Laurel Lakes Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 201 Franklin Farm Lane, Chambersburg, Pennsylvania 17201
- CMS Provider Number
- 395613
- Inspections on file
- 45
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Laurel Lakes Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
The facility failed to ensure timely availability and administration of ordered medications for three newly admitted residents, including multiple antiseizure, diabetic, and other chronic medications. One resident with a long history of well-controlled epilepsy missed several doses of Carbamazepine and Phenobarbital because the drugs were not available, and subsequently experienced a seizure with a head laceration and a right elbow fracture, requiring hospital treatment. Two other residents missed multiple doses of seizure, diabetic, and other prescribed medications over several days, with MAR entries and nursing notes consistently documenting that the medications were not available. Leadership reported that the contracted pharmacy delivers twice daily and that a backup pharmacy exists for emergent needs, but acknowledged a breakdown in communication that resulted in these medications not being on hand.
The facility did not maintain comfortable temperatures in two nursing units, with several rooms and a dining area exceeding the recommended temperature range, leading to resident discomfort. Additionally, a resident's room was found to have an unclean fan with visible dust buildup, indicating a lapse in cleaning practices.
A resident with elevated liver enzymes was supposed to have atorvastatin held and liver function labs rechecked per hospital discharge and physician instructions. Instead, the resident continued to receive atorvastatin daily for several months, and no lab work was ordered or completed to monitor liver enzymes, as confirmed by review of records and DON interview.
Two residents with end stage renal disease did not have their dialysis access site dressing checks completed or documented as ordered due to a transcription error that prevented the orders from appearing on their medication or treatment administration records, as confirmed by the DON.
Kitchen staff repeatedly used a dish machine that operated below the required minimum wash temperature for food service safety. Despite awareness of the issue and available options to address it, the machine continued to be used at unsafe temperatures, and temperature logs showed this was an ongoing problem with no corrective action taken.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
A resident filed a grievance about meal service, but although the concern was marked as resolved by staff, there was no documentation or follow-up communication to inform the resident of the outcome, contrary to facility policy requiring timely notification.
Two residents, one with dementia and another with anxiety disorder and mobility issues, were subjected to mental abuse and neglect when a staff member instructed them not to use their call bells, disregarding care plan interventions that required call bells to be kept in reach and used for assistance. The DON confirmed awareness of these incidents, which violated residents' rights.
A resident with bipolar disorder and depression was prescribed buspirone for anxiety, but the facility failed to document side effect or behavior monitoring in the clinical record or care plan, as required by policy. The DON confirmed that such monitoring and documentation should have been in place.
Surveyors identified that three residents' MDS assessments were inaccurately coded, including errors regarding physical impairments, fall history, medication management, and feeding status. These inaccuracies were confirmed by the DON and did not match clinical records or resident interviews.
A resident with limited mobility and multiple chronic conditions did not receive timely or appropriate restorative nursing services to maintain or improve range of motion and mobility. The care plan lacked a program for bed mobility, and the active ROM program was delayed and inconsistently documented as 'Not Applicable.' The DON confirmed that restorative programs should have been initiated upon therapy discharge and that documentation practices were not appropriate.
A resident with multiple diagnoses received diclofenac gel for pain without a specified dose or appropriate application sites, contrary to prescribing guidelines. The pharmacist's reviews did not identify these issues, resulting in the resident receiving the medication 127 times over a month to areas not recommended for use.
Multiple grievances and resident interviews revealed that food was frequently served cold, with a test tray confirming that hot foods were below the recommended temperature and cold items were not properly chilled. Staff acknowledged improper food handling practices, and the DON confirmed that food was not served at appetizing temperatures as expected.
Two residents did not receive meals according to their stated preferences due to errors in processing meal change requests. One resident received an alternate entree without requesting it, while another did not receive the alternate entree he had requested, despite proper documentation. The dietary aide misread the meal change log, resulting in the wrong meals being served.
A resident with morbid obesity and acute respiratory failure was dried off with disposable paper towels instead of bath towels during daily care, despite bath towels being available elsewhere in the facility. The staff member did not obtain proper supplies, resulting in care that did not promote the resident's dignity.
A resident was discharged with a credit balance, but the facility did not issue the refund or provide a final accounting of the funds within the required 30-day period. Staff interviews indicated the delay was due to a third-party billing system error, and the standard process for issuing refunds was not followed.
A resident with a history of hypertension and diabetes experienced a decline after a COVID-19 diagnosis, showing signs of dehydration and potential infection. The facility failed to follow alert charting procedures, leading to inadequate monitoring and communication with the medical director. This resulted in the resident being found unresponsive and hospitalized with septic shock. An audit revealed similar deficiencies for 10 other residents with changes in condition.
A facility failed to refund a discharged resident's account balance in a timely manner, as required by their policy. A resident was discharged, and the complainant, who paid the account, did not receive the $2,424.00 refund within the 30-day period stipulated by the facility's policy. The NHA acknowledged the delay, citing the need for corporate approval, and confirmed that the complainant had been calling weekly to request the refund.
