Kadima Rehabilitation & Nursing At Luzerne
Inspection history, citations, penalties and survey trends for this long-term care facility in Drums, Pennsylvania.
- Location
- 463 North Hunter Hwy, Drums, Pennsylvania 18222
- CMS Provider Number
- 395484
- Inspections on file
- 33
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Luzerne during CMS and state inspections, most recent first.
The facility failed to provide nutritionally adequate meals and consistent bedtime snacks, with residents reporting not receiving snacks for months and meals not meeting therapeutic or nutritional needs. Staffing shortages, lack of qualified dietary oversight, and non-operational kitchen equipment led to substitute meals that were not documented as nutritionally equivalent, placing all residents in Immediate Jeopardy.
The facility failed to ensure proper sanitization of food-contact surfaces and safe food handling practices in the kitchen, as staff did not perform or document required sanitizer and temperature checks, lacked necessary supplies, and did not follow hand hygiene protocols. Unsanitary conditions were observed throughout the kitchen, and improper use of dishwashing and manual cleaning equipment placed all residents at risk for foodborne illness.
The facility did not ensure on-site oversight of its food and nutrition services by a qualified dietitian after the resignation of the full-time RD. Instead, a part-time RD provided remote services and was unavailable during regular hours, and the corporate RD did not conduct on-site supervision or staff training, resulting in a deficiency in compliance with federal requirements.
The facility did not prepare or serve meals according to planned menus, resulting in residents on pureed, mechanical soft, and gluten-free diets receiving incorrect or incomplete meals. Staff substituted menu items, used unmeasured portions, and omitted required foods, while a resident with a gluten allergy was not provided with appropriate alternatives and had to supply her own food. The Certified Dietary Manager confirmed these discrepancies and lack of consultation with the Registered Dietitian.
Multiple residents reported receiving cold, unappetizing, and delayed meals, with test tray evaluations confirming that hot foods were served below safe temperatures and were bland or difficult to chew. Observations showed significant delays in meal service, and interviews with residents and the CDM confirmed ongoing issues with food temperature, palatability, and timeliness.
A resident was transferred to the hospital on multiple occasions without receiving the required written notices detailing the reason for transfer and ombudsman contact information. Documentation confirming that these notices were provided to the resident or their representative was not available, as confirmed by interviews with the NHA and DON.
A resident with severe cognitive impairment and a court-appointed guardian was transferred to the hospital multiple times, but the facility did not provide the required written notice of its bed-hold policy to the guardian at the time of transfer. The admission agreement included the policy, but there was no evidence the guardian received or signed it, and staff confirmed no written notice was issued during the resident's hospitalizations.
A resident with Medicaid coverage was transferred to the hospital for behavioral issues, and the facility did not provide required written notice of bed-hold or readmission rights. Despite policy allowing a 15-day bed hold, there was no documentation of informing the resident or representative, nor evidence of clinical reassessment or discharge planning. The facility imposed additional conditions for return and did not coordinate with the hospital for the resident's readmission.
The facility failed to maintain a hazardous area enclosure in the Soiled Utility room, affecting one of three smoke compartments. Observations revealed two unsealed penetrations in the wall around two pipes, confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain its cooking facilities according to NFPA 101 standards, as it lacked documentation for the second semi-annual hood duct cleaning for 2024. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager, affecting one of the two floors.
The facility failed to properly install ABHR dispensers in two resident rooms, placing them over electrical wall-mounted lights, which violates safety standards. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
The facility failed to maintain its sprinkler system as per NFPA 25 standards, affecting the entire facility. During an observation, it was found that the facility lacked documentation for sample testing or replacement of sprinklers in service for 50 years, with sprinkler heads dated 1974 and 1975 still in use. This was confirmed in an exit interview with the Facility Administrator and Facilities Manager.
The facility did not conduct monthly inspections of portable fire extinguishers in four locations, affecting both floors. The 'K' extinguisher in the kitchen and extinguishers in the basement level's laundry, maintenance shop, and boiler room were overdue for inspection. This was confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain its emergency generator, as a 4-hour load bank test revealed a shutdown due to a low coolant sensor failure. The facility could not provide documentation confirming the sensor's replacement, leading to a deficiency citation.
The facility failed to maintain electrical systems in one smoke compartment. An observation revealed a missing light switch cover plate in the Soiled Utility room, exposing wiring. This was confirmed in an interview with the Facility Administrator and Facilities Manager.
A corridor door in a smoke compartment was found to be deficient as it was getting stuck on the flooring, requiring excessive force to close. This issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility did not conduct two required fire drills for the 3rd shift in the 3rd and 4th quarters of 2024, affecting both floors. This was confirmed through documentation review and interviews with the Facility Administrator and Facilities Manager.
The facility failed to provide adequate headroom in the basement-level exit access corridor used by staff, as observed during a survey. The headroom was less than the required six feet eight inches due to sprinkler piping and heads, confirmed by the Facility Administrator and Facilities Manager.
The facility failed to provide sufficient staff with the necessary skills for nutritional oversight, as the Director of Food and Nutrition Services was not a qualified dietitian and did not receive frequent consultations from a qualified dietitian. The part-time registered dietitian worked remotely and did not conduct on-site consultations, limiting effective oversight of residents' nutritional needs.
The facility did not conduct a comprehensive assessment to determine necessary resources for resident care, including the absence of a qualified dietitian on-site. A resident receiving enteral feeding requires a dietitian's services, but the facility's part-time dietitian works remotely, completing assessments offsite. This deficiency could negatively impact resident care quality.
A resident with hypertension and other conditions was prescribed Amlodipine Besylate with specific parameters for administration. However, the medication was administered 19 times outside of these parameters, including instances where vital signs were not documented or were below the specified thresholds. The DON confirmed the failure to follow nursing standards, leading to multiple medication errors.
The facility failed to adequately monitor and address the nutritional needs of three residents, leading to significant weight loss and inadequate interventions. A resident with Huntington's disease experienced a notable weight loss without timely weight monitoring or updated care plans. Another resident with cerebral infarction had a delayed reweight, and a third resident with heart disease and dementia experienced significant weight loss without timely reweights or notifications to the care team. The facility relied on a part-time remote dietitian, resulting in limited oversight of residents' nutritional needs.
A resident with a history of polysubstance use disorder ingested a marijuana edible gummy provided by a visitor, leading to an overdose event. The facility failed to implement safety measures or provide education to prevent the recurrence of consuming nonprescribed substances.
The facility failed to maintain oxygen equipment properly for two residents. One resident's oxygen concentrator filter was missing, while another's was covered in dust, contrary to facility policy. These issues were confirmed by an LPN and the Nursing Home Administrator.
