Laurel Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Uniontown, Pennsylvania.
- Location
- 75 Hickle Street, Uniontown, Pennsylvania 15401
- CMS Provider Number
- 395243
- Inspections on file
- 21
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Laurel Ridge Center during CMS and state inspections, most recent first.
A resident with a history of stroke, hypertension, and mobility issues, identified as a risk for elopement, left the facility unsupervised and was missing for nearly a day before being found by police. Staff failed to provide adequate supervision, relied on assumptions about the resident's location, and did not conduct regular checks, resulting in delayed recognition of the resident's absence.
Six residents were affected by environmental deficiencies, including a dusty fan blowing toward a resident's bed and repeated loud slamming of a kitchen door that startled both residents and staff. Despite complaints to the NHA, the issues persisted, impacting comfort and the homelike atmosphere.
Comprehensive MDS assessments were not completed within the mandated 14-day period for four residents. Both the DON and the administrator confirmed that these assessments were completed late, in violation of regulatory requirements.
A resident with diabetes and heart failure experienced multiple episodes of critically high blood glucose levels, as documented in the clinical record. Despite facility policy and physician orders requiring notification for blood sugar readings above 500 mg/dL, there was no documentation that the provider was notified. This deficiency was confirmed by the DON and the Nursing Home Administrator.
Two residents received potassium chloride at times inconsistent with physician orders, with repeated late or early administrations documented over several days. An LPN was observed administering the medication outside the prescribed time and was unable to document it properly in the electronic record. The DON and Nursing Home Administrator confirmed the failure to prevent significant medication errors.
The facility did not provide written notice of its bed-hold policy to residents or their representatives during multiple hospital transfers, as required by facility policy. Several residents with complex medical conditions were transferred for acute health issues, but clinical records lacked documentation of the required notification. This deficiency was confirmed by both record review and staff interviews.
Three staff members, including a nurse aide, an LPN, and a dietary employee, did not receive required annual training on the facility's QAPI program, as confirmed by document review and interviews with the administrator and DON.
A resident with Parkinson's and severe cognitive impairment was restrained with a gait belt without a physician's order, violating facility policy. The resident had a history of falls and difficulty maintaining safe positioning due to rigidity. Despite discussions with the resident's family and attempts to find suitable positioning devices, the unauthorized use of the gait belt led to a deficiency finding.
A resident with severe cognitive impairment was improperly restrained with a gait belt tied to a wheelchair by an RN, contrary to facility policy. Several staff members witnessed the incident but failed to report it to supervisors or authorities, violating state law and facility procedures. The facility's management confirmed the failure to implement necessary reporting policies.
The facility failed to notify physicians and assess residents for abnormal glucose levels, affecting three residents with diabetes. Despite care plans requiring monitoring and reporting of hypo-/hyperglycemia symptoms, residents experienced abnormal CBG levels without proper assessment or physician notification. Interviews with LPNs and the DON revealed inconsistencies in following protocols for managing abnormal glucose levels.
A resident with multiple health issues was neglected when two nurse aides transferred them from a wheelchair to a bed without using the required lift, resulting in severe pain and injury. The aides admitted to the manual transfer due to the absence of a lift pad, contrary to the facility's policy on preventing neglect.
Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, high blood pressure, and difficulty walking eloped from the facility without staff knowledge or supervision. The resident was assessed as cognitively intact with a BIMS score of 15 and had a care plan in place identifying a risk for wandering or elopement. Despite this, staff did not provide adequate supervision, and the resident was able to leave the facility undetected for approximately 22 hours before being located by police. Multiple staff members observed the resident throughout the evening, noting that he was frequently walking in the hallways and was last seen between 8:00 and 9:00 p.m. Staff relied on assumptions about the resident's whereabouts, with some believing he was in the dining room or elsewhere in the building, and did not verify his location during rounds. The facility's practice was to conduct two-hour checks only on incontinent residents, and staff admitted to bypassing the resident's room during rounds due to his usual activity of walking around the facility. The facility was unaware of how or when the resident exited the building, and it was noted that door codes may have been accessible to residents. The lack of consistent supervision and failure to account for the resident's whereabouts resulted in a delay in recognizing his absence. The deficiency was confirmed by the facility's administration, who acknowledged that staff should have realized the resident was missing sooner.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six of seventeen residents on one of three nursing units and in the main dining room. Observations revealed that a large box fan in a resident's room was covered in dust while actively blowing air toward the resident's bed, indicating a lack of cleanliness and attention to environmental safety. Additionally, during a group interview, multiple residents reported that kitchen staff routinely slammed the kitchen door during meal times and activities, causing discomfort and startle responses among residents. One resident stated that this concern had been reported to the Nursing Home Administrator weeks prior, but the issue persisted. Further observations confirmed that the kitchen entry/exit hallway door repeatedly slammed shut due to its automatic mechanism and the vacuum effect created when the dining room door was kept closed, as instructed by maintenance staff. Staff members working near the door were observed to flinch at the loud noise, and interviews confirmed that both staff and residents were affected by the repeated slamming. The Nursing Home Administrator acknowledged the facility's failure to maintain a safe, clean, and comfortable environment as required by policy and state regulations.