The facility failed to ensure accurate MDS documentation for four residents, leading to errors in coding restraints, antipsychotic medication GDR, dialysis, and antiplatelet medication. The NHA confirmed these discrepancies during interviews.
The facility failed to review and revise care plans for four residents, leading to deficiencies in care. A resident with heart failure had outdated weight monitoring interventions, while another with Alzheimer's had unresolved care plan entries for healed wounds. A third resident's care plan included unnecessary humidification interventions, and a fourth resident lacked documentation for specific behaviors despite relevant physician orders. These issues were confirmed by the NHA.
The facility failed to adhere to professional standards for three residents. A resident with end-stage renal disease had blood pressure documented from a restricted arm multiple times, likely due to documentation errors. Another resident with similar conditions had blood pressure recorded from a restricted arm, also attributed to documentation issues. Additionally, a resident with heart conditions was left with medications at her bedside without proper evaluation for self-administration, contrary to facility policy.
The facility failed to monitor the effects and side effects of psychotropic medications for three residents. A resident with psychotic disorder and depression was on Seroquel without monitoring or a care plan. Another resident with heart disease and delusions was on Risperidone, but initial orders lacked side effect monitoring. A third resident with Alzheimer's and depression was on olanzapine without side effect monitoring. The NHA confirmed that monitoring should have been in place.
The facility failed to maintain safe dish machine temperatures, with wash and rinse cycles consistently below the required standards, leading to inadequate cleaning of dishes. This issue persisted over several months, as revealed by temperature logs, indicating a systemic problem with equipment operation and monitoring.
The facility failed to maintain a data collection system for infection surveillance for three months, as required by their policy. The Infection Control Preventionist could not find data from October to December 2023, and the Nursing Home Administrator was unable to provide the necessary infection control data, despite discussions at QAPI meetings.
A resident with a left above the knee amputation and seizure disorder had her call bell repeatedly placed out of reach, contrary to facility policy and her care plan. Observations confirmed the call bell was wrapped around her enabler bar, and interviews revealed this was a common occurrence. The Nursing Home Administrator expected the call bell to be accessible, but no further information was provided to rule out neglectful intent.
A facility failed to conduct a Significant Change MDS for a resident admitted to hospice services, as required by CMS guidelines. Instead, an Annual MDS was completed, despite the resident's diagnoses of Alzheimer's and diabetes. The Nursing Home Administrator acknowledged the oversight during a staff interview.
The facility failed to monitor fluid restrictions for two residents, leading to deficiencies in their nutrition and hydration needs. One resident with heart failure and hypertension exceeded their fluid restriction multiple times without proper follow-up. Another resident with end-stage renal disease and chronic heart failure also exceeded their fluid restriction on several occasions, with no documentation of supervisor notification. The NHA acknowledged the staff's failure to adhere to the restrictions.
A resident with COPD and anemia took a leave of absence (LOA) from the facility, but the documentation was incorrect. The resident informed an LPN about the LOA, but the LPN forgot to document it on the correct date, making a late entry the following day. The Nursing Home Administrator confirmed that documentation should include details of a resident's LOA and expected return, leading to a deficiency citation.
A resident with COPD and dysphagia experienced a delay in receiving emergency dental care after staff accidentally broke their dentures. Despite a policy for 24-hour emergency dental services, the facility failed to arrange timely replacement, resulting in the resident requesting pureed textures. The dentures were ready after a fitting, but non-payment by the corporate office delayed their receipt.
A resident with paraplegia and atrial fibrillation experienced a significant weight loss and developed a stage 2 pressure ulcer. Despite these changes, the facility did not complete a Minimum Data Set (MDS) assessment. The DON confirmed that an assessment should have been conducted.
A facility failed to secure controlled substances, resulting in a missing morphine card. An LPN left the medication unsecured on a cart, and it was later found in a wandering resident's drawer, with some tablets missing. The resident, with a low BIMS score, could not be interviewed. The DON confirmed the policy was not followed.
A facility failed to secure controlled medications when an LPN did not follow procedures, resulting in a card of morphine being left unsecured and later found in a resident's drawer. Eight pills were removed, and one was missing. The resident, known to wander, and her roommates showed no change in status. The LPN was terminated for this negligence.