A resident with atherosclerotic heart disease, dementia, and diabetes did not receive a pneumococcal vaccine despite having a signed consent form. The facility's policy requires offering the vaccine unless contraindicated, and obtaining consent after providing education. However, there was no documentation of the vaccine being administered, confirmed by the DON.
The facility was found to be non-compliant with regulatory space requirements for resident rooms. A single-bedded room measured only 85 square feet instead of the required 100 square feet. Additionally, eight two-bedded rooms were only 143 square feet each, failing to meet the 160 square feet requirement for semi-private rooms.
A facility failed to maintain accurate records of a resident's personal possessions upon admission and discharge. The inventory list for a resident, who was admitted and later discharged, included sixteen personal items but lacked signatures from the resident or their representative and a staff member. This was confirmed by the DON, highlighting a deficiency in the facility's process to protect residents' personal and property rights.
The facility failed to provide physician discharge summaries for three residents, missing final diagnoses and prognoses or causes of death. This was confirmed through record reviews and a DON interview.
The facility failed to meet the required nurse aide to resident ratios on multiple shifts, as mandated by the regulation effective July 1, 2024. Staffing records showed insufficient nurse aides on various dates, with no higher-level staff available to compensate. The director of nursing confirmed the deficiency during an interview.
The facility failed to meet the required LPN to resident ratios across multiple shifts, with 24 out of 63 shifts lacking adequate LPN staffing. On several occasions, the number of LPNs on duty was below the required levels for the day, evening, and night shifts based on the facility's census, with no additional higher-level staff available to compensate for these deficiencies.
The facility did not meet the required RN to resident ratio of 1:250 during the night shift on three occasions. On these dates, no RNs were on duty despite having a census of 32 and 33 residents. This was confirmed through staffing records and an interview with the DON, with no additional higher-level staff available to compensate.
The facility did not consistently provide the required 3.2 hours of direct nursing care per resident per day, as evidenced by staffing levels on a specific date showing only 3.01 hours per resident. This was confirmed by the DON during an interview.
A resident's prescribed medication was incorrectly prepared by an LPN, who pre-poured medications not prescribed for the resident. An RN identified the error and administered the correct medication. The facility's policy on medication administration was not followed, leading to an investigation into potential medication diversion, which was not substantiated. The LPN was terminated for failing to submit a statement.
The facility consistently failed to meet state-mandated nurse staffing levels, as identified in multiple surveys over a year. The deficiencies included not providing the required number of nurse aides, LPNs, and RNs per resident during various shifts, and failing to meet the minimum general nursing care hours per resident. These issues were confirmed by the Director of Nursing.
The facility failed to maintain a clean and safe environment, with surveyors observing dirt, debris, and unsanitary conditions in various areas, including resident rooms, bathrooms, and common areas. Mold-like substances, cracked tiles, and accumulations of dust were also noted. The DON confirmed the expectation for daily maintenance to ensure cleanliness.
The facility failed to maintain a clean environment and provide adequate clean bath linens. Observations showed dirty bathrooms, hallways, and resident rooms, with feces and debris present. Residents reported insufficient housekeeping staff and a lack of clean washcloths, leading some to purchase their own. Only two clean washcloths were available for 36 residents, as confirmed by staff.
A resident with severe cognitive impairment and a history of elopement risk was not provided with an individualized plan to manage dementia-related behaviors, leading to frequent wandering and aggression. The facility failed to assess the required supervision level and implement effective interventions, resulting in distress among other residents and staff.
A resident with hemiparesis and COPD, who is cognitively intact, expressed a desire to find housing closer to family. Despite a care plan that included making referrals and assisting with housing applications, there was no documented evidence of discharge planning after a certain date. Interviews confirmed the lack of documentation and communication with the resident regarding discharge plans.
Failure to Provide Adequate Meals and Snacks, Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide meals and snacks in accordance with resident needs, preferences, and requests, resulting in nutritionally inadequate meals for all residents. Surveyors found that the facility did not consistently provide bedtime snacks as required, and residents reported not receiving snacks for several months. The facility's policy required three meals daily and snacks, with no more than 14 hours between the evening meal and breakfast unless a nourishing bedtime snack was provided. However, there was no documentation to confirm that snacks were offered or that meals met nutritional and therapeutic requirements, especially for residents with special dietary needs such as pureed or gluten-free diets. During the survey, the kitchen's dishwasher and three-compartment sink were non-operational due to sanitation issues, and the facility was unable to provide the planned meals. Meals were served in disposable containers, and residents requiring texture-modified diets received commercial baby food with only about 100 calories per serving. There was no evidence that these substitute meals were nutritionally equivalent to the planned menu or met physician-ordered dietary restrictions. Additionally, the facility lacked a contingency plan for meal provision during dietary staff absences, and there was no qualified dietary staff present to prepare meals on the morning of the survey. Staffing challenges further contributed to the deficiency, as the facility had only one inexperienced cook on staff, and other staff members with limited food service experience were temporarily assigned to kitchen duties. The Registered Dietitian was working remotely and did not physically oversee the dietary program. Interviews with residents and staff confirmed that bedtime snacks were not consistently offered, and there was no process in place to ensure their provision. The lack of documentation, qualified staff, and oversight resulted in the failure to provide adequate nutrition and hydration to all residents, placing them in Immediate Jeopardy.
Improper Sanitization and Unsafe Food Handling in Dietary Department
Penalty
Summary
The facility failed to follow safe and sanitary food handling practices during the washing, sanitizing, and preparation of cooking equipment, dishware, tableware, and utensils in the kitchen. Observations revealed that the low-temperature dish machine and three-compartment sink were both in use, but critical components such as sanitizer test strips and chemical supply hoses were missing or disconnected. Staff were unable to provide documentation of required temperature and sanitizer concentration checks, and there was no evidence that these checks had been performed. The dishwashing machine was used without verification of proper sanitization, and the three-compartment sink lacked both detergent and sanitizer, rendering the sanitization step impossible. During meal preparation, a cook was observed handling dirty pots, raw and cooked food, and kitchen equipment without changing gloves or washing hands, moving between contaminated and clean tasks. The same sink compartment was used for rinsing soiled cookware and draining cooked vegetables without cleaning or disinfecting between uses. The cook also handled raw ground beef, spices, and prepared food without any hand hygiene or glove changes, and then served food to residents. Staff interviews confirmed a lack of training on sanitation processes, and employees were unaware of who was responsible for maintaining or testing chemical sanitizers for either the sink or the dishwashing machine. Environmental observations of the kitchen revealed unsanitary conditions, including dirty floors, debris under the sink, uncovered garbage cans near food preparation areas, and visibly soiled dishware and utensils. The ice machine was also found with heavy lint on its exterior filters. The Maintenance Director confirmed that sanitizer was not connected to the three-compartment sink and that chemical supply lines were disorganized and possibly dispensing the wrong chemicals. The facility was unable to provide maintenance records or documentation for the dishwashing machine, and the dietary staff had not been performing or documenting required sanitization checks. These failures resulted in the improper sanitization of food-contact surfaces and placed all residents at risk for foodborne illness.
