication if the blood pressure was below 120/80. Despite this, the resident received the medication multiple times when the blood pressure was below the specified threshold. The Director of Nursing confirmed the lack of documentation indicating that the medication was held as ordered. Similarly, Resident 46, who required blood pressure monitoring three times daily, had no documented evidence of blood pressure recordings on several shifts as ordered. Resident 60, with a diagnosis of peripheral vascular disease and a non-pressure chronic ulcer, had orders for specific wound care treatments that were not documented as administered on multiple occasions. The wound nurse confirmed the absence of documentation for these treatments. Resident 87, diagnosed with hidradenitis suppurativa, had orders for wound care treatments that were not documented as completed on several dates. The Infection Control/Wound Care Registered Nurse confirmed the lack of documentation for these treatments.
Controlled Medication Accountability Issues
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents. For Resident 56, there was no documented evidence that the signed-out tablets of Oxycodone were administered on specific dates and times, despite being signed out for administration. The Director of Nursing confirmed the lack of documentation for these administrations. Additionally, for Resident 71, an entire card of Oxycodone pills was reported missing. The investigation could not determine who took the narcotic medication, although it was suspected to be an agency nurse, who was subsequently prevented from returning to the facility. For Resident 93, after the resident's death, there was a failure to follow the facility's policy for the destruction of controlled drugs. Licensed Practical Nurse 7 destroyed several pre-filled syringes of Lorazepam and Morphine, as well as tablets of Tramadol, without a second nurse present to verify the destruction, as required by the facility's policy. The Director of Nursing acknowledged that the destruction should have been witnessed by two nurses.
Incomplete and Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for two residents. For one resident, physician's orders required foley catheter care and output recording every shift. However, the Treatment Administration Records (TARs) for September, October, and November 2024 showed missing documentation of these tasks on multiple dates, despite nurse aide documentation indicating completion. The Director of Nursing confirmed the lack of documentation by licensed staff on the TARs for the specified dates. Another resident, who had impaired cognition and a Stage 4 pressure ulcer, had physician's orders for daily wound care. The TARs for October and November 2024 revealed missing documentation of wound care on several dates. The Infection Control/Wound Care Registered Nurse confirmed that the wound care was completed as ordered, but there was an error in documentation.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices were followed, as evidenced by several deficiencies observed during a survey. A registered nurse did not disinfect a glucometer between blood sugar checks for two residents, despite facility policy and confirmation from the Director of Nursing that the device should be cleaned after each use. Additionally, the nurse did not perform hand hygiene between glove changes during wound care for a resident with a Stage 4 pressure ulcer, contrary to the facility's hand hygiene policy. Another deficiency involved a resident with an indwelling catheter who was supposed to be on Enhanced Barrier Precautions (EBP). There was no signage or PPE station to indicate these precautions were in place, and a nurse aide was unaware of any specific precautions for the resident. The Infection Preventionist confirmed that EBP should have been implemented for this resident, as per the facility's policy and CDC guidelines. Lastly, a resident with a history of acute respiratory failure and pneumonia was observed with oxygen tubing on the floor, which was then placed directly into the resident's nostrils by a registered nurse without replacing it. The Infection Preventionist and Director of Nursing confirmed that the tubing should have been replaced before use. These observations highlight lapses in infection control practices, as outlined in the facility's policies and CDC guidelines.
Failure to Ensure Privacy for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide dignity for a resident with an indwelling urinary catheter. A quarterly Minimum Data Set (MDS) assessment for the resident revealed impaired cognition and the need for staff assistance with daily care tasks. During an observation, the resident was found lying in bed with the urinary drainage bag hooked to the side of the bed, visible from the door, and without a privacy cover. The yellow urine in the bag was visible. Interviews with a nurse aide and the Director of Nursing confirmed that the resident's urinary drainage bag should have had a privacy cover, which was not in place.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive annual Minimum Data Set (MDS) assessments within the required timeframe for three residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an annual MDS assessment must be completed no later than 14 calendar days after the assessment reference date (ARD). For Resident 25, the assessment was completed 16 days after the ARD. Resident 84's admission comprehensive MDS assessment was completed 19 days after the ARD, and Resident 92's assessment was completed 15 days after the ARD. These delays were confirmed in an interview with the Director of Nursing.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for 17 out of 56 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly assessment is due every 92 days, with the completion date being the Assessment Reference Date (ARD) plus 14 days. However, the facility did not adhere to these guidelines, resulting in assessments being completed late for multiple residents. Specific instances of non-compliance include assessments for several residents being completed between two to 51 days late. For example, one resident's assessment was completed 51 days late, while others were completed between two to 27 days late. The Director of Nursing confirmed that these assessments were not completed within the required timeframes, indicating a systemic issue in adhering to the mandated assessment schedule.
