Laurel View Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Davidsville, Pennsylvania.
- Location
- 2000 Cambridge Drive, Davidsville, Pennsylvania 15928
- CMS Provider Number
- 395891
- Inspections on file
- 22
- Latest survey
- May 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Laurel View Village during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of falls experienced a fall resulting in a skin tear and later reported shoulder pain. Although a nurse assessed the resident and documented the findings in investigation documents, this assessment was not included in the clinical record, leading to incomplete documentation.
The facility failed to follow physician's orders for bowel protocols for two residents, resulting in extended periods without bowel movements. Additionally, a resident did not have their Salonpas patch removed within the prescribed 12-hour period. These deficiencies were confirmed through interviews with the Nursing Home Administrator.
The facility's QAPI committee failed to address repeated deficiencies in following physician's orders, catheter care, and nutrition maintenance, as identified in a recent survey. Despite previous plans of correction involving audits and committee reviews, the same issues were cited again, indicating ineffective corrective actions.
Laurel View Village was cited for inaccuracies in MDS assessments for four residents, failing to accurately code the administration of medications such as diuretics, antianxiety, antibiotics, and anticonvulsants. These errors were confirmed through staff interviews and review of clinical records.
A facility failed to provide restorative nursing programs as per a resident's care plan, resulting in a deficiency. The resident, who required assistance due to Parkinsonism, had a care plan for active range of motion and ambulation programs, which were not consistently documented or completed. Staff interviews confirmed the lack of adherence to the care plan, and the Nursing Home Administrator acknowledged the documentation gaps.
A resident with an indwelling urinary catheter was found with the catheter bag and tubing in direct contact with the floor, contrary to facility policy. Additionally, the facility failed to document the resident's urinary output as required, with multiple instances of missing records across various shifts. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to provide a resident with recommended nutritional interventions, specifically ice cream twice a day, to address unplanned weight loss. Despite the dietician's recommendation, there was no documented evidence that the ice cream was provided, and the resident's weight decreased. Interviews revealed that the ice cream was not included in the resident's meal ticket, and the usual process for adding nutritional support items was not followed.
A facility failed to provide a resident with a divided plate as ordered by the physician, despite the resident's moderate cognitive impairment and need for set-up assistance with eating. The absence of the divided plate was observed during a meal and confirmed by an LPN.
The facility failed to follow physician orders for two residents. One resident received duplicate wound care treatments due to an old order not being discontinued, while another resident's physician was not notified when insulin was held due to low blood sugar levels. These deficiencies were confirmed by the DON.
A facility failed to follow physician's orders for a resident's suprapubic catheter care. The resident, who was dependent on staff for daily care, had orders for the catheter to be changed every four weeks. However, there was no documented evidence of catheter changes over a specified period, as confirmed by the Nursing Home Administrator.
A facility failed to maintain a therapeutic No Salt Added diet for a resident with kidney failure when their diet texture was downgraded to mechanical soft due to chewing difficulties. Despite physician's orders, there was no documentation to indicate the continuation of the therapeutic diet, as confirmed by the Nursing Home Administrator.
Incomplete Clinical Record Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for one resident. An admission MDS assessment indicated that the resident was cognitively impaired, dependent on staff for daily care, and had a history of falls. On the day of the incident, the resident experienced a fall and sustained a skin tear, with subsequent complaints of shoulder pain. Although a registered nurse assessed the resident following the fall and documented the assessment in the facility's investigation documents, this assessment was not included in the resident's clinical record. The Nursing Home Administrator confirmed that the investigation documents were not part of the clinical record, resulting in incomplete documentation for the resident.
Failure to Follow Physician's Orders for Bowel Protocols and Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding bowel protocols for two residents and medication administration for another resident. For one resident, the facility did not administer the prescribed Dulcolax suppository and Fleets enema after Milk of Magnesia proved ineffective, resulting in the resident not having a