Lack of On-Site Dietitian Oversight in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that a registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department. After the resignation of the full-time RD, the facility arranged for a part-time RD to provide services remotely for approximately 10 hours per week. This RD was not available during regular day shift hours and completed all dietary documentation and nutritional assessments remotely. The corporate RD also did not conduct on-site supervisory oversight, including staff training, direct observation of residents for nutritional assessments, or monitoring of meal services. A review of the RD's job description indicated that the position required on-site administrative duties, participation in facility surveys, and involvement in quality assurance programs, none of which were performed on-site after the full-time RD's resignation. The facility did not provide the necessary on-site oversight and consultation by a qualified dietitian or clinically qualified nutrition professional, as required by federal regulations, resulting in a deficiency related to the management and oversight of food and nutrition services.
Failure to Follow Planned Menus and Meet Specialized Dietary Needs
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned menus, resulting in residents not receiving food that met their nutritional needs and specialized dietary requirements. Observations revealed that residents on pureed and mechanical ground diets were served meals that did not match the planned menu items or prescribed diet textures. Specifically, residents requiring pureed diets received pureed ground beef instead of pureed pepper steak, pureed carrots, mashed potatoes, and gelatin without fruit, omitting required items such as pureed Texas toast and fruited gelatin. Similarly, residents on mechanical soft diets were served chopped fried ground beef, whole carrots, Texas toast, and plain gelatin, instead of the specified chopped pepper steak, chopped carrots, and gelatin with fruit. The preparation of these meals was not consistent with facility recipes or portion sizes, as the cook used unmeasured amounts of ingredients and substituted menu items without proper guidance. The Certified Dietary Manager (CDM) acknowledged discrepancies in portion sizes and substitutions, stating that she did not consult the Registered Dietitian (RD) due to his limited availability. The CDM also confirmed that the cook, who had only been employed for three weeks, did not follow facility recipes, and that there was insufficient beef steak and peppers available, leading to the use of ground beef as a substitute. Additionally, fruit was omitted from the gelatin dessert, contrary to the menu. A resident requiring a gluten-free diet was not provided with appropriate menu alternatives and was served standard menu items containing gluten. The CDM confirmed that there was no formal gluten-free menu and that the resident had to purchase her own gluten-free bread, with the facility only occasionally providing gluten-free pasta. The facility failed to follow planned menus and did not ensure that residents received meals in accordance with their prescribed dietary needs, as required by regulations.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe, palatable, and appetizing temperatures, as required by federal and state regulations. Multiple residents submitted concern forms over several weeks, reporting issues such as cold food, poor taste, unpalatable meals, small portion sizes, and late meal service. Observations during meal service revealed significant delays, with residents seated in the dining room for extended periods before receiving their meals. Test tray evaluations showed that hot foods were served below the required safe temperature, with items such as beef and vegetables measured at 124°F and 114.7°F, respectively, and gravy at 90°F. The food was also described as bland, tough, mushy, and difficult to chew. Interviews with residents and the Certified Dietary Manager confirmed ongoing dissatisfaction with food temperature, palatability, and timeliness, despite previous assurances from dietary staff that concerns would be addressed. The facility's posted meal schedule was not followed, resulting in further delays and contributing to the serving of food at unsafe and unappetizing temperatures. These findings were corroborated by direct observation, resident interviews, and review of concern forms, establishing a pattern of noncompliance with dietary service regulations.
Failure to Provide Required Written Notices for Facility-Initiated Transfers
Penalty
Summary
The facility failed to provide sufficiently detailed written notices of facility-initiated hospital transfers to a resident and the resident's representative. Specifically, for three separate hospital transfers involving the same resident, there was no evidence in the clinical record or facility documentation that written notices were given to either the resident or their representative. The required notices were missing key information, including the reason for the transfer, contact information for the Office of the State Long-Term Care Ombudsman, and, if applicable, contact information for the agency responsible for the protection and advocacy of individuals with developmental disabilities or mental illness. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility was unable to produce documentation showing that the required written notices had been provided for the transfers. The deficiency was identified through a review of clinical records, written notices, and staff interviews, and was found to be in violation of state regulations regarding resident rights and facility responsibilities.
Failure to Provide Written Bed-Hold Policy Notice to Resident's Guardian
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to the representative of a resident who was transferred to the hospital on multiple occasions. The resident in question was severely cognitively impaired, diagnosed with dementia, and had been legally declared incapacitated, with a court-appointed guardian responsible for medical and financial decisions. Although the facility's admission agreement included information about the bed-hold policy, there was no documented evidence that the guardian had reviewed or signed the agreement, nor that a copy of the policy was provided to the guardian upon admission. Additionally, the facility's policy stated that Medicaid would pay for a bed hold during hospitalization or therapeutic leave, but there was no documentation that this information was communicated in writing to the guardian at the time of any of the resident's hospital transfers. Interviews with facility staff revealed that the business office manager (BOM) was responsible for issuing bed-hold information, but the facility had not had a BOM for an extended period and could not provide employment dates for the previous BOM. The Nursing Home Administrator confirmed that no written notice of the bed-hold policy was issued to the resident's representative during the relevant hospital transfers. The lack of written notification meant the resident's guardian was not informed of the specifics of the bed-hold policy, including the duration, payment terms, or the right to return, as required by regulation.
Failure to Provide Bed-Hold Notice and Permit Return After Hospitalization
Penalty
Summary
The facility failed to implement and document required procedures regarding bed-hold policies and resident rights for a Medicaid-covered resident who was transferred to the hospital for behavioral concerns, including physical aggression toward staff. There was no evidence that the resident or their representative received a written notice of the facility's bed-hold or readmission policy at the time of transfer, nor any documentation indicating acceptance or declination of a bed hold. Despite the facility's policy allowing a 15-day bed hold for Medicaid residents, the clinical record lacked any indication that the resident was informed of their rights to return or that the facility planned for the resident's readmission. Following the resident's transfer, social service notes documented attempts to place the resident in other facilities, all of which declined. Hospital staff repeatedly requested the resident's readmission, but the facility's corporate admissions representative imposed conditions for return that were not part of the documented policy. There was no evidence of a clinical reassessment or evaluation of the facility's ability to meet the resident's needs, nor any transfer or discharge planning documents. The Nursing Home Administrator and Director of Nursing confirmed the decision not to readmit the resident due to safety concerns, but there was no formal documentation of a review of the facility's capacity to care for the resident upon potential return.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain a hazardous area enclosure, specifically in the Soiled Utility room, which affected one of three smoke compartments. During an observation on January 22, 2025, at 11:26 a.m., it was noted that there were two unsealed penetrations in the wall around two pipes. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:30 p.m.