Delayed MDS Assessment Submissions
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for nine residents. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual mandates that comprehensive MDS assessments be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments within 14 days of the MDS Completion Date. However, the facility did not adhere to these guidelines, resulting in delayed submissions for several residents. For instance, the MDS assessment for one resident was completed on August 30, 2024, but was not submitted until October 1, 2024, well past the September 12, 2024 deadline. Similar delays were noted for other residents, with submission dates consistently falling on October 1, 2024, despite varying completion dates and deadlines. An interview with the Director of Nursing confirmed these delays, indicating a systemic issue in the timely electronic transmission of MDS assessments.
Inaccurate MDS Assessments for Hospice and Injection Records
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents. For one resident, the care plan indicated that the resident was receiving hospice services since admission. However, the quarterly MDS assessment did not reflect this, as Section O0100K2 was not checked to indicate hospice services were being received. This discrepancy was confirmed by the Director of Nursing during an interview. For another resident, the MDS assessment inaccurately recorded the number of days injections and insulin were administered. Physician's orders and the Medication Administration Record showed that the resident received various injections on specific days, but the MDS assessment incorrectly indicated that injections were received on all seven days of the look-back period. Similarly, it inaccurately recorded insulin injections as being administered on all seven days, when they were only given on three days. This error was also confirmed by the Director of Nursing.
Failure to Develop Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for three residents, as required by their policy. Resident 36, who was cognitively impaired and had high blood pressure, did not have a care plan addressing his medication needs, despite physician's orders for Lopressor with specific parameters for administration. The Director of Nursing confirmed the absence of a care plan for this resident's high blood pressure management. Similarly, Resident 84, who was cognitively intact and required oxygen therapy due to heart failure, high blood pressure, and respiratory failure, lacked a care plan for his oxygen use. The Director of Nursing acknowledged this oversight. Additionally, Resident 85, who was cognitively impaired and diagnosed with PTSD from childhood trauma, did not have a care plan addressing her mental health needs. The Director of Nursing confirmed the lack of a care plan for her PTSD. These deficiencies were identified through clinical record reviews and staff interviews.
Failure to Update Resident Care Plan for Feeding Tube Management
Penalty
Summary
The facility failed to update the care plan for a resident to reflect changes in care needs, specifically regarding the management of the resident's feeding tube. The resident, who had a feeding tube, was assessed quarterly, and the care plan was supposed to be reviewed by the interdisciplinary team. However, the care plan, last updated in January 2024, did not include the current physician's orders from December 2024, which specified checking the residual of the feeding tube every shift and administering a 25 ml water flush before and after each medication. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan did not include the updated physician's orders. This oversight was identified during a review of policies, clinical records, and staff interviews, indicating a lapse in ensuring that the care plan was revised to incorporate the latest medical directives for the resident's feeding tube management.
Failure to Clarify Physician's Order for Nutritional Support
Penalty
Summary
The facility failed to clarify a questionable physician's order for a resident, leading to a deficiency in the administration of nutritional support. The Pennsylvania Code requires registered nurses to collect and analyze data to determine nursing care needs and carry out actions that promote well-being. However, the facility did not adhere to these standards when handling the physician's orders for the resident's Osmolite 1.5 feeding. The orders were inconsistent, with one order instructing staff to stop the feeding at 6:00 a.m., another to administer 60 ml per hour for 18 hours starting at noon, and a third to administer 56 ml per hour continuously during the evening shift. Despite these conflicting orders, there was no documented evidence that the physician was contacted to clarify which feeding regimen should be followed. Interviews with a registered nurse and the Director of Nursing confirmed that the order should have been clarified with the physician. This oversight resulted in staff documenting the administration of the feeding according to all three conflicting orders, without a clear directive from the physician.
Failure to Provide Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to ensure that residents received programs to maintain or improve their mobility and ambulation, specifically for one resident. The facility's policy for a restorative nursing program, dated November 4, 2024, stated that residents should be assessed quarterly for appropriate programs to prevent decline in activities of daily living. However, for Resident 45, who was cognitively intact and required assistance with walking due to conditions including high blood pressure, diabetes, and an acquired absence of the left leg below the knee, there was no evidence of such a program being implemented. Resident 45 expressed a desire to be walked by staff to facilitate discharge home, but was informed that staff did not have enough time to assist. The resident's physical therapy was discontinued, and a discharge summary indicated the resident required assistance with a wheeled walker. Interviews with the physical therapist and the Director of Nursing confirmed the absence of a restorative nursing program and any initiatives to maintain the resident's walking ability. This lack of a program was a direct violation of the facility's policy and regulatory requirements.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered for a resident, leading to a deficiency finding. The resident, who was cognitively intact and required assistance for daily care needs, had an unstageable pressure injury on the left abdomen. Physician's orders specified daily wound care, including cleansing with normal saline, applying medihoney, and covering with a dry dressing. However, the treatment administration records (TARs) showed that the wound care was not documented as completed on several specified dates in November and December 2024. An interview with the Infection Control/Wound Care Registered Nurse confirmed the lack of documented evidence for the wound care on those dates.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place as care planned for a resident. The facility's policy on fall management aimed to reduce the risk of falls and prevent injury. A quarterly Minimum Data Set (MDS) assessment revealed that the resident was severely cognitively impaired, required extensive assistance for bed mobility and transfers, and had physician orders for a perimeter mattress on his bed. The resident's care plan, revised earlier in the year, also indicated the need for a perimeter mattress due to impaired memory and a history of falls. However, observations during the facility survey showed that the resident did not have a perimeter mattress on his bed at any time. Interviews with a nurse aide and the Director of Nursing confirmed the absence of the perimeter mattress, despite its necessity as per the care plan and physician orders.
