Lancaster Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Pennsylvania.
- Location
- 900 East King Street, Lancaster, Pennsylvania 17602
- CMS Provider Number
- 395774
- Inspections on file
- 37
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Lancaster Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple complex conditions, including anoxic brain damage, respiratory failure, malnutrition, and tracheostomy status, had physician orders for continuous Glucerna 1.5 via PEG tube at 60 ml/hr with a total daily volume of 1320 ml and hourly 40 ml water flushes. Surveyors found no MAR documentation of enteral feeding or medications for one dayshift, observed the feeding pump beeping with an empty Glucerna bottle, and noted that an RN restarted the feeding and hydration but set the pump total volume to 1667 ml instead of the ordered 1320 ml. Review of MARs and task forms for two months showed no evidence the resident consistently received the ordered total daily volume of formula or the prescribed hydration flushes, and facility leadership confirmed the lack of documentation.
The facility failed to maintain a sanitary and homelike environment on multiple units, where surveyors observed live and dead roaches in several shower rooms, a lobby area, and on shower curtains. A resident reported previously finding live roaches in their bed and stated this had been reported to Maintenance weeks earlier. Exterminator service reports documented repeated calls for roach activity in spa rooms, resident rooms, and staff areas over several weeks, and leadership reported having a standing contract with an exterminating company and a ticketing system for staff to request pest control services.
A resident with unstageable pressure ulcers on both heels did not receive prescribed wound care on one occasion, as documented in clinical records and confirmed by staff interview. The missed treatment was attributed to workflow issues, resulting in noncompliance with physician orders.
A resident with severe cognitive impairment who required assistance with personal hygiene was found to have long, thick, and curled toenails, with no record of toenail care provided. Staff could not confirm when foot care was last given, and the resident had not been seen by a podiatrist since admission, as no follow-up was made after sending a permission form to the guardian.
Two cognitively intact residents reported that their mail was opened without their consent, with one envelope showing a date stamp and initials. The NHA confirmed that the Business Office had opened residents' mail, violating their right to privacy and confidentiality.
A resident who required assistance with activities of daily living did not receive showers as ordered by the physician, with documentation missing for showers after a certain date. Staff interviews suggested a shower was provided, but no records supported this, and the DON confirmed the lack of documentation.
Surveyors found that multiple insulin pens, vials, and a Lidocaine vial were opened and undated on several medication carts, contrary to facility policy and manufacturer guidelines. LPNs confirmed these medications should have been dated when opened, and unidentified loose tablets were also found in a medication cup. The facility did not maintain proper storage and labeling of medications and biologicals.
The facility did not consistently monitor or document resident weights as required, resulting in missed or delayed identification and confirmation of significant weight changes for multiple residents. In several cases, significant weight losses were not promptly rechecked, and monthly weights were not recorded as ordered, despite facility policy and staff acknowledgment of the required procedures.
A resident with multiple chronic conditions received PRN Hydromorphone without the use of a pain scale as recommended by the consultant pharmacist and agreed to by the nurse practitioner. Documentation also failed to show that non-pharmaceutical interventions were attempted before administering the narcotic, and the medication was given for a range of pain levels, including when pain was recorded as zero.
Staff failed to follow infection control protocols during medication administration and meal service. A licensed staff member gave a resident a pill that had fallen onto a tray table by picking it up with bare hands and without hand hygiene. In a separate incident, a non-licensed staff member handed a piece of bread directly to a resident without performing hand hygiene or cleaning the resident's hands, and then continued to serve other residents without hand hygiene.
A resident with quadriplegia and total dependence on staff for transfers reported that staff would enter his room, turn off his call bell, and leave without providing assistance. Documentation showed the resident repeatedly requested help to get out of bed but was told delays were due to CNA training, and the NHA confirmed these findings.
A resident with dementia, anxiety, heart failure, and atrial fibrillation on anticoagulant therapy experienced an unwitnessed fall resulting in a facial bruise. The facility did not provide timely notification to the physician as required by policy, and the nurse practitioner only learned of the incident the following day after observing the injury. Documentation of timely notification was lacking, leading to a deficiency in communication and adherence to regulatory requirements.
A resident with moderate cognitive impairment and a traumatic brain injury was not afforded dignity during breakfast when a non-licensed staff member used bare hands to hand food directly to the resident while distributing meal trays in the hallway.
A resident's room was not cleaned for several days despite a daily housekeeping schedule, resulting in a dried, light brown substance remaining under the urinary drainage bag for at least four days. The resident reported the lack of cleaning, and there was no documentation of refusal of housekeeping services. The NHA confirmed these findings.
The facility did not ensure accurate completion of MDS assessments for two residents. One resident's MDS incorrectly documented significant weight loss, which was not reflected in their weight records, while another resident's MDS failed to indicate ongoing hospice care despite physician orders. Staff confirmed both errors.