Failure to Ensure Timely Availability of Ordered Medications for New Admissions
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services to meet the needs of residents, specifically by not ensuring timely availability and administration of ordered medications for three residents. Facility policy required routine and timely pharmacy service, including 24/7 emergency access and use of primary, backup, or emergency medication supplies so that new medication orders would be available by the next routine delivery unless otherwise requested. Despite this, multiple ordered medications, including critical antiseizure drugs, were not available and were not administered as ordered for several newly admitted residents. One resident with diagnoses including epilepsy, type 2 diabetes mellitus, and sepsis was admitted from the hospital with multiple medication orders, including Carbamazepine and Phenobarbital for epilepsy. Review of the MAR and nursing notes showed that the resident’s evening dose of Carbamazepine and Doxycycline on the day of admission, and the following morning doses of Carbamazepine, Doxycycline, Finasteride, Metoprolol, Phenobarbital, Pregabalin, and Rosuvastatin were not given because the medications were not available. The clinical record confirmed that the resident missed one dose of Carbamazepine on the first day and two doses of antiseizure medications (Carbamazepine and Phenobarbital) on the next day. Later that day, the resident was found on the floor next to the bed, unresponsive with seizure-like activity and a moderate amount of blood on the forehead; the episode lasted approximately five minutes, after which the resident was lethargic and postictal. EMS transported the resident to the hospital, where evaluation documented treatment for seizure activity and a head laceration, and imaging revealed a mildly displaced fracture of the right radial head. The emergency room physician documented that the resident reported having lifelong seizures that were very well controlled with medication, with the last seizure occurring in the 1990s, and that the facility did not have the seizure medications in stock and was unable to administer them. A second resident, with diagnoses including type 2 diabetes mellitus, epilepsy, and sepsis, was admitted from the hospital with orders for multiple medications, including Divalproex Sodium and Levetiracetam for seizures, Glipizide for diabetes, Memantine, Movantik, and Unisom. Review of the MAR showed that several scheduled doses over multiple days were either left blank or coded as not given, with corresponding nursing notes stating that the medications were not available. Missed or unavailable doses included evening doses of Divalproex and Unisom on the day of admission, and on subsequent days, morning and later doses of Divalproex, Glipizide, Levetiracetam, Movantik, Memantine, and Unisom. A third resident, with epilepsy and major depressive disorder, was admitted from the hospital with orders for Imipramine, Lamotrigine, and Topiramate. The MAR and nursing notes showed that several initial doses of these medications on the first and second days after admission were not administered because the medications were not available. During interviews, facility leadership stated that the contracted pharmacy delivers twice daily and that a local pharmacy can be used as backup for emergent medications, and acknowledged uncertainty about where the communication breakdown occurred that led to the unavailability of medications.
Failure to Maintain Comfortable Temperatures and Clean Environment
Penalty
Summary
The facility failed to maintain comfortable temperatures on two of five nursing units (E and F), resulting in resident rooms and common areas reaching temperatures above the recommended range for resident comfort. Multiple residents reported feeling uncomfortably warm, and room temperatures were recorded as high as 87 degrees Fahrenheit in the dining room and over 83 degrees Fahrenheit in several resident rooms. The HVAC system was reported as functioning, but the facility relied on portable air conditioning units to address the elevated temperatures. Staff interviews and temperature logs confirmed that the temperature in some areas exceeded the facility's stated comfort range of 71-81 degrees Fahrenheit. Additionally, the facility failed to provide a clean, homelike environment in at least one resident room. Observations over several days revealed that a black pedestal fan in a resident's room had a moderate amount of gray fuzz on the casing and blades, indicating it was not being cleaned regularly. The DON confirmed that the fan should have been included on a cleaning schedule, but this was not being done at the time of the observations.
Failure to Hold Medication and Monitor Labs per Physician Orders
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility with elevated liver transaminase levels and required assistance with personal care. The resident's hospital discharge summary and subsequent physician notes clearly instructed that atorvastatin therapy should be held until liver function tests returned to normal, and that liver enzyme laboratory work should be rechecked in a few weeks. Despite these instructions, the resident continued to receive atorvastatin daily from the time of readmission through several months, as documented in the Medication Administration Records for April, May, June, and July. There was no evidence in the clinical record that laboratory work to monitor liver enzymes was ordered or completed during this period. Interviews with the Director of Nursing confirmed that the expectation was for the medication to be held and for labs to be obtained in accordance with the physician's notes and plan of care. The failure to implement the resident-directed care and treatment as specified in the physician orders and plan of care resulted in the resident receiving medication contrary to medical instructions and without appropriate laboratory monitoring.
Failure to Document and Complete Dialysis Access Site Dressing Checks
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received care and services consistent with professional standards of practice. Specifically, for two residents with end stage renal disease who were dependent on renal dialysis, physician orders required that dialysis access site dressings be checked every shift, reinforced as needed, and the physician notified as necessary. However, review of the clinical records for both residents did not show evidence that these dressing checks were being completed as ordered. Interviews with the Director of Nursing revealed that a transcription error had occurred, resulting in the physician's orders not populating on the medication or treatment administration records for both residents. As a result, the facility could not provide documentation that the required dialysis access site dressing checks were performed. The DON confirmed that it was the facility's expectation for physician orders to be transcribed correctly and for the dressing checks to be completed and documented as ordered.
Failure to Maintain Safe Dish Machine Temperatures in Kitchen
Penalty
Summary
The facility failed to utilize kitchen equipment in accordance with professional standards for food service safety. Observations over several days revealed that the dish machine in the main kitchen was consistently operating below the required minimum wash temperature. Specifically, the dish machine was observed with wash temperatures of 138°F, 136°F, and 140°F on consecutive days, despite the Certified Dietary Manager stating that the minimum wash temperature should be 150°F. Additionally, the manager acknowledged the possibility of linking a sanitizing solution to the machine for safe use at lower temperatures but did not do so. A review of the dish machine temperature logs for December 2024 showed that rinse temperatures were recorded below the minimum safe temperature at all meals throughout the month, with no corrective action documented. During interviews, staff confirmed the expectation that kitchen equipment should be used according to professional standards, but the observed and recorded temperatures did not meet these standards, and no interventions were implemented to address the ongoing issue.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure was observed and documented by surveyors during their review.