Plan Of Correction
The soiled utility unsealed penetrations are being sealed. A facility wide audit was conducted, and no other unsealed penetrations were found. The maintenance director was re-educated to ensure all walls are free from penetration. The NHA or designee will conduct a one-time audit to ensure soiled utility rooms are free from any wall penetration. The results will be submitted to the QAPI committee for review and analysis of the need of ongoing monitoring.
Deficiency in Cooking Facility Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically regarding the maintenance of hood duct cleaning. During an observation on January 22, 2025, at 10:29 a.m., it was noted that the facility lacked documentation for the second semi-annual hood duct cleaning for the year 2024. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:30 p.m. The deficiency affected one of the two floors in the facility.
Plan Of Correction
1. Facility cannot retroactively go back on second hood cleaning. 2. Beach lake sprinklers are contracted to do our hood cleaning. A calendar will be created to oversee hood cleaning from maintenance director. 3. Maintenance director was reeducated on the importance of hood cleaning. 4. Biannual audit will be done to make sure hood cleaning is performed. The results will be submitted to the QAPI committee for review and analysis of the need of ongoing monitoring.
Improper Installation of ABHR Dispensers Over Electrical Sources
Penalty
Summary
The facility failed to comply with the NFPA 101 standards for the installation of Alcohol Based Hand Rub Dispensers (ABHR) in two resident rooms, affecting one of two floors. During an observation on January 22, 2025, it was noted that ABHR dispensers were improperly installed over electrical wall-mounted lights in Resident Room 12 and Resident Room 9. This installation does not meet the requirement that dispensers should not be installed within 1 inch of an ignition source. The deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
1. The hand sanitizers were moved away from an electrical mounted light in rooms 9 and 12. 2. Whole house audit of ABHR dispensers done for the facility to ensure that they are not found over electrical outlets. 3. The maintenance director was reeducated on the importance of moving ABHR dispensers away from electrical outlets. 4. NHA or designee will perform monthly audits to ensure no new dispensers are installed in accordance with NFPA 101 standards.
Failure to Maintain Sprinkler System Documentation
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, affecting the entire facility. During an observation on January 22, 2025, at 11:10 a.m., it was found that the facility could not provide documentation for sample testing data or the replacement of sprinklers that had been in service for 50 years. The sprinkler report indicated that sprinkler heads dated back to 1974 and 1975 were still in use throughout the facility. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:30 p.m., where they acknowledged the lack of documentation for the required 50-year sample testing or replacement.
Plan Of Correction
1. NHA and Maintenance Director could not retroactively complete the sample testing for the sprinklers. 2. The whole house audit was done of the sprinkler system to identify which heads are from 1974 and 1975. 3. The maintenance director was reeducated on the importance of sprinkler testing/ Replacement of sprinkler heads every 50 years. Sprinkler heads are being replaced when they hit the 50-year mark. 4. A one-time audit was completed of sprinkler heads due for replacement to make sure replacement was completed. The results will be submitted to the QAPI committee for review and analysis of the need of ongoing monitoring.
Failure to Maintain Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to maintain monthly inspections of portable fire extinguishers in four specific locations, affecting both floors of the building. During an observation on January 22, 2025, it was noted that the 'K' extinguisher in the kitchen had not been inspected since May 2024. Additionally, the portable fire extinguishers in the basement level, specifically in the laundry, maintenance shop, and boiler room, had not been inspected since October 2024 and August 2024, respectively. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
1. The maintenance director could not retroactively do monthly fire extinguisher inspections. 2. A facility wide audit of fire extinguishers was completed and updated. 3. The Maintenance Director was re-educated on the maintenance of portable fire extinguishers. 4. NHA or designee will do a whole house monthly audit x 3 months of fire extinguisher testing.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the emergency generator that serves the entire center, as evidenced by a deficiency found during a document review and interview. On January 22, 2025, an observation revealed that the 4-hour load bank test documents dated May 31, 2024, indicated the generator shut off when the temperature reached 180 degrees due to a low coolant sensor failure. The documents noted that the generator's 4-hour load bank was completed using 2/0 pigtails and mentioned that the low coolant sensor would be replaced. However, the facility was unable to provide documentation confirming that the sensor had been replaced. This lack of documentation was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on January 22, 2025. The absence of proper maintenance records and the failure to replace the faulty sensor led to the deficiency being cited.
Plan Of Correction
1. There was no negative effect or loss of generator power. 2. Genserve will be performing 4-hour load bank testing annually and was out to facility on 1/31 for service. Part was ordered awaiting installation date based off part available. 3. Maintenance director reeducated on importance of generator service and upkeep. 4. The maintenance director will conduct random audits that generator is fully functional.
Exposed Wiring in Soiled Utility Room
Penalty
Summary
The facility failed to maintain the electrical systems in one of its smoke compartments. During an observation on January 22, 2025, at 11:25 a.m., it was noted that the Soiled Utility room had a missing light switch cover plate, which exposed the wiring within the room. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:30 p.m.
Plan Of Correction
1. The light switch cover was replaced. 2. There are no missing light covers found in the facility. 3. The Maintenance Director was re-educated on maintaining electrical wiring and equipment. 4. The NHA conducted a onetime audit to ensure the soiled utility was free from exposed wiring. The results will be submitted to the QAPI committee for review and analysis of need for ongoing monitoring.
Corridor Door Deficiency in Smoke Compartment
Penalty
Summary
The facility failed to maintain a corridor opening in compliance with NFPA 101 standards, specifically affecting one of three smoke compartments. During an observation on January 22, 2025, it was noted that the door to Resident Room 9 was getting stuck on the flooring, which required excessive force to close. This issue was identified as a deficiency because it impeded the proper functioning of the door, which is required to resist the passage of smoke and close without impediment. The deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day. The report highlights that the door's inability to close properly could potentially compromise the safety measures intended to protect residents from smoke in the event of a fire. The report does not provide any additional information about the resident(s) involved or their condition at the time of the deficiency.
Plan Of Correction
1. The room 9 door was adjusted to fully latch. 2. A facility wide audit was conducted and no other doors in need of adjustment were identified. 3. The maintenance director was re-educated on ensuring all doors fully latch. 4. The NHA or designee will conduct a one-time audit to ensure room 9 positively latches. The results will be submitted to the QAPI committee for review and analysis of need of ongoing monitoring.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct two out of twelve required fire drills, specifically missing the 3rd shift drills for the 3rd and 4th quarters of 2024. This deficiency was identified during a documentation review and interview process. The absence of documentation for these fire drills was observed on January 22, 2025, at 9:40 a.m., and was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day at 12:30 p.m. This failure affected both floors of the facility, indicating a lapse in compliance with the NFPA 101 fire drill requirements, which mandate quarterly drills on each shift under varying conditions.