The facility did not develop comprehensive care plans for two residents: one with severe cognitive impairment and exit-seeking behaviors, and another requiring continuous use of a wound vac for a sacral wound. Despite documented risks and physician orders, the care plans failed to address these specific needs, as confirmed by staff interviews.
Three residents did not receive care in accordance with physician orders, including two residents with fluid restrictions for conditions such as CHF and hyponatremia, where there was no documentation that the restrictions were followed, and a third resident who received antihypertensive medication despite not meeting the ordered blood pressure threshold.
A resident with a Stage 4 pressure ulcer and osteomyelitis did not receive wound vac therapy as ordered, as the device was found off and not functioning for several hours. Nursing staff failed to monitor the wound vac as required, and documentation did not reflect consistent checks or adherence to the physician's order for continuous negative pressure therapy.
A resident with multiple health conditions, including respiratory failure and difficulty walking, did not receive necessary bed rails for positioning and mobility until two months after an evaluation indicated their need. The facility's Director of Nursing was unaware of the incomplete evaluation, resulting in a delay in accommodating the resident's needs.
The facility did not meet the required nurse aide staffing levels on four days, failing to provide adequate coverage during day, evening, and night shifts. This resulted in insufficient hours worked compared to the required hours based on the resident census.
The facility did not meet the required LPN staffing levels on two days, failing to provide the minimum LPN hours per resident during the day shift. On one day, 106.17 hours were provided instead of the required 119.0, and on another day, 114.89 hours were provided instead of 119.68, as confirmed by the NHA.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient per day, providing only 3.12 hours on two days during a 7-day review period. This was confirmed with the NHA.
A resident with multiple health issues experienced significant weight loss, dropping from 275.7 to 180 pounds, without timely notification to the physician or dietician. Despite a physician's order for weekly weight monitoring, the facility failed to document the required weights, and the resident refused meals on several days. The Nursing Home Administrator confirmed the oversight in monitoring and following orders.
The facility did not implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, as required by their infection control policy. Observations showed a lack of EBP signage in residents' rooms, and staff interviews revealed insufficient knowledge and implementation of EBP due to supply delays.
The facility failed to follow physician orders for three residents, leading to deficiencies in care. A resident exceeded their fluid restriction, another did not receive prescribed medication for constipation, and a third had inaccurate fluid intake documentation. These issues were confirmed with the Nursing Home Administrator.
The facility failed to provide enteral nutrition as ordered for four residents, resulting in discrepancies in the volume of nutrition administered. A resident with anoxic brain damage and another with ALS received less than the prescribed volume, while another resident's intake was not documented properly. These deficiencies were identified through clinical record reviews and staff interviews.
A resident received Oxycodone, a narcotic pain reliever, for pain levels rated between 0 and 3, contrary to the physician's order for moderate to severe pain. The DON confirmed that the medication should not have been administered for these lower pain ratings.
A resident undergoing dialysis experienced significant medication errors, including incorrect insulin administration and missed doses of other medications on dialysis days. The facility failed to follow physician's orders to hold insulin on specific days and did not document offering missed medications upon the resident's return.
A resident with diabetes, legal blindness, and brachial plexus disorder did not receive recommended adaptive eating equipment for over a month, despite being cognitively intact and having specific needs. Observations and staff interviews confirmed the absence of adaptive utensils and plates, with a lack of communication and awareness among staff about the provision of these items.
The facility failed to monitor and respond to significant weight changes in two residents, as per its policy. One resident with ALS experienced a 5.77% weight loss, and the re-weigh was delayed by eight days, with the dietitian not informed promptly. Another resident lost 10.6% and 11.9% of their weight over two periods without re-weighs or dietitian review. These actions breached the facility's protocol.
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their clinical records. A resident was found with fractures and a hematoma, but the MDS inaccurately reported no fall or fracture. Another resident's MDS incorrectly noted a fall with major injury, and a third resident's discharge was inaccurately recorded as to an acute care hospital instead of home.
A facility failed to develop a comprehensive care plan for a resident prescribed Eliquis for paroxysmal atrial fibrillation. Despite a physician's order and confirmation in the resident's MDS assessment, the care plan lacked interventions for the anticoagulant. This deficiency was confirmed by the Nursing Home Administrator and had been previously cited.
The facility failed to ensure medications were properly labeled and stored on the 8th SW Floor Medication Cart. Several insulin medications were found opened and undated, and some had open dates exceeding the manufacturer's recommended discard period. Employee E3 confirmed that the medications should have been dated once opened and discarded after 28 days.