Oxygen Therapy Not Administered as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician for a resident. The facility's policy required staff to check the physician's orders for the correct liter flow and method of administration. A resident, who was cognitively intact and required assistance for daily care needs, had a physician's order to receive oxygen at 2 liters per minute via nasal cannula due to conditions including heart failure, high blood pressure, and respiratory failure. However, during an observation, it was found that the resident was receiving oxygen at 5 liters per minute instead of the prescribed 2 liters. This discrepancy was confirmed by a registered nurse and the Director of Nursing, indicating a failure to adhere to the physician's orders.
Failure to Monitor Dialysis Care and Ensure Communication
Penalty
Summary
The facility failed to obtain physician's orders for the care and monitoring of dialysis sites and did not ensure communication between the dialysis provider and the nursing staff for a resident requiring dialysis services. The facility's policy, dated November 4, 2024, required that the resident's surgical dialysis site be assessed for signs of infection and that medical information from the dialysis provider be maintained as part of the resident's medical record. However, there was no documented evidence in the clinical record of Resident 56 to indicate that staff monitored the dialysis site in accordance with the facility's policy, nor were physician's orders obtained for the care and treatment or monitoring of the access site. Resident 56, who was cognitively intact and required assistance for daily care needs, had a diagnosis of kidney failure and required dialysis treatments. Observations revealed a dry gauze dressing on her right chest, and the resident confirmed that no communication binder or papers were exchanged between the dialysis center and the nursing facility. The Director of Nursing confirmed the lack of documented evidence for physician's orders and monitoring of the dialysis sites, as well as the absence of routine collaboration and communication between the facility and the dialysis center.
Failure to Implement Non-Pharmacological Interventions Before Antipsychotic Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications by not attempting non-pharmacological behavioral interventions before administering as-needed antipsychotic medications. This deficiency was identified for one resident, who was cognitively impaired and had diagnoses including Alzheimer's, dementia, bipolar disorder, and depression. The facility's policy, dated November 4, 2024, stated that antipsychotics should not be used for certain behaviors unless they pose a danger, and that gradual dose reductions and behavioral interventions should be attempted unless clinically contraindicated. For Resident 46, physician's orders included 25 mg of quetiapine fumarate every eight hours as needed for restlessness. The Medication Administration Record showed that the resident received this medication multiple times between September 28 and October 4, 2024, without documented evidence of non-pharmacological interventions being attempted first. An interview with the Director of Nursing confirmed that these interventions should have been attempted prior to administering the medication.
Failure to Label Multi-Dose Vials
Penalty
Summary
The facility failed to properly label multi-dose containers of insulin and Tuberculin vials, as required by their policy and manufacturer's instructions. Specifically, a Lantus insulin vial for a resident and a Humalog insulin vial for another resident were found opened and undated on the East 1 Front Medication Cart. The facility's policy, dated November 4, 2024, mandates that multi-dose vial medications must be dated when opened to determine the discard date. Manufacturer's instructions for Lantus and Humalog insulin specify that these should be discarded 28 days after opening, even if there is insulin left. Observations confirmed that these vials were not dated, which was acknowledged by Registered Nurse 8. Additionally, the facility failed to label multi-dose Tuberculin vials in two medication refrigerators. Observations revealed three opened and undated vials of Tubersol Tuberculin injection in the East 1 medication room refrigerator and one in the west medication room refrigerator. Manufacturer's instructions for Tubersol indicate that vials should be discarded 30 days after opening. Interviews with Registered Nurse 2 and the Director of Nursing confirmed that these vials were opened and undated, contrary to the facility's policy and manufacturer's guidelines.
Failure to Obtain Hospice Certification
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident receiving hospice services. An agreement between the facility and Bridges Hospice, dated June 19, 2024, stipulated that the hospice provider would be responsible for providing the facility with the physician's certification of terminal illness for each patient. However, for a resident admitted to the facility's contracted hospice provider on September 28, 2024, there was no documented evidence in either the resident's clinical record or the hospice provider's clinical record that the facility obtained this certification. This deficiency was confirmed during an interview with the Director of Nursing on December 3, 2024.
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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