Plan Of Correction
1. NHA and Maintenance Director could not retroactively complete the missed annual fire drills. 2. NHA and the Director of Maintenance were re-educated on the importance of completing scheduled annual fire drills. 3. NHA and the Maintenance Director created a new schedule for fire drills to ensure they happen monthly on each shift (12 per year). 4. NHA will perform monthly audits to ensure one fire drill was performed that month.
Deficient Headroom in Basement Exit Corridor
Penalty
Summary
The facility was found to have a deficiency in providing acceptable exits on one of its two levels. During an observation on January 22, 2025, at 11:45 a.m., it was noted that the basement-level exit access corridor, which is used exclusively by staff, did not meet the required headroom clearance of six feet eight inches. This was due to the presence of sprinkler piping and sprinkler heads that reduced the available headroom. The deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 12:30 p.m.
Plan Of Correction
1. The facility cannot retroactive more headroom in the basement. 2. The facility will submit for an FSES exemption. 3. The maintenance director was reeducated on headspace requirements and means of egress. 4. Random audits will be done to make sure nothing is stored or placed too close to ceilings. The results will be submitted to the QAPI committee for review and analysis of need of ongoing monitoring.
Inadequate Nutritional Oversight Due to Staffing Deficiencies
Penalty
Summary
The facility failed to employ sufficient staff with the necessary competencies and skills to ensure appropriate nutritional oversight for residents. The full-time Director of Food and Nutrition Services (FSD) was not a qualified dietitian or clinically qualified nutrition professional and did not receive frequent consultations from a qualified dietitian. The facility's assessment did not indicate the necessity of a qualified dietitian to meet the nutritional needs of the residents, which is a requirement under federal regulations. The FSD, who is a Certified Dietary Manager, confirmed that she does not meet the minimum qualifications to be a qualified dietitian. Although the facility employs a part-time registered dietitian (RD) who works remotely, the FSD's interactions with the RD were limited to email and telephone communications. The FSD attended care plan meetings and documented residents' food preferences, but her scope of practice did not include clinical assessment and evaluation for medically related nutritional therapy. The part-time RD confirmed that she completes all job tasks remotely and does not conduct on-site consultations or oversight. She relies on input from the interdisciplinary team, including the FSD, to complete nutritional assessments. The RD has not been in the facility to observe residents' eating abilities or provide direct nutritional consultation, which limits her ability to fulfill her responsibilities effectively. The nursing home administrator could not provide documentation confirming the RD's on-site consultation or oversight role.
Plan Of Correction
1. A RD was hired to provide 10 hours/week of onsite dietary support and evaluation. 2. The facility will maintain an onsite RD. 3. The recruiter was re-educated on ensuring that an onsite RD was available to the facility for at least 10 hours/week. The NHA will report open positions to the recruitment department. 4. The NHA or designee will conduct an audit of RD onsite hours weekly x 4 weeks then monthly x 2 months to ensure onsite support is provided. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Facility Fails to Conduct Comprehensive Assessment and Ensure Qualified Dietitian On-Site
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources to care for its residents competently during both day-to-day operations and emergencies. The assessment did not include specific information about the facility's population, the resources required, or the current staff employed to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. The Centers for Medicare and Medicaid Services Memorandum requires that the facility assessment include an evaluation of diseases, conditions, and limitations of the resident population, which should inform staffing decisions and the skills and competencies staff must possess. The review of the facility's Resident Matrix identified a resident receiving enteral feeding who would require the services of a qualified dietitian. However, the facility's full-time foodservice director, who is a Certified Dietary Manager, does not meet the qualifications to be a qualified dietitian. The facility employs a part-time registered dietitian who works remotely, completing nutritional assessments and progress notes offsite without face-to-face interaction with residents. This lack of a comprehensive assessment and the absence of a qualified dietitian on-site have the potential to negatively affect the quality of care and quality of life for all residents.
Plan Of Correction
1. The Facility Assessment was updated to reflect the current resident population and needs. 2. The Facility Assessment will be reviewed at least quarterly and PRN. 3. The facility's IDT were re-educated on completion of the Facility Assessment to accurately reflect the current resident population and needs. The NHA will ensure regular updates. 4. The NHA will conduct an audit of the Facility Assessment monthly x 6 months to ensure accuracy. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Medication Administration Errors for a Resident
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses accurately administered prescribed medication for one of the sampled residents. Specifically, Resident 29, who was admitted with diagnoses including atherosclerotic heart disease, hypertension, and dementia with mild psychotic disturbance, was prescribed Amlodipine Besylate to manage hypertension. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was less than 60. Upon review of the Medication Administration Record (MAR) for November 2024 through January 2025, it was found that the medication was administered 19 times outside of the prescribed parameters. On several occasions, the medication was given without documenting the resident's blood pressure or heart rate, and on other occasions, it was administered despite the resident's vital signs being below the specified thresholds. The Director of Nursing confirmed that the nursing staff failed to adhere to acceptable standards of nursing practice during medication administration, resulting in multiple medication errors.
Plan Of Correction
1. Resident 29 was assessed and there were no adverse effects noted. MD/RP aware. 2. 14 days look back was completed to ensure medications with orders for parameters were followed. 3. Licensed Nursing staff were re-educated on the Medication Administration policy with a focus on medication parameters. The DON will complete spot checks of medications with parameters in the orders to ensure parameters are followed. 4. The DON or designee will conduct an audit of medications with parameters weekly x 4 weeks then monthly x 2 months to ensure parameters are followed. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately assess, evaluate, and monitor the nutritional needs of three residents, leading to significant weight loss and inadequate nutritional interventions. Resident 18, diagnosed with Huntington's disease and oropharyngeal dysphagia, experienced a weight loss from 129.7 pounds in July 2024 to 114 pounds by January 2025. Despite the significant weight loss and the resident's high aspiration risk, the facility did not obtain timely weights or update the care plan following the implementation of enteral feeding. The registered dietitian did not evaluate the resident's nutritional requirements or update the care plan, and the facility lacked an on-site dietitian, relying instead on a part-time remote dietitian. Resident 12, admitted with a diagnosis of cerebral infarction, experienced a 6.8-pound weight loss between December 2024 and January 2025. The facility failed to obtain a reweight within the required 72-hour timeframe, and the reweight was only obtained 14 days late following surveyor inquiry. The Director of Nursing confirmed that the reweight was not timely obtained, indicating a lapse in the facility's adherence to its own policies regarding weight monitoring and nutritional assessment. Resident 29, with diagnoses including atherosclerotic heart disease, hypertension, and dementia, experienced significant weight loss from 140.2 pounds in June 2024 to 127.4 pounds by September 2024. The facility did not conduct a reweight within the required timeframe, nor did it notify the physician, dietitian, or interdisciplinary team of the significant weight change. There was no evidence of updated nutritional assessments or individualized interventions between the resident's admission in October 2023 and September 2024. The Director of Nursing confirmed the facility's failure to obtain and record reweights and to notify the necessary parties of the resident's significant weight loss, impacting the ability to accurately assess and address the resident's nutritional needs.