Failure to Provide and Document Ordered Enteral Nutrition and Hydration
Penalty
Summary
The facility failed to provide enteral nutrition and hydration as ordered for a resident with complex medical conditions, including anoxic brain damage, osteomyelitis, acute and chronic respiratory failure, mild protein calorie malnutrition, and tracheostomy status. The resident was admitted with physician orders dated January 19, 2026, for continuous Glucerna 1.5 via PEG tube at 60 ml per hour with a total daily volume of 1320 ml, and an additional order for hydration flushes of 40 ml of water every hour with documentation of milliliters in the enteral flush task. Review of the February 2026 MAR showed no documentation that the resident received enteral feeding or medications for the dayshift on February 12, 2026. On observation on February 12, 2026, at 11:20 a.m., the resident’s enteral feeding machine had an empty Glucerna bottle hanging and the pump was beeping. At 11:25 a.m., an RN entered the room, administered medications, and hung a new bottle of Glucerna and hydration fluids. The RN confirmed the enteral feeding should have been continuous. After setup, the pump settings showed a rate of 60 ml with a total feed volume of 1667 ml instead of the ordered 1320 ml. Review of the MARs for January and February 2026 did not show documentation that the resident received the ordered total daily volume of 1320 ml, and review of task forms revealed no enteral flush task documenting the ordered hydration amounts. The Nursing Home Administrator and Director of Nursing confirmed there was no documented evidence that the resident received the prescribed amounts of Glucerna or water.
Failure to Maintain Sanitary Environment Due to Ongoing Roach Infestation
Penalty
Summary
The facility failed to maintain a sanitary, safe, and comfortable environment on three of seven units, specifically the 4th, 5th, and 6th floors. On the 6th floor west side shower room, surveyors observed one live roach and five dead roaches in a supply cabinet, and one dead roach in the sink. A dying roach approximately three inches in length was also observed in the 6th floor lobby in front of the elevators. On the 5th floor east side shower room, multiple dead roaches were seen in the toilet and shower rooms, along with one live roach on the shower curtain. On the 4th floor west shower room, multiple dead roaches were observed in the shower room and one live roach was seen on the shower curtain. A resident reported having previously found live roaches in his bed and stated that he reported this to the Maintenance department several weeks prior to the survey. Review of exterminator Service Inspection Reports showed repeated service calls for roach activity in spa rooms, resident rooms, and staff areas on multiple dates in November and December, including treatment of this resident’s room. During an interview, the Nursing Home Administrator and DON stated that the facility has a contract with an exterminating company that provides weekly and as-needed services, and that all staff can submit tickets through a system that prompts Maintenance to contact the exterminator for targeted treatment.
Failure to Follow Physician's Wound Care Orders
Penalty
Summary
The facility failed to follow a physician's wound care order for a resident who was admitted with unstageable pressure ulcers on both heels. According to the clinical records, the physician's order specified daily wound care, including cleansing the heels, applying Santyl at a nickel thickness, covering with alginate and abdominal dressing, and wrapping with Kling during each day shift. However, a review of the Treatment Administration Record (TAR) showed that the wound treatment was not performed on September 21, 2025. Nursing progress notes for that date indicated the treatment was not administered due to workflow. This was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the wound care was missed for both heels on that day.
Failure to Provide Foot Care and Podiatry Services
Penalty
Summary
A resident with severe cognitive impairment and a need for partial to moderate assistance with personal hygiene was observed to have thick, long, and curled toenails on both big toes, as well as long toenails on the second and third toes of both feet. During observation, a licensed nursing employee was unable to determine when foot care was last provided, and a review of the clinical record showed no documentation of toenail care. Further interview with the Nursing Home Administrator confirmed that the resident had not received podiatry nail care since admission, and although a permission form for podiatrist care was sent to the resident's guardian in 2023, no follow-up was made. The facility failed to provide necessary foot care for the resident.
Failure to Protect Residents' Right to Unopened Mail
Penalty
Summary
The facility failed to protect and facilitate residents' rights to receive unopened mail, as evidenced by two cognitively intact residents reporting that their mail was opened against their wishes. Resident 16, with a perfect score on the Brief Interview of Mental Status (BIMS), stated during an interview that mail addressed to them was opened without consent. Similarly, Resident 17, also cognitively intact per their BIMS score, reported receiving mail that had been opened, with the envelope showing a date stamp and initials on the back. The Nursing Home Administrator confirmed that the Business Office had opened residents' mail, in violation of resident rights as outlined in 28 Pa Code 201.29 (j).
Failure to Follow Physician Orders for Resident Showers
Penalty
Summary
The facility failed to follow physician orders regarding showers for one resident who was unable to perform activities of daily living independently. Clinical record review showed that the resident was scheduled to receive a shower every Monday evening shift and as needed. Documentation indicated that the resident received showers on three occasions within the review period and refused a shower on one occasion. However, there was no documentation of any showers provided after a specific date, despite staff interviews indicating that the resident had received a shower since then. The Director of Nursing confirmed that there was no documentation to support that the resident had received a shower after the last recorded date.