Failure to Timely Communicate Grievance Resolution to Resident
Penalty
Summary
The facility failed to provide a timely response to a resident's grievance as required by its own policy. A resident submitted a grievance regarding food concerns, specifically not being served her meal in a timely manner and at the appropriate temperature. Although the grievance form was marked as resolved and signed by the dietary manager and grievance officer, there was no documentation indicating that the resident was notified of the resolution or the method and date of notification. Interviews confirmed that no follow-up communication was made to the resident regarding the outcome of her grievance, despite facility policy requiring resolution and communication within five working days.
Failure to Protect Residents from Mental Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from mental abuse and neglect, as evidenced by staff actions that disregarded residents' rights and care plan interventions. For one resident with dementia and muscle weakness, an employee entered the resident's room, turned off the call bell, and told the resident not to ring the call bell again after the resident requested ice water. This occurred despite the resident's care plan specifying that the call bell should be kept within reach due to a risk for falls. Another resident, diagnosed with anxiety disorder and difficulty walking, reported that the same employee instructed her not to use her call bell during specific time periods when staff were serving meals, stating that call bells would not be answered during those times. The resident's care plan included interventions to keep the call bell in reach and to reinforce the need to call for assistance. The Director of Nursing confirmed awareness of the alleged abuse and acknowledged that it should not have occurred.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not providing adequate monitoring and documentation related to the use of an antianxiety medication. The facility's policy requires that psychotropic medications, including antianxiety drugs, be prescribed, monitored, and reviewed with specific attention to indications for use, dosage, duration, and monitoring for efficacy and adverse consequences. For a resident diagnosed with bipolar disorder and depression, the clinical record showed an active order for buspirone hydrochloride to be administered three times daily for anxiety. However, the resident's clinical record and Medication Administration Records did not contain any evidence of side effect monitoring or behavior monitoring associated with the use of buspirone. Additionally, the resident's care plan did not reflect the use of the antianxiety medication, nor did it include any monitoring for side effects, identification of behaviors to monitor, or other interventions related to the medication. During an interview, the DON confirmed that monitoring and care plan documentation should have been present for the resident receiving the antianxiety medication.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of three residents. For one resident with hemiplegia and hemiparesis following a stroke, the Medicare 5 Day MDS was coded as having no impairment in upper extremities, despite clinical records indicating otherwise. The DON confirmed this MDS coding was inaccurate. Another resident with bipolar disorder, depression, opioid dependence, and a healing femur fracture was inaccurately coded in several areas: the MDS indicated two or more falls with no injury, although a skin tear was documented after one fall; a gradual dose reduction of antipsychotic medication was recorded without supporting documentation; and a significant change MDS failed to note a recent femur fracture from a fall, as well as omitted physician documentation that a gradual dose reduction was clinically contraindicated, despite a psychiatric consult stating so. The DON confirmed these MDS assessments were also inaccurate. A third resident, diagnosed with type 2 diabetes mellitus and cerebral palsy, was incorrectly coded as receiving tube feedings on the quarterly MDS, although both the resident and clinical records confirmed that tube feedings were never provided and no physician orders existed for such treatment. The DON acknowledged this MDS assessment was incorrect. These findings were based on clinical record reviews and interviews with residents and staff.
Failure to Provide Timely Restorative Nursing Services for Mobility
Penalty
Summary
A deficiency was identified when a resident with limited mobility and diagnoses including muscle weakness, COPD, and chronic systolic congestive heart failure did not receive appropriate restorative nursing services to maintain or improve range of motion (ROM) and mobility. The facility's policy required restorative care to promote optimal safety and independence, and the resident's physical therapy discharge summary specified the need for a Restorative Nursing Program (RNP) for bed mobility and active ROM. However, review of the resident's care plan revealed that only active ROM was included, and there was no RNP for bed mobility as recommended. Additionally, the ROM program was not initiated until several weeks after therapy discharge, and documentation showed it was marked as 'Not Applicable' on multiple shifts, indicating the interventions were not provided as required. During interviews, the resident expressed concerns about not receiving enough therapy to prepare for discharge home. The Director of Nursing confirmed that both restorative programs should have been started immediately after therapy discharge and that 'Not Applicable' was not an appropriate documentation response. These findings demonstrate that the facility failed to ensure the resident received timely and appropriate restorative services, equipment, and assistance to maintain or improve mobility, as required by facility policy and regulatory standards.