Plan Of Correction
1. Residents 12, 18 and 29 have been weighed. A nutritional assessment will be completed and their care plans updated. 2. The facility has hired an RD for 10 hrs/week to provide onsite support. 3. The licensed staff were re-educated on the Weight/Re weight policy. The RD was re-educated on the importance of completing nutritional assessments timely and updating the care plans as needed. 4. The RD/Designee will audit resident weights to ensure resident weights are obtained per policy. The Registered Dietician will be notified of any weight changes that are of concern. The results of the audits will be reviewed at QAPI for review and analysis of ongoing education.
Failure to Prevent Ingestion of Illegal Substance
Penalty
Summary
The facility failed to implement effective safety measures to prevent a resident from ingesting an illegal substance. Resident 25, who has a history of schizoaffective disorder, bipolar type, chronic pain, and polysubstance use disorder, was admitted to the facility and was cognitively intact with a BIMS score of 15. On December 9, 2024, the resident exhibited symptoms such as slurred speech and tremors, which worsened by the early hours of December 10, 2024, leading to a transfer to the emergency room. It was discovered that a visitor had given the resident a marijuana edible gummy, resulting in an overdose event. The resident's care plan did not include interventions or a plan to prevent the recurrence of consuming nonprescribed medications. Additionally, there was no documentation of education provided to the resident regarding the risks of ingesting nonprescribed substances. The Director of Nursing confirmed that no interventions or educational measures had been implemented to prevent the resident from being provided with or consuming nonprescribed medications.
Plan Of Correction
1. Resident 25 was educated on risks of consumption of non-prescription medications and care plan was updated with interventions to prevent recurrence. 2. New admissions will be educated on risks of consumption of non-prescription medications. The outside medication policy was revised to include illegal substances that are prohibited from entrance to the facility. This policy will be sent to all residents and responsible parties to ensure compliance. 3. Licensed Nursing staff were re-educated on providing risk education to residents following non-compliant episodes and applying effective interventions to care plans post incident, as well as the changes and revisions to the new outside medication policy. The DON will review incident reports for effective intervention implementation and education. 4. The DON or designee will conduct an audit of incidents weekly for 4 weeks, then monthly for 2 months to ensure effective interventions are care planned and necessary education is completed. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Oxygen Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to maintain oxygen equipment in a functional and sanitary manner for two residents. Resident 13, who was admitted with chronic obstructive pulmonary disease (COPD) and hypertension, had a physician's order for oxygen therapy at 4.0 liters per minute. An observation revealed that the oxygen concentrator filter was missing from the unit, which was confirmed by a licensed practical nurse (LPN) and the Nursing Home Administrator. Resident 24, diagnosed with moderate persistent asthma and dependent on supplemental oxygen, had a physician's order for oxygen therapy at 2.0 liters per minute as needed. During an observation, the oxygen concentrator filter was found to be visibly covered in dust. This condition was also confirmed by the LPN and the Nursing Home Administrator, indicating non-compliance with the facility's policy for maintaining oxygen delivery equipment.
Plan Of Correction
1. Resident 13 and 24's oxygen concentrator filters are clean and in place. 2. An oxygen concentrator audit was completed to ensure filters are clean and in place. 3. Licensed Nursing staff were re-educated on the Maintenance of Oxygen Delivery policy. The Infection Control Nurse will complete weekly audits of oxygen concentrators to ensure compliance. 4. The Infection Control Nurse or designee will conduct an audit of oxygen concentrators weekly x 4 weeks then monthly x 2 months to ensure appropriate maintenance. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and/or provide the pneumococcal immunization to a resident, despite having a signed consent form. The facility's policy, last reviewed on September 16, 2024, mandates that each resident should be offered a pneumococcal immunization unless it is medically contraindicated. Additionally, nursing staff are required to provide educational information to the resident or their authorized representative before administering the vaccine, and a signed consent form must be obtained. In this case, Resident 29, who was admitted with diagnoses including atherosclerotic heart disease, dementia, and diabetes, had a signed consent form dated July 18, 2024, indicating permission for the pneumococcal vaccine. However, upon review of Resident 29's clinical record, there was no documented evidence that the pneumococcal vaccine was administered as per the signed consent. This deficiency was confirmed during an interview with the Director of Nursing on January 16, 2025. The failure to administer the vaccine as requested is a violation of several Pennsylvania codes related to the responsibility of the licensee, management, medical records, and resident care policies.
Plan Of Correction
1. Resident 29 was administered a PNA vaccination. 2. A facility wide audit was completed to ensure residents that want the PNA vaccination were offered it and received it. 3. The Infection Control Nurse was re-educated on ensuring PNA vaccinations are administered to residents wanting them. The DON will complete random vaccination administration audits to ensure that they are administered per resident preference. 4. The DON or designee will conduct an audit of new admissions weekly x 4 weeks then monthly x 2 months to ensure those that want the PNA vaccination receive it timely. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Deficiency in Resident Room Square Footage
Penalty
Summary
The facility failed to meet the regulatory requirements for minimum square footage in resident rooms, as observed on January 14, 2025. Specifically, one single-bedded resident room measured only 85 square feet, falling short of the required 100 square feet. Additionally, eight two-bedded resident rooms were found to have only 143 square feet each, which does not meet the minimum requirement of 160 square feet for semi-private rooms. These deficiencies were identified in rooms 15, 16, 17, 18, 19, 20, 21, and 23, indicating a significant shortfall in compliance with the space requirements outlined in CFR 483.90(d)(1)(ii) and 28 Pa. Code: 205.20 (d)(f).
Plan Of Correction
This situation poses no threat to the safety or well-being of the residents in these rooms; therefore, the facility has requested a waiver continuation of 42CFR 428.70 (d) (1) (ii) by previously submitted letter. Please note that the facility meets the variation in square footage requirements adopted by the Commonwealth of Pennsylvania at 28 PA Code section 205.20 € and 205.30 (g). The facility is selective in room placement and considers residents' needs and safety when assigning rooms. This facility remains committed to assuring the special needs of the residents in these rooms are met to ensure that their health and safety are not adversely affected. If a resident or family member requests a room change, the facility makes every effort to place the resident in a different room. NHA or designee will discuss room change requests at the Interdisciplinary Team meeting. NHA or designee will audit resident Council meeting minutes to ensure concerns regarding room placement are addressed monthly x 6 months. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.