Failure to Properly Store and Label Medications on Medication Carts
Penalty
Summary
Surveyors identified that the facility failed to properly store and label medications on all four medication carts reviewed. Facility policy and manufacturer guidelines require that multi-dose vials and insulin pens be dated when opened and discarded within 28 days, unless otherwise specified. During observations, multiple insulin pens and vials, including Lantus, Lispro, Novolog, Insulin Aspart, and Insulin Gargline, were found opened and undated across the 7th and 8th floor medication carts. Additionally, a Lidocaine vial was found opened and undated, and a medication cup containing 16 unidentified white tablets was discovered in one cart. Licensed nurses present during the observations confirmed that these medications should have been dated upon opening and were unable to identify the loose tablets. The findings were discussed with the Nursing Home Administrator, and it was confirmed that the facility did not maintain correct storage and labeling practices for medications and biologicals as required by policy and regulation. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure that resident weights were consistently monitored and that significant weight changes were promptly addressed for five out of fifteen residents reviewed. According to the facility's policy, any weight change of 5% or more should be retaken the next day for confirmation, and if verified, nursing should notify the dietitian. However, for several residents, there were missed or delayed weight recordings, and required reweights were not obtained as per policy. For example, one resident experienced a 9.4% weight loss over two weeks, but a confirming weight was not obtained until nine days later, and subsequent monthly weights were missed. Another resident had a 9.34% decrease in weight, but staff did not retake the weight the following day as required. Additional residents had missing monthly weights for various months, and in one case, the last recorded weight was several months prior to the review. Staff interviews confirmed that the standard practice is to weigh residents monthly and to obtain reweights within 72 hours if significant changes are noted. Despite these standards and physician orders specifying monthly weights, the facility did not consistently follow through with timely weight monitoring or documentation. The Nursing Home Administrator confirmed these findings during interviews, and the deficiencies were cited under relevant state patient care and nursing services regulations.
Failure to Implement Pain Scale and Non-Pharmaceutical Interventions Prior to PRN Narcotic Administration
Penalty
Summary
The facility failed to implement a pain scale for the administration of Hydromorphone as recommended by the consultant pharmacist and agreed to by the nurse practitioner for a resident with diagnoses including encephalopathy, osteoarthritis of the left shoulder, and chronic tension headaches. Despite the recommendation, review of the resident's Medication Administration Records (MAR) for March and April 2025 showed no evidence that a pain scale was added to the physician's order. Additionally, documentation did not show that non-pharmaceutical interventions were attempted prior to administering the PRN Hydromorphone, as required. The resident received Hydromorphone multiple times for varying pain levels, including instances where pain was documented as zero.
Failure to Follow Infection Control Practices During Medication and Meal Service
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration and meal set-up for two residents. In one instance, a licensed staff member prepared medication for a resident and, after a pill fell onto the resident's tray table, picked up the pill with bare hands without performing hand hygiene before giving it to the resident. In another instance, a non-licensed staff member provided a resident with a piece of bread by picking it up with bare hands and handing it directly to the resident, again without performing hand hygiene or cleaning the resident's hands. The same staff member continued to distribute meal trays to other residents without performing hand hygiene between contacts. These actions were observed during routine care and were confirmed through staff interviews, demonstrating a lack of adherence to infection prevention and control protocols as required by regulation.
Failure to Respond Timely to Call Bell Requests
Penalty
Summary
A deficiency was identified when staff failed to respond to a resident's call bell in an appropriate amount of time. The resident involved had significant medical needs, including a spinal cord injury, quadriplegia, and muscle wasting, and was completely dependent on staff for transfers using a mechanical lift. The resident reported that when he activated his call bell for assistance, staff would enter his room, turn off the call bell, and then leave without providing the requested help. Documentation in the clinical record showed that the resident rang for assistance to get out of bed multiple times within short intervals, but was repeatedly told that the assigned CNA was delayed due to training a new CNA. The resident expressed dissatisfaction with this explanation. The Nursing Home Administrator confirmed these findings during an interview.