Failure to Ensure Medication Regimen Free from Unnecessary Drugs Due to Incomplete Diclofenac Order
Penalty
Summary
A deficiency was identified when a resident with diagnoses including bipolar disorder, depression, opioid dependence, and a healing femur fracture was prescribed diclofenac sodium external gel 1% for pain management. The physician's order for this medication lacked a specified dose and did not indicate the exact body location for application, contrary to established dosage guidelines. The order also included application to areas such as the back and legs, which are not recommended for diclofenac gel according to the Physician's Desk Reference. The pharmacist's admission medication regimen reviews on two separate occasions failed to identify these omissions and inappropriate indications in the order. The resident received the diclofenac gel 127 times over a period of approximately one month, with the medication being applied to multiple body areas as per the incomplete order. During an interview, the DON confirmed that the pharmacist's reviews should have identified the lack of a specified dose and inappropriate application sites. The failure to ensure the medication order was complete and appropriate resulted in the resident receiving unnecessary drugs, as the medication regimen was not free from unnecessary medications as required.
Failure to Serve Palatable Food at Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and served at appetizing temperatures, as evidenced by multiple grievances, resident interviews, and direct observation. Several grievances were filed by residents over a period of months, consistently reporting that food was served cold, including specific complaints about cold meals and long wait times before receiving food. During interviews, multiple residents confirmed that food was often cold by the time it reached them, with one resident stating that food service was 'lousy.' A review of the facility menu and a test tray evaluation further substantiated these concerns. During the test tray assessment, food items such as ham loaf and broccoli were found to be below the recommended serving temperature, with recorded temperatures of 123°F and 121°F, respectively, while the fruit cup was served at 66°F. The Certified Dietary Manager acknowledged that the fruit cups should have been kept refrigerated until service, rather than being left on top of the meal carts. The DON confirmed the expectation that food should be served at palatable and appetizing temperatures, but the observed practices did not meet this standard.
Failure to Provide Meals According to Resident Preferences
Penalty
Summary
The facility failed to ensure that residents received meals according to their stated preferences, resulting in two residents not receiving their requested food options. One resident reported frequently not receiving the meal he selected, and on the observed date, he received an alternate entree (salmon patty) without having requested it. Another resident was observed scraping sauce off his chicken and stated he did not receive the meal he had requested, which was the alternate entree. His roommate confirmed that both had made a timely request for the alternate entree, and while the roommate received it, the resident in question did not. Review of the meal change request log confirmed that both residents' names were listed for the alternate entree, but the dietary aide misread one resident's name and provided the alternate meal to the wrong individual. The meal ticket for the resident who did not receive his requested meal did not indicate the correct entree. The dietary aide acknowledged the error and confirmed the process for handling meal change requests, which was not followed correctly in this instance. Facility documentation and staff interviews supported these findings.
Failure to Provide Dignified Care During Resident Hygiene
Penalty
Summary
A deficiency occurred when a resident with morbid obesity and acute respiratory failure was not provided care in a manner that promoted dignity. During daily care, the resident was dried off with disposable paper towels instead of bath towels after being assisted by a staff member. Although bath towels were available in other units, the staff member did not leave the unit to obtain them and instead used paper towels, which led the resident to file a complaint. Facility policy requires that residents be cared for in a way that enhances their sense of well-being and self-worth, but this standard was not met in this instance.
Delayed Refund of Resident Funds After Discharge
Penalty
Summary
The facility failed to convey a discharged resident's funds within the required 30-day period and did not provide a final accounting of those funds upon discharge. Clinical record review showed that a resident was admitted and later discharged from the facility, with a final billing statement indicating a credit balance of $638.00. This refund was not issued until several months after discharge, as a check was processed on May 30, 2025, despite the resident having left on February 27, 2025. Staff interviews revealed that the delay was due to an error with a third-party billing system, which required the transaction to be reversed and reprocessed. The Business Office Manager confirmed that the standard process is to issue refunds within 30 days, and the DON had no additional information regarding the delay.
Failure to Monitor Change in Condition Leads to Resident's Decline
Penalty
Summary
The facility failed to provide adequate care and services following a change in condition for a resident, leading to severe consequences. Resident 1, who had a history of hypertension, Type 2 diabetes, and a displaced bimalleolar fracture, experienced a decline in health after being diagnosed with COVID-19. The resident's cognitive status deteriorated, and there were signs of dehydration and potential infection, as noted by a family member. Despite these concerns, the facility did not follow through with appropriate alert charting or notify the medical director of the resident's declining condition, including lower-than-normal blood pressure and decreased oral intake. The facility's lack of a specific policy or documented process for alert charting contributed to the oversight. Employee 1, a registered nurse, was aware of the alert charting process but did not ensure it was properly documented in the electronic medical record. As a result, there was no consistent monitoring or documentation of the resident's condition, and vital signs were not recorded during critical moments. This lack of documentation and communication with the medical director led to the resident being found unresponsive and eventually hospitalized with septic shock due to a complicated urinary tract infection. The deficiency in care extended beyond Resident 1, as an audit revealed that 10 additional residents with changes in condition were also not adequately monitored. These residents experienced various health issues, such as vomiting, shortness of breath, and urinary tract infections, without proper alert charting or monitoring. The facility's failure to ensure consistent monitoring and communication with medical staff placed these residents in immediate jeopardy, highlighting significant gaps in the facility's care processes.
Removal Plan
- An audit will be completed on all residents with reported change of conditions to ensure monitoring (alert charting) was completed, after a change in condition was identified. If monitoring was not completed, a RN assessment will be completed to ensure resident is at baseline.