Failure to Maintain Accurate Inventory Records
Penalty
Summary
The facility failed to maintain a complete and accurate record of a resident's personal possessions upon admission and discharge. This deficiency was identified for one resident out of three sampled, specifically Resident 187. Upon review of the clinical records, it was found that the inventory list for Resident 187, who was admitted on October 23, 2024, and discharged on November 24, 2024, included sixteen personal items. However, the inventory list lacked the necessary signatures from the resident or their responsible party, as well as from a staff member, both at the time of admission and discharge. An interview with the Director of Nursing on January 16, 2025, confirmed the absence of these signatures, indicating a failure in the facility's process to ensure the protection of personal and property rights of residents, as required by the regulation.
Plan Of Correction
1. Resident 187 has discharged from the facility. 2. A facility wide audit of Inventory Sheets was conducted to ensure accuracy and appropriate signatures. 3. Licensed Nurses were re-educated on completing a Resident Inventory Sheet with signature on admission and discharge. The Administrative Assistant will complete random chart checks to ensure completion. 4. The NHA or designee will complete a resident inventory sheet audit weekly x 4 weeks and monthly x 2 months of resident admissions and discharges to ensure accuracy and appropriate signatures. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Missing Physician Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to ensure that a discharge summary, including the physician's final diagnosis and prognosis or cause of death, was completed for three discharged residents. This deficiency was identified during a review of closed clinical records and confirmed through a staff interview. Specifically, the records of three residents who were either discharged or expired at the facility lacked the required physician's discharge summary. Resident 35 was admitted to the facility and expired there, yet their record did not contain a discharge summary with the final diagnosis and cause of death. Similarly, Resident 187, who was discharged from the facility, and Resident 34, who was also discharged, both had records missing the physician's discharge summary with the final diagnosis and prognosis. The Director of Nursing confirmed the absence of these summaries during an interview.
Plan Of Correction
1. Residents 34, 35 and 187 had physician discharge summaries completed. 2. A 30 day look back was completed and physician discharge summaries were completed. 3. The DON was re-educated on ensuring physician discharge summaries are completed on discharge. The Administrative Assistant will complete discharge chart audits to ensure completion. 4. The NHA or designee will conduct an audit of discharged resident charts weekly x 4 weeks then monthly x 2 months to ensure completion of the physician discharge summary. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on 23 out of 63 shifts reviewed. The regulation, effective July 1, 2024, mandates a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. However, the facility's staffing records revealed multiple instances where the number of nurse aides was insufficient according to the census. For example, on December 22, 2024, there were only 2.13 nurse aides on the night shift, whereas 2.40 were required for a census of 36. Similar deficiencies were noted on various dates across day, evening, and night shifts. The director of nursing confirmed during an interview that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the staffing deficiencies. This lack of adequate staffing was consistent across several shifts, indicating a systemic issue in maintaining the required staffing levels as per the regulation.
Plan Of Correction
1. The Facility is unable to retroactively provide a minimum CNA ratio for cited days. 2. A facility wide audit was completed to ensure ratios were met. Recruitment initiatives were increased, and wages remain competitive for the area. 3. The DON and recruitment were reeducated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting CNAs. The DON will review census and schedule daily to ensure adequate staffing. 4. The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI committee for review and analysis of need on an ongoing basis.
LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum LPN staffing levels on 24 out of 63 shifts reviewed. The deficiency was noted on various dates, including December 24, 2024, through January 13, 2025, where the number of LPNs on duty was consistently below the required ratios for the day, evening, and night shifts based on the facility's census. For instance, on December 24, 2024, the facility had only 1 LPN on the day shift when 1.36 were required for a census of 34 residents. Similarly, on January 1, 2025, the night shift had only 0.25 LPNs when 1 was required for a census of 33 residents. The report indicates that no additional higher-level staff were available to compensate for these deficiencies, highlighting a consistent shortfall in meeting the regulatory staffing requirements.
Plan Of Correction
1. The facility is unable to retroactively provide a minimum LPN ratio for cited dates. 2. A wide audit of the facility was completed to ensure ratios were met. Recruitment initiatives were increased, LPN sign on bonuses, and wages are competitive with surrounding areas. 3. The DON and Recruitment were re-educated on ensuring that nursing care ratios are provided, and that the facility is actively recruiting LPNs. The DON will review census and schedule daily to ensure adequate staffing of LPN's. 4. The DON or designee will conduct an audit of the nursing care ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Failure to Meet RN Staffing Ratios on Night Shifts
Penalty
Summary
The facility failed to meet the required Registered Nurse (RN) to resident ratio of 1 RN per 250 residents during the night shift on three occasions. Specifically, on December 26, 2024, December 31, 2024, and January 2, 2025, the facility had no RNs on duty during the night shift, despite having a census of 32 and 33 residents, respectively. This deficiency was confirmed through a review of the facility's weekly staffing records and an interview with the Director of Nursing on January 16, 2025. No additional higher-level staff were available to compensate for this deficiency on the mentioned dates.
Plan Of Correction
1. The facility is unable to retroactively provide minimum registered nurse ratio for cited dates. 2. A facility wide audit was completed to ensure ratios were met. Recruitment increased, RN sign on bonuses, and wages are competitive with surrounding areas. 3. The DON was re-educated on ensuring that the nursing care ratios are provided, and that the facility is actively recruiting RNs. The DON will review census and schedule daily to ensure adequate staffing of RN's each day. 4. The DON or designee will conduct an audit of the registered nurse ratios to ensure it is provided weekly x4 weeks then monthly x 2 months. The results will be submitted to the QAPI Committee for review and analysis of need of ongoing monitoring.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of the facility's staffing levels indicated that on January 12, 2025, the facility provided only 3.01 hours of direct care nursing per resident, which is below the mandated minimum. This deficiency was confirmed during an interview with the Director of Nursing on January 16, 2025, who acknowledged the failure to meet the required nursing care hours consistently.
Plan Of Correction
1. The facility is unable to retroactively correct PPD for dates cited. 2. A facility wide audit was completed to ensure the minimum PPD of 3.2 hours are met daily for each resident. 3. The DON/Designee were reeducated on the total number of hours of general nursing care provided in each 24-hour period be a minimum of 3.2 hours. The DON will review the census daily to ensure 3.2 hours of nursing care are being provided within a 24-hour period. If staffing levels are not being met, DON will instruct the scheduler to adjust the schedule by filling any gaps with per diem staff. The facility continues all effort to recruit and hire licensed staff. 4. The DON/Designee will conduct an audit of daily staffing sheets weekly x 4 weeks and then monthly x 2 months to ensure facility meets the minimum daily 3.2 nursing hours for each resident. The results will be submitted to the QAPI committee for review and analysis of need of ongoing monitoring.