Failure to Timely Notify Physician After Resident Fall with Injury
Penalty
Summary
The facility failed to promptly notify the attending physician of an unwitnessed fall with facial injury involving a resident diagnosed with dementia, anxiety, heart failure, and atrial fibrillation, who was also on anticoagulant therapy (Eliquis). According to the facility's policy, the physician should be notified within 24 hours of any significant change in a resident's condition, including accidents or incidents. On the morning of the incident, the resident was found on the floor with a swollen right eye and hematoma after attempting to self-toilet. The incident report indicated that the nurse practitioner and family were notified via voicemail, but there was no documented evidence of timely physician notification. Further review revealed that the nurse practitioner was not made aware of the fall until the following day, after observing the resident's facial bruise during a visit. The nurse practitioner confirmed not being notified on the day of the fall and stated that, if notified, would have considered holding the resident's anticoagulant medication. The nurse responsible for the incident report claimed to have notified the nurse practitioner via text message but could not provide proof of this communication. This lapse resulted in a failure to meet the facility's policy and regulatory requirements for timely physician notification following a significant change in a resident's condition.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
A deficiency was identified when a staff member failed to maintain a resident's dignity during a meal. Resident 51, who had a moderate cognitive impairment and a diagnosis of traumatic brain injury, was observed sitting in a recliner in the hallway outside their room. During this time, a non-licensed employee, while distributing breakfast trays, interrupted a conversation between the resident and a surveyor and stated that the resident was about to have breakfast. Instead of properly setting up the resident for the meal, the employee opened the resident's breakfast tray while it was still on the food cart, used bare hands to pick up half a piece of French toast, and handed it directly to the resident. The resident then began eating the food placed in their hand by the staff member, while the employee continued to distribute trays to other residents. This incident demonstrated a failure to ensure the resident's dignity was maintained during the breakfast meal service.
Failure to Maintain Clean and Home-like Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and home-like environment for one resident, as required by policy and regulation. Housekeeping was scheduled to clean the resident's room daily between 8:00 a.m. and 9:00 a.m., but interviews and multiple observations over several days confirmed that the room had not been cleaned. A dried, light brown substance was observed under the resident's urinary drainage bag and remained present for at least four days, as verified by staff and surveyors. The resident reported that housekeeping had not cleaned the room for several days, and there was no documentation indicating that the resident had refused housekeeping services. The Nursing Home Administrator confirmed these findings.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident with diagnoses including traumatic brain injury, diabetes mellitus, protein calorie malnutrition, gastrostomy, and tracheostomy, the quarterly MDS assessment incorrectly indicated significant weight loss, which was not supported by the resident's weight summary. Staff confirmed this was an error. For another resident, the MDS assessment failed to indicate that the resident was receiving hospice care, despite physician orders documenting hospice services since December 11, 2024. Staff interviews confirmed the inaccuracies in both cases.
Failure to Develop Comprehensive Care Plans for Residents with Elopement Risk and Wound Vac Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents as required. For one resident with severe cognitive impairment who utilized a wheelchair, clinical records indicated an incident where the resident was found on the ground floor attempting to leave the building. An elopement evaluation identified this resident as being at risk for elopement, with documented behaviors such as a history of attempted leaving, verbalizing a desire to go home, packing belongings, and wandering near exit doors. Despite these findings and the application of an Alpha Watch device, there was no care plan addressing the resident's exit-seeking behavior. For another resident, observations and physician orders confirmed the continuous use of a wound vac for a sacral wound, with specific instructions for device settings, placement checks, and canister changes. However, a review of the care plan revealed that it did not include a comprehensive plan of care for the use of the wound vac. Interviews with the Nursing Home Administrator confirmed that care plans addressing these specific needs were not developed for either resident.
Failure to Follow Physician Orders for Fluid Restriction and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for medication administration and fluid restrictions for three residents. One resident with diagnoses of congestive heart failure and acute respiratory failure had a physician order for a 2000 ml fluid restriction per 24 hours, divided between dietary and nursing, but there was no documentation that this restriction was followed. Another resident with hyponatremia had a physician order for a 1000 ml fluid restriction, also divided between nursing and dining, and again, there was no documentation that the fluid restriction was adhered to, as confirmed by the Nursing Home Administrator. A third resident with coronary artery disease, hypertension, and carotid artery stenosis had a physician order for Amlodipine 2.5 mg to be administered daily only if the systolic blood pressure was greater than 140 mm Hg. However, the Medication Administration Records for February, March, and April showed that the resident received Amlodipine multiple times when the systolic blood pressure was less than 140 mm Hg. These findings were confirmed through clinical record review and interviews with facility staff.
Failure to Follow Wound Vac Orders for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to follow a physician's order for wound care for a resident admitted with a Stage 4 pressure ulcer to the sacrum, who also had osteomyelitis and was receiving IV antibiotics. The physician's order required the use of a wound vac on a continuous setting, with placement and function to be checked every shift and the canister changed as needed. Observations revealed that the wound vac machine was off and not functioning for several hours, with the canister filled and the device unplugged from the adaptor. Documentation did not show that the wound vac was monitored during this period. Interviews with nursing staff indicated a lack of awareness regarding the wound vac's status, with one nurse stating they had not checked the device all day and only discovered it was not connected when prompted. Another nurse reported having observed the wound vac working earlier and documented it as such, but there was no evidence of monitoring between the observed times. The clinical records did not reflect consistent monitoring or adherence to the physician's order for continuous wound vac therapy.