- Director of Nursing (DON) or designee will provide re-education to facility licensed staff that after a resident has a change in condition, monitoring a resident with a change in condition needs to be completed. Licensed Nursing staff will be educated on how to enter alert charting process, what to monitor for, how often, how to document interventions, document detailed code interventions i.e. EMS arrival and leave times, ongoing status, and document the physician response when notified. Any nursing licensed staff member that did not receive education will not be able to work their next scheduled shift until education is provided.
- During daily clinical meeting process, progress notes will be reviewed, and alert charting will be monitored for compliance, the alert charting log binders will be brought to daily clinical meeting for review of the log to ensure residents with a change in condition are added to the log for monitoring.
- DON or designee will complete random audits of any change of condition to ensure the monitoring is completed and documented.
- Audit findings will be reported to the monthly QAA (Quality Assessment and Assurance) meeting for review and recommendation.
Failure to Timely Refund Resident Account Balance
Penalty
Summary
The facility failed to convey a resident's account balance in accordance with State law and did not close the account in a timely manner upon discharge. The facility's policy, last revised on May 5, 2023, requires that private pay credit balances be refunded within 30 days. However, for Resident 12, who was discharged on May 24, 2024, the refund of $2,424.00 was not processed within this timeframe. The complainant, who paid for Resident 12's account, repeatedly contacted the facility to request the refund but did not receive it. The Nursing Home Administrator acknowledged the delay, attributing it to the need for corporate approval, and confirmed that the complainant had been calling weekly to request the refund.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for four residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. Resident 17, diagnosed with diabetes mellitus and atrial fibrillation, was incorrectly coded as using a restraint, despite the resident's denial and lack of documentation supporting restraint use. The Nursing Home Administrator (NHA) confirmed this coding error during an interview. Resident 100, with a history of atherosclerotic heart disease and psychotic delusions, had incomplete documentation regarding the gradual dose reduction (GDR) of antipsychotic medication. The MDS lacked entries for the date of the last attempted GDR and the date it was deemed clinically contraindicated, despite the physician's documentation of contraindication in January 2024. The NHA acknowledged this omission during an interview. Resident 117, suffering from end-stage renal disease and congestive heart failure, was not coded for receiving dialysis in the MDS, despite having a physician's order for dialysis three times a week. Similarly, Resident 131, with dementia and a history of stroke, was not coded for receiving antiplatelet medication and had errors in documenting the GDR of antipsychotic medication. The NHA confirmed these errors, indicating a failure to accurately complete MDS assessments.
Care Plan Review and Revision Deficiencies
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four residents, leading to deficiencies in their care. Resident 3, diagnosed with heart failure and hypertension, had a care plan intervention for weekly weights that was not updated after the weights were discontinued. The care plan was last revised on August 6, 2024, but the last recorded weight was on August 8, 2024, indicating a lack of timely revision. Resident 45, who had Alzheimer's dementia and difficulty walking, had a care plan for a resolved pressure ulcer and completed antibiotic treatment for a wound infection. However, the care plan was not updated to reflect the resolution of these conditions, with the last revision dated July 3, 2024. This oversight was confirmed during an interview with the NHA and DON. Resident 88, with COPD and chronic respiratory failure, had a care plan that included interventions for humidification, despite the discontinuation of oxygen with humidification orders in February 2023. Additionally, Resident 131, diagnosed with dementia, cerebral infarction, and depression, lacked a care plan focus for their specific behaviors, despite having physician orders addressing anxiety, depression, and insomnia. These deficiencies were acknowledged by the NHA during interviews.
Documentation Errors and Medication Mismanagement
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for three residents. Resident 11, who has end-stage renal disease and requires hemodialysis, had a physician's order specifying that no blood pressure should be taken from her right arm. However, documentation revealed that her blood pressure was recorded from her right arm on 78 occasions over a six-month period. The Nursing Home Administrator (NHA) suggested this was likely a documentation error, as Resident 11 reportedly did not allow blood pressure to be taken from her right arm. Similarly, Resident 117, who also has end-stage renal disease and is dependent on renal dialysis, had a physician's order to avoid blood pressure measurements from the left arm. Despite this, records showed that blood pressure was documented as being taken from the left arm on 65 occasions. The NHA and Director of Nursing (DON) indicated that this was believed to be a documentation issue, as staff should have been aware of the restriction. Additionally, Resident 326, diagnosed with congestive heart failure and atrial fibrillation, was observed with a medication cup containing crushed medications left at her bedside. She had not been evaluated or determined capable of self-administering her medications safely. The resident expressed difficulty in taking the medications due to their taste, and the NHA confirmed that medications should not have been left at her bedside without proper assessment and authorization.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that the effects and side effects of psychotropic medications were being monitored for three residents. Resident 67, diagnosed with psychotic disorder and depression, was prescribed Seroquel, but there was no monitoring or care plan in place for the use of this antipsychotic medication. The Nursing Home Administrator confirmed that the facility's expectation was to monitor the use of such medications. Resident 100, with atherosclerotic heart disease and psychotic delusions, was prescribed Risperidone. Although side effect tracking orders were added later, the initial orders did not include monitoring for side effects. The Nursing Home Administrator acknowledged that monitoring should have been included from the start. Similarly, Resident 131, diagnosed with late-onset Alzheimer's dementia and depression, was prescribed olanzapine, but there was no monitoring for side effects. The Nursing Home Administrator and Director of Nursing confirmed that monitoring should have been implemented when the medication was first ordered.