Medication Administration Deficiency Due to Incompetency
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to accurately prepare and administer prescribed medications to residents. This deficiency was identified during a review of employee personnel files, facility policy, and interviews with facility staff. Specifically, the issue involved a resident who was prescribed oxycodone for pain management. The resident's medications were incorrectly prepared by an LPN, who pre-poured medications that were not prescribed for the resident, including Bactrim and Glipizide, instead of the prescribed oxycodone. The incident occurred when the LPN, due to a previous negative interaction with the resident, asked an RN to administer the pre-poured medications. Upon review, the RN noticed the discrepancy and did not administer the incorrect medications. Instead, the RN obtained the correct medication from the facility's emergency medication box and administered it as prescribed. The facility's investigation revealed that the narcotic medications were accounted for without discrepancies, and drug screenings for both involved staff were negative. The facility's policy on medication administration was not followed, as medications were pre-poured and not administered by the person who prepared them. This led to an investigation into potential medication diversion, although it was not substantiated. The LPN involved failed to submit a statement and was subsequently terminated. The facility's failure to ensure that nursing staff demonstrated the competencies and skills to accurately administer medications was confirmed by the Nursing Home Administrator and Director of Nursing.
Repeated Non-Compliance with Nurse Staffing Regulations
Penalty
Summary
The facility has repeatedly failed to comply with state regulations regarding minimum nurse staffing levels as outlined in the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations. The deficiencies were identified through multiple surveys conducted by the State Survey Agency over the course of a year. These surveys revealed that the facility did not meet the required staffing ratios for nurse aides, LPNs, and RNs across various shifts. Specifically, the facility failed to provide the mandated number of nurse aides per resident during day, evening, and night shifts, as well as the required number of LPNs and RNs per resident during all shifts. The surveys conducted on several dates, including July 5, 2023, September 7, 2023, October 26, 2023, December 28, 2023, February 29, 2024, May 15, 2024, and July 23, 2024, consistently found that the facility did not meet the minimum staffing requirements. For instance, on multiple occasions, the facility failed to provide a minimum of 1 nurse aide per 12 residents during the day and evening shifts, and 1 nurse aide per 20 residents during the night shift. Similarly, the facility did not meet the required LPN and RN staffing ratios, failing to provide 1 LPN per 25 residents during the day shift, 1 LPN per 30 residents during the evening shift, and 1 LPN per 40 residents during the night shift, as well as 1 RN per 250 residents during all shifts. Additionally, the facility did not provide the minimum number of general nursing care hours required per resident in a 24-hour period. The surveys documented that the facility failed to meet the minimum of 2.87 hours of direct resident care per resident, which increased to 3.2 hours as of July 2024. These deficiencies were confirmed by the Director of Nursing during an interview, acknowledging the facility's non-compliance with the state licensure regulations for over a year.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations of unsanitary conditions. On July 23, 2024, surveyors observed dirt and debris on the floors throughout the hallway of the south side nursing unit. In the common resident bathroom, hair and a dried yellow-urine like substance were found on the toilet. In one resident room, dried feces were observed on the toilet and toilet seat, along with dirt and debris on the bathroom floor. Another resident room had dirt, debris, and a dried red substance on the floor, with streaks on the wall next to the door. Additional observations included dried stain streaks on the wall next to a resident's dresser, with an accumulation of dust and dirt stuck to these streaks. Further observations revealed a black and brown mold-like substance coating the caulking in the resident shower room on the north hall. In another resident room, a dried brown substance and food crumbs were scattered on the floor, with black streaks and dried fecal-like brown spots on the toilet seat. The resident shower room in the middle hall had cracked floor tiles, and another resident room had dried liquid spots on the floor and dried brown drips on the wall. An accumulation of dust and dirt was also observed behind the ice machine in the resident dining room. The Director of Nursing confirmed that the facility is expected to be maintained daily to ensure a clean and sanitary environment for residents.
Inadequate Housekeeping and Linen Supply in LTC Facility
Penalty
Summary
The facility failed to maintain a clean and orderly environment and ensure the availability of clean bath linens for residents. Observations and interviews revealed that the facility's housekeeping services were inadequate, particularly when the part-time housekeeper was not working. Residents reported dirty bathrooms and hallways, with one resident expressing frustration over shared bathroom conditions, including feces on the toilet and floor. During a facility tour, the resident shower room was found with soiled items, debris, and discolored caulking, while hallways and resident rooms had dirt, debris, and stains. Dead insects and debris were also observed under a light fixture. Additionally, the facility was unable to provide sufficient clean washcloths and towels for residents. Interviews with residents and staff confirmed that the facility often ran out of these essential items, leading some residents to purchase their own. Observations in the clean linen rooms and laundry room revealed a severe shortage of clean washcloths, with only two available for 36 residents. The Nursing Home Administrator acknowledged the facility's responsibility to maintain a clean environment and adequate supplies of clean bath linens.
Failure to Manage Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the safety and well-being of the resident and others. Resident 26, who was admitted with severe cognitive impairment and a history of elopement risk, required one-to-one supervision according to prior hospital documentation. However, the facility did not assess the level of supervision needed or implement effective interventions to manage the resident's wandering and aggressive behaviors. The care plan for Resident 26 included interventions such as offering diversions, structured activities, and psychiatric consultations, but these were not individualized or effectively implemented. The resident frequently wandered into other residents' rooms, causing distress and fear among them. Despite being redirectable at times, the resident exhibited verbal and physical aggression towards staff and other residents, including making inappropriate comments and physical threats. The facility's failure to maintain a stop sign across a resident's doorway, which was a temporary measure to prevent Resident 26 from entering, further exemplified the lack of effective interventions. The Director of Nursing and Nursing Home Administrator confirmed the absence of an individualized plan and the lack of assessment for the required supervision level, acknowledging the ongoing issues with Resident 26's behavior.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for Resident 22, who was admitted with diagnoses including hemiparesis and COPD. The resident, who is cognitively intact, expressed a desire to find housing in the community and be closer to family. The care plan included interventions such as making referrals and assisting with housing applications. However, after April 4, 2024, there was no documented evidence of discharge planning or status updates for the resident's desired transfer. Interviews revealed that Resident 22 had been trying to discuss discharge plans with social services staff but had not been met with since April 4, 2024. The Director of Social Services and the Nursing Home Administrator confirmed the lack of documentation for discharge planning from April 4, 2024, to the survey date. This deficiency was noted under 28 Pa. Code 201.29 (a) Resident rights and 28 Pa. Code 211.16 (a)(1) Social services.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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