Failure to Provide Necessary Bed Rails for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's needs, as evidenced by the lack of bed rails that were necessary for the resident's positioning and mobility. The resident, who was admitted with acute respiratory failure, chronic obstructive pulmonary disease, anxiety disorder, muscle wasting, and difficulty walking, had a documented need for bed rails to assist with positioning and rising from a lying to a sitting position. Despite a request from the resident's power of attorney for care and a completed Bed Side Rail Evaluation indicating the need for bed rails, the facility did not install them until January 10, 2025. The Director of Nursing was unaware of the incomplete evaluation from November 11, 2024, which resulted in the resident not receiving the necessary bed rails until two months later. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the resident should have had bed rails installed as per the evaluation conducted in November 2024. This deficiency highlights a failure in accommodating the resident's needs in a timely manner, as required by the regulations.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. 1. Resident Ginny Godfrey currently has enabler bars on bed. 2. Residents with side rails/enablers were reviewed for order. Bed side rail evaluation is complete and that side rail/enablers are appropriate. 3. Licensed nursing staff were re-educated on completion of Bed side rail evaluation and completing work order to ensure that side rail/enablers are placed on the bed. 4. DON or designee will complete random audits of Bed side rail evaluation, will be completed weekly X4, then monthly x2 on completed assessments to ensure that if side rails/enablers are appropriate they are placed on the bed. 5. Date of compliance: 2/25/25.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the minimum staffing requirements for nurse aides on four out of seven days reviewed, from January 3 to January 6, 2025. Specifically, on January 3, the evening shift had a census of 374 residents, requiring 255.00 hours, but only 246.36 hours were worked. On January 4, the day shift had a census of 372 residents, requiring 279.0 hours, but only 261.71 hours were worked. On January 5, the night shift had a census of 374 residents, requiring 187.0 hours, but only 186.66 hours were worked. On January 6, the day shift required 280.50 hours with a census of 374, but only 256.54 hours were worked, and the evening shift required 255.0 hours, but only 238.38 hours were worked. These deficiencies were confirmed during a telephone conversation with the Nursing Home Administrator on January 10, 2025.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. P 5520 Effective July 1, 2024 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. 1. Findings of Nurse aide care ratios cannot be retroactively corrected. 2. The facility will provide 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. 3. The scheduling coordinators will be educated on the requirements of 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. 4. NHA or designee will conduct random audits to verify that the requirements are met for nurse aides. Nurse aide ratios of 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. Audits will be conducted daily x 7 days then weekly for 3 weeks and then monthly for 2 months. Audit results will be presented at QAPI meeting for review and recommendations.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the state regulation requiring a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day shift on two specific days. On January 4, 2025, with a census of 372 residents, the facility was required to provide 119.0 LPN hours but only provided 106.17 hours. Similarly, on January 5, 2025, with a census of 374 residents, the required LPN hours were 119.68, but the facility provided only 114.89 hours. These deficiencies were confirmed during a telephone conversation with the Nursing Home Administrator on January 10, 2025.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. P 5530 Effective July 1, 2023 a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. 1. Findings of LPN nursing staff care ratios cannot be retroactively corrected. 2. The facility will provide a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. 3. The scheduling coordinators will be educated on the requirements of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. 4. NHA or designee will conduct random audits to verify that LPN ratios on all shifts meet the requirements of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight. Audits will be conducted daily x 7 days then weekly for 3 weeks and then monthly for 2 months. Audit results will be presented at QAPI meeting for review and recommendations.
Deficiency in Meeting Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state regulation requiring a minimum of 3.2 hours of direct resident care per patient per day over a 7-day period from January 1, 2025, to January 7, 2025. Specifically, on January 4 and January 6, 2025, the facility provided only 3.12 hours of general nursing care per patient per day, falling short of the mandated requirement. This deficiency was identified through a review of the facility's staffing data and was confirmed with the Nursing Home Administrator on January 10, 2025.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. P 5640 Effective July 1, 2024 the total number of hours of general nursing care provided in each 24-hr period shall, when totaled for the entire facility, be a minimum of 3.20 hours of direct resident care for each resident. 1. Findings of PPD cannot be retroactively corrected. 2. The facility will have daily staffing meetings to review staffing levels and make the necessary adjustments as possible to meet the state minimum requirements of 3.2. 3. NHA or designee will provide re-education to facility nursing administration and scheduling that staffing levels must be a 3.2 or above and have the appropriate staff to perform care in the facility. 4. Facility leadership will complete random audits weekly x 4 and then monthly x 2 months to ensure the facility had a PPD of 3.2 or above. The audits will be reviewed by the QAPI committee and the QAPI committee will determine the need for further audits.