Failure to Maintain Safe Dish Machine Temperatures
Penalty
Summary
The facility failed to utilize equipment in accordance with professional standards for food service safety in the main kitchen. Observations revealed that the dish machine's wash cycle temperature was consistently below the minimum standard for safety, with readings of 132 degrees Fahrenheit and 125 degrees Fahrenheit, both below the required 150 degrees Fahrenheit. Additionally, dishes coming out of the cycle still had food particles on them, indicating inadequate cleaning. Interviews with staff, including the Dietary Manager and the Nursing Home Administrator (NHA), confirmed that the dish machine was not functioning properly, and a work order had been placed for repairs. A review of the dish machine temperature logs from December 2023 to August 2024 showed numerous instances where both wash and final rinse cycle temperatures were recorded below the minimum safe temperature across various shifts. This pattern of non-compliance with temperature standards was observed over several months, indicating a systemic issue with the dish machine's operation and monitoring. The NHA acknowledged the problem and discussed the possibility of staff recording incorrect temperatures, highlighting a lack of adherence to professional standards in kitchen equipment utilization and monitoring.
Failure to Maintain Infection Surveillance Data
Penalty
Summary
The facility failed to maintain a data collection system of surveillance for infections for three months, specifically October 2023, November 2023, and December 2023. According to the facility's policy titled 'Surveillance for Infections,' which was last reviewed in January 2024, the facility is required to maintain a monthly line list of residents with infections. This list should include identifying information, date of onset, symptoms, site, pathogen, and any invasive procedures or risk factors. However, during an interview with the Infection Control Preventionist (ICP) on August 20, 2024, it was revealed that the facility was unable to find any data collection system of surveillance from the previous full health survey through June 2024. The ICP, who was recently hired, could only provide data from July 2024, which did not meet the policy requirements. Further investigation on August 21, 2024, showed that the facility was able to retrieve a data collection system of surveillance for January 2024 through June 2024 from the corporate office. However, the data for October 2023 through December 2023 remained unavailable. During an interview with the Nursing Home Administrator (NHA) on July 22, 2024, the NHA was unable to provide the required infection control data for those months, although they mentioned that a discussion at the Quality Assessment Performance Improvement (QAPI) meetings about the infections should suffice. This failure to maintain proper surveillance data is a violation of the facility's policy and state regulations.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that the needs of a resident, identified as Resident 4, were accommodated regarding call bell accessibility. Observations in Resident 4's room on two separate occasions revealed that her call bell was out of reach, wrapped around her left enabler bar. This was confirmed during an interview with Resident 4, who stated that staff often placed her call bell out of reach intentionally. The facility's policy on answering call lights, last revised in September 2022, mandates that call lights should be accessible to residents at all times, which was not adhered to in this case. Resident 4's clinical record indicated she had a left above the knee amputation, muscle weakness, and a seizure disorder, making call bell accessibility crucial for her safety and care. Her care plan, which included an intervention for keeping the call bell within reach, was not followed. An interview with a Licensed Practical Nurse suggested that the call bell might have been wrapped around the bar due to the absence of a clip. The Nursing Home Administrator acknowledged the expectation for the call bell to be within reach, but no further information was provided to rule out neglectful intent by the staff.
Failure to Conduct Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to conduct a Significant Change Minimum Data Set (MDS) assessment for a resident who was admitted to hospice services. According to the Centers for Medicare and Medicaid Services' Resident Assessment Instrument Version 3.0 Manual, a Significant Change MDS is required when a terminally ill resident enrolls in a hospice program. However, the facility conducted an Annual MDS assessment instead of the required Significant Change MDS for the resident, who had been diagnosed with Alzheimer's disease and diabetes mellitus type II. The resident was admitted to hospice services on July 10, 2024, but the facility did not perform the necessary Significant Change MDS. Instead, an Annual MDS assessment was completed with an assessment reference date of July 13, 2024, which was approximately seven months after the previous Annual MDS assessment. During a staff interview, the Nursing Home Administrator acknowledged that the facility should have conducted a Significant Change MDS due to the resident's enrollment in hospice services.
Failure to Monitor Fluid Restrictions for Residents
Penalty
Summary
The facility failed to properly monitor fluid restrictions for two residents, leading to deficiencies in their nutrition and hydration needs. Resident 3, diagnosed with heart failure and hypertension, had a physician order for a fluid restriction of 1800 cc per 24-hour period. However, documentation revealed that Resident 3's fluid intake exceeded this restriction on multiple occasions, with intakes recorded as high as 2420 cc. There was no documentation indicating that a nursing supervisor was notified of these exceedances for appropriate follow-up. Similarly, Resident 117, who had end-stage renal disease and chronic heart failure, also had a physician order for a fluid restriction of 1800 cc per 24-hour period. Despite this, Resident 117's fluid intake exceeded the restriction on several dates, with intakes reaching up to 2000 cc. Again, there was no documentation showing that a nursing supervisor was informed of these exceedances. During an interview, the Nursing Home Administrator acknowledged that staff should have adhered to the fluid restrictions and followed up when the restrictions were exceeded.