Failure to Complete MDS Assessments Within Required Time Frame
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for four of eight residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. Documentation showed that the MDS assessments for these residents were completed after the required 14-day period. This was confirmed by both the Director of Nursing and the Nursing Home Administrator during interviews, who acknowledged that the assessments were not completed on time as required by regulation.
Failure to Notify Physician of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of significantly elevated capillary blood glucose (CBG) levels for a resident with diabetes and heart failure. According to facility policy, licensed nurses are required to report abnormal laboratory values, including changes in blood glucose, to the physician or advanced practice provider. The resident's care plan specifically directed staff to monitor for signs and symptoms of hyperglycemia or hypoglycemia and to report abnormal findings to the physician. A physician order was in place instructing staff to call the physician if the resident's blood sugar exceeded 500 mg/dL. Despite these directives, the clinical record showed multiple instances where the resident's blood sugar readings were at or above 500 mg/dL, with no documentation that the provider was notified. This was confirmed by the DON and the Nursing Home Administrator during interviews. The failure to notify the physician of these abnormal blood glucose levels constituted a violation of facility policy and state regulations regarding resident care and physician notification.
Failure to Prevent Significant Medication Errors in Scheduled Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of potassium chloride at incorrect times for two residents. For one resident with diagnoses of atrial fibrillation and chronic kidney disease, physician orders specified potassium chloride to be administered at 10:00 a.m. and 10:00 p.m., and furosemide at 8:00 a.m. However, observations and medication audit reports revealed that potassium chloride was administered outside the prescribed times on multiple occasions, including one instance where the medication was given at 8:44 a.m. instead of the scheduled time, and the administration could not be properly documented in the electronic medical record due to timing restrictions. Additional audit findings showed repeated late administrations over several days. Another resident with dementia and a thyroid disorder also had orders for potassium chloride at 10:00 a.m. and furosemide at 8:00 a.m. Medication audit reports indicated that these medications were frequently administered and documented at times inconsistent with the physician's orders, with doses given significantly earlier or later than scheduled. Interviews with the DON and Nursing Home Administrator confirmed that the facility did not ensure residents were free from significant medication errors, as required by facility policy and state regulations.
Failure to Provide Written Bed-Hold Policy Notification at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to the hospital for five out of nine residents reviewed. According to the facility's own policy, written notification of the bed-hold policy is required for all residents at the time of transfer, regardless of payer source. Clinical record reviews for multiple residents revealed no documentation that this notification was given during several hospital transfers. These residents had various medical conditions, including cerebral palsy, paraplegia, seizure disorder, coronary artery disease, history of stroke, chronic kidney disease, diabetes, heart failure, and psychotic disorder. Transfers occurred for reasons such as high fever, hypertensive crisis, low oxygen levels, erratic behavior, hallucinations, low blood sugar, pain, and other acute symptoms. Staff interviews with the Nursing Home Administrator and the DON confirmed that the facility did not ensure written notice of the bed-hold policy was provided at the time of transfer for the affected residents. The deficiency was identified through policy review, clinical record review, and staff interviews, with no evidence found in the records that the required notifications were given during any of the documented transfers for these residents.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to three of eight reviewed staff members, as required by its Facility Assessment and state regulations. Specifically, a nurse aide, an LPN, and a dietary employee did not have documented QAPI in-service education within the required annual period based on their hire dates. This deficiency was identified through a review of facility documents, personnel in-service training records, and was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of a physical restraint without a physician's order. The incident involved a resident with Parkinson's disease, a leg/hip fracture, and a BIMS score of 5, indicating severe cognitive impairment. The resident had a history of repeated falls and was being managed for behavior to ensure safety. On a particular weekend, a gait belt was applied to the resident's torso, effectively restraining them without a physician's order. This action was contrary to the facility's policy, which requires documentation of the medical symptom being treated and an order for the use of any restraint. The incident was reported after a concern was raised about the use of the gait belt as a restraint. The resident had previously fallen multiple times and was experiencing rigidity due to Parkinson's disease, making it difficult to keep them safely positioned. Despite attempts to find a suitable positioning device, the resident continued to slide out of chairs. The RN involved in the incident noted the lack of sufficient staff for one-on-one monitoring and discussed the situation with the resident's son, who agreed to the use of a lap buddy. However, the use of the gait belt as a restraint was not authorized, leading to the deficiency finding.
Failure to Report and Address Improper Use of Restraints
Penalty
Summary
The facility failed to implement its policies and procedures for reporting suspected abuse, neglect, or misuse of restraints, as evidenced by an incident involving a resident with cognitive impairment and a history of falls. The resident, who had a BIMS score of 5 indicating severe cognitive impairment, was found to have been improperly restrained with a gait belt tied around their torso to a wheelchair. This restraint was applied by an RN to prevent the resident from sliding out of the chair, which is against the facility's policy prohibiting the use of restraints not required to treat medical symptoms. Multiple staff members, including nurse aides and an LPN, were aware of the improper use of the gait belt but failed to report the incident to their supervisors or the appropriate authorities as mandated by the facility's abuse prohibition policy and state law. Witness statements revealed that some staff members observed the resident tied to the chair and either did not report it or reported it to peers who did not take further action. This lack of reporting and failure to follow established procedures contributed to the deficiency. The facility's management, including the Nursing Home Administrator and the Director of Nursing, confirmed the failure to implement the necessary policies and procedures for reporting suspected abuse. This deficiency was identified during a review of the facility's documents, clinical records, and staff interviews, highlighting a significant lapse in the facility's responsibility to protect residents from abuse and ensure staff compliance with reporting requirements.
Failure to Notify Physicians and Assess Residents for Abnormal Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting three residents. Resident R5, diagnosed with diabetes, high blood pressure, and anxiety, had several instances of low CBG levels recorded, but there was no assessment for hypoglycemia, monitoring for treatment effectiveness, or physician notification. The care plan required monitoring and reporting of hypo-/hyperglycemia symptoms, which was not followed. Resident R30, with diabetes and end-stage renal disease, experienced both high and low CBG levels. Despite the care plan's directives to monitor and report abnormal glucose levels, the resident was not assessed for hyperglycemia, and the physician was not informed of the abnormal results. Similarly, Resident R37, with diabetes and chronic obstructive pulmonary disease, had multiple instances of abnormal CBG levels without proper assessment or physician notification, contrary to the care plan and physician orders. Interviews with LPNs and the Director of Nursing (DON) revealed inconsistencies in following facility protocols for managing abnormal glucose levels. The DON confirmed the facility's failure to provide timely communication to physicians and to recognize and document diabetes-related complications. The facility did not adhere to its policies for monitoring and documenting diabetic residents' conditions, including vital signs, meal consumption, and blood glucose results.
Neglect Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to protect a resident from neglect by not following physician's orders during a transfer from a wheelchair to a bed. The resident, who had diagnoses including kidney disease, bladder dysfunction, adult failure to thrive, chronic pain, and a sacral pressure ulcer, was supposed to be transferred using a total lift with the assistance of two staff members. However, on one occasion, two nurse aides transferred the resident without using the lift, resulting in the resident experiencing severe pain in the right lower extremity, bruising, and internal rotation of the right leg. The incident was reported by the resident to a registered nurse, who assessed the resident's pain as a ten out of ten. The resident's roommate confirmed overhearing staff discussions about the transfer without the lift. The nurse aides involved admitted to lifting the resident manually due to the absence of a lift pad under the resident, which they attributed to the previous shift's actions. The facility's policy on abuse prohibition, which includes neglect, was not adhered to, as the staff failed to provide necessary services to avoid physical harm to the resident.
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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