Failure to Monitor Weight Loss and Follow Physician Orders
Penalty
Summary
The deficiency involved a failure to monitor a resident's significant weight loss and to follow physician orders. Resident R1, who had multiple diagnoses including obesity, depression, chronic pain, and a congenital brain malformation, experienced a drastic weight reduction from 275.7 pounds to 180 pounds over a period of approximately five weeks. Despite this significant weight loss, the resident's attending physician and dietician were not informed until June 21, 2024, when the dietician noted the weight loss and requested weekly weight monitoring for four weeks. The physician's order for weekly weight monitoring was initiated on June 24, 2024, but the facility failed to comply with this order. The clinical records, including the Medication Administration Records (MARs) for June and July 2024, did not show evidence of the required weekly weight monitoring. Weights were not recorded for the second and third weeks of July 2024, and there were blank entries for specific dates in July. Additionally, the resident refused meals on several consecutive days in early July, which was documented. The Nursing Home Administrator confirmed that the weights were not monitored and physician orders were not followed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for nine residents who required such measures due to their medical conditions, which included wounds, indwelling medical devices, and tracheostomy tubes. Observations revealed that there was no evidence of EBP signage or communication in the rooms of these residents, indicating a lack of adherence to the facility's infection control policy. The policy, dated April 2024, mandates the use of gowns and gloves during high-contact care activities to prevent the transmission of multidrug-resistant organisms (MDROs). Interviews with staff, including a licensed nurse and the Director of Nursing (DON), confirmed the deficiency. The licensed nurse was unable to provide information regarding the EBP process, and the DON acknowledged that the EBP process was not fully implemented due to a delay in receiving necessary supplies. This lack of implementation was observed during the survey conducted on various dates, where residents with conditions such as stage 4 pressure ulcers, indwelling Foley catheters, gastrostomy tubes, and tracheostomy tubes did not have the required EBP signage or communication in their rooms.
Failure to Follow Physician Orders for Fluid Restriction and Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to deficiencies in care. Resident 67 had a physician's order for a 24-hour fluid restriction of 1800 milliliters, with specific allocations from nursing and dining. However, the clinical records for April and May 2024 showed that the resident exceeded the nursing-provided fluid amount on multiple occasions, and there was no documentation of fluid intake with meals for May 2024. This lack of adherence to the fluid restriction order was confirmed with the Nursing Home Administrator. Resident 222 had a physician's order for Milk of Magnesia to be administered as needed for constipation if no bowel movement occurred in three days. Despite not having a recorded bowel movement from May 5 to May 9, 2024, the medication was not administered on May 8, 2024, as required. Additionally, Resident 223 had a fluid restriction order of 1500 milliliters per day, but there was no documentation of fluid intake for March and April 2024, and the May 2024 records inaccurately reflected the fluid intake, indicating a failure to ensure the fluid restriction was followed. These issues were discussed with the Nursing Home Administrator, confirming the deficiencies in documentation and adherence to physician orders.
Failure to Provide Adequate Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to provide enteral nutrition in accordance with physician's orders for four residents receiving enteral feeding. Resident 72's records showed that the prescribed volume of Jevity 1.5 via PEG tube was exceeded on multiple occasions, and staff documentation was inconsistent, recording the rate instead of the total volume received. Resident 244, diagnosed with anoxic brain damage and having a tracheostomy and gastrostomy tube, was not provided with the ordered total volume of Osmolyte on several days, receiving significantly less than prescribed. Resident 259, with a diagnosis of ALS and a tracheostomy and gastrostomy tube, had missing documentation for feeding tube intake and received less than the ordered volume of Nutren 1.5 on certain days. Similarly, Resident 364, who had a cerebral infarction and a tracheostomy and gastrostomy tube, was not provided with the prescribed total volume of Jevity 1.5 on multiple days. These deficiencies were identified through clinical record reviews and staff interviews, indicating a failure to ensure residents on tube feeding received adequate and ordered nutrition.
Inappropriate Administration of Pain Medication
Penalty
Summary
The facility failed to administer as needed pain medications appropriately for a resident, leading to a deficiency in the resident's drug regimen. The resident had a physician's order for Oxycodone, a narcotic pain reliever, to be administered every 8 hours as needed for moderate to severe pain. However, the resident received Oxycodone on multiple occasions in March, April, and May 2024 for pain levels rated between 0 and 3 on a scale of 1-10, which is below the moderate to severe pain threshold. The Director of Nursing confirmed that the medication should not have been administered for pain ratings of 0-3, as moderate to severe pain should be rated between 4-6.