Failure to Document Resident's Leave of Absence Accurately
Penalty
Summary
The facility failed to document completely and accurately on the clinical records for a resident, identified as Resident 1. The deficiency was identified through a review of the facility's policy on charting and documentation, which emphasized the importance of facilitating communication between the interdisciplinary team. Resident 1, who had diagnoses including congestive obstructive pulmonary disease (COPD) and anemia, was observed resting in bed without complaints. However, it was discovered that Resident 1 had taken a leave of absence (LOA) from the facility on July 17, 2024, but the documentation was incorrect. The resident's family member signed the resident out with the wrong date, and the resident confirmed the correct date of the LOA during an interview. The deficiency was further highlighted during interviews with the resident and staff. Resident 1 informed the surveyor that he had notified the medication nurse, identified as Employee 1, about the LOA on the day it occurred. However, Employee 1 admitted to forgetting to document the LOA on the correct date and only made a late entry the following day. The Nursing Home Administrator confirmed that documentation should include details of a resident's LOA and the expected return date and time. This oversight in documentation led to the deficiency being cited under 28 Pa. Code 211.12(d)(1).
Failure to Provide Timely Emergency Dental Care
Penalty
Summary
The facility failed to provide timely emergency dental care for a resident, identified as Resident 13, whose lower dentures were accidentally broken by staff on September 22, 2023. Despite the facility's policy stating that emergency dental care is available on a 24-hour basis, the resident's clinical records showed no progress notes or physician orders for dental visits to replace the broken dentures. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and dysphagia, requested a change to pureed textures due to the broken dentures, indicating a need for immediate dental intervention. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that the resident was sent for a final denture fitting and adjustment on December 18, 2023, but the dentures were not received due to non-payment by the facility's corporate office. Correspondence from the dental practice indicated that the resident had been calling daily to inquire about the dentures, and the practice had informed the facility of the non-payment issue. The DON confirmed that the dentures should have been received immediately after the final adjustment, highlighting a significant delay in addressing the resident's dental needs.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who experienced a notable decline in health. The resident, diagnosed with paraplegia and atrial fibrillation, had a documented usual weight range of 168.3 to 172.0 pounds before January 2024. In February 2024, the resident experienced a significant weight loss of 15%, dropping to 143.0 pounds from 168.3 pounds on January 1, 2024. Additionally, the resident developed a stage 2 pressure ulcer on February 21, 2024. By March 4, 2024, the resident's weight further decreased to 134 pounds, indicating an additional 9-pound loss. Despite these significant changes, the facility did not complete a Minimum Data Set (MDS) assessment to address the weight loss and pressure ulcer. The Director of Nursing confirmed that a significant change assessment should have been conducted.
Failure to Secure Controlled Substances Leads to Missing Medication
Penalty
Summary
The facility failed to prevent potential accidents and hazards related to controlled substances on one nursing unit, specifically involving a wandering resident. The incident began when a Licensed Practical Nurse (LPN), referred to as Employee 1, delivered a card containing 30 tablets of morphine to another LPN, Employee 2. Employee 2 placed the medication bag on the medication cart pole and forgot to secure it, as she was distracted by a resident needing assistance. The medication was left unsecured throughout the shift, and by the end of the shift, the morphine card was missing. The missing morphine was later found in the bottom drawer of a wandering resident's bedside stand, with eight tablets popped out and one tablet unaccounted for. The resident, who had a Brief Interview of Mental Status (BIMS) score of three, was unable to be interviewed. Other residents in the room either denied seeing the medication or were unable to be interviewed due to their mental status. The Director of Nursing (DON) confirmed that the facility's policy for securing controlled substances was not followed, and the notification of the missing medication was not timely.
Failure to Secure Controlled Medications
Penalty
Summary
The facility failed to adhere to its procedures for securing controlled medications on one of its nursing units, specifically the B Wing. According to the facility's policy, any discrepancies in the controlled substance count must be documented and reported immediately to the Director of Nursing (DON) services, and controlled substances should be stored in a locked container separate from non-controlled medications. However, an incident occurred where a Licensed Practical Nurse (LPN), referred to as Employee 2, did not secure a card containing 30 tablets of morphine upon delivery. Instead, the medication was left hanging on the pole of the medication cart and was later found missing at the end of the shift. The missing morphine was discovered approximately 10 hours later in the bottom drawer of a resident's bedside stand. This resident was known to frequently wander on the unit. Eight pills were removed from the card, and one pill was unaccounted for. The resident and her roommates were assessed, and no changes in their status were noted. The physician and pharmacy were notified of the incident. Employee 2 was terminated for failing to follow the facility's policy and for not securing the morphine upon its arrival.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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