Medication Errors for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident undergoing dialysis was free from significant medication errors. The resident, identified as Resident 220, reported receiving insulin incorrectly and not receiving certain medications on dialysis days. A review of the resident's physician's orders indicated specific instructions for insulin administration, including holding the morning dose on dialysis days, which were Mondays, Wednesdays, and Fridays. However, the Medication Administration Record (MAR) showed that insulin was administered on these days, contrary to the physician's orders. Additionally, the resident did not receive several other prescribed medications at 8:00 a.m. on dialysis days, as they were out of the facility for treatment. There was no documentation indicating that these medications were offered upon the resident's return. The Nursing Home Administrator confirmed these findings, indicating a lapse in following the prescribed medication regimen and ensuring the resident's medication needs were met on dialysis days.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide a resident with the necessary adaptive eating equipment, which was recommended by occupational therapy to aid in self-feeding. The resident, who is cognitively intact, has a medical history that includes diabetes with mononeuropathy, legal blindness, and brachial plexus disorder, resulting in limitations in hand and finger function. Despite these needs, the resident reported not receiving the special spoon, fork, and plate for over a month. Observations confirmed that the resident was served meals with regular utensils and plates, contrary to the adaptive equipment listed on the meal ticket. Interviews with staff, including a licensed nurse and a nurse aide, revealed a lack of awareness and communication regarding the provision of adaptive equipment, with the kitchen reportedly not supplying the necessary items. The rehabilitation director confirmed the occupational therapy recommendation for adaptive devices, highlighting the facility's failure to ensure the resident's needs were met during mealtime.
Failure to Monitor and Respond to Significant Weight Changes
Penalty
Summary
The facility failed to adhere to its policy on weight assessment and intervention, resulting in a deficiency related to the monitoring of residents' weights. According to the facility's policy, any weight change of 5% or more should prompt a re-weigh the following day for confirmation, and if verified, the dietitian must be notified in writing. However, for Resident 259, who has a diagnosis of Amyotrophic Lateral Sclerosis (ALS) and relies on a Gastrostomy Tube for nutrition, a significant weight loss of 5.77% was recorded between April 19 and May 13, 2024. The re-weigh was not conducted until May 21, 2024, eight days after the initial weight loss was identified, and the dietitian was not informed until the re-weigh was completed. Similarly, Resident 348 experienced a significant weight loss of 10.6% between April 4 and May 7, 2024, and a further loss of 11.9% by May 12, 2024, without any re-weighs being conducted. The Registered Dietitian confirmed that re-weighs should have been performed within 24-48 hours of identifying a significant weight change. The clinical records for Resident 348 also lacked evidence of review by the dietitian following the significant weight loss. These failures indicate a breach in the facility's protocol for monitoring and responding to significant weight changes in residents.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their clinical records. Resident 165 was found on the floor with severe pain and diagnosed with multiple fractures and a hematoma. However, the significant change MDS inaccurately indicated that the resident had not experienced a fall or fracture related to a fall in the specified timeframes. This error was confirmed by the RNAC during an interview. Resident 250's quarterly MDS inaccurately reported a fall with a major injury, despite the clinical record showing no such incident in the past year. This was confirmed by a licensed nursing employee. Additionally, Resident 396's discharge MDS incorrectly stated a discharge to an acute care hospital, while progress notes indicated the resident was discharged to home. This discrepancy was also confirmed by a licensed nursing employee.
Failure to Develop Comprehensive Care Plan for Anticoagulant Medication
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed Eliquis, an anticoagulant medication, for paroxysmal atrial fibrillation. The physician's order for this medication was dated September 22, 2023, and the resident's quarterly Minimum Data Set (MDS) assessment on March 20, 2024, confirmed the resident was receiving an anticoagulant. However, upon review, it was found that the resident's current care plan did not include any care plan or interventions related to the anticoagulant medication. This deficiency was confirmed during an interview with the Nursing Home Administrator on May 21, 2024, at 1:30 PM. The facility had previously been cited for similar issues on July 27, 2023, under the regulations 483.21 Comprehensive Resident Centered Care Plan, 28 Pa. Code 211.5(f) Clinical records, and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored on the 8th SW Floor Medication Cart. During an observation conducted on January 4, 2024, at 12:30 p.m., it was found that several insulin medications, including Insulin Lispro, Insulin Aspart, Levemir Insulin, and Insulin Gargline, were opened and undated. Additionally, some insulin vials had open dates that exceeded the manufacturer's recommended discard period of 28 days. Specifically, one Insulin Gargline vial had an open date of November 30, 2023, and one Novolog insulin vial had an open date of November 25, 2023. These findings were confirmed by Employee E3 during an interview at 12:40 p.m. on the same day, who acknowledged that the medications should have been dated once opened and discarded after 28 days. The review of the manufacturer's storage guidelines for the various insulin types revealed that they must be stored at room temperature and discarded within 28 days after opening, except for Levemir FlexTouch, which must be discarded 42 days after opening. The facility's failure to adhere to these guidelines resulted in the improper labeling and storage of medications on the 8th SW Floor Medication Cart, as evidenced by the undated and outdated insulin vials and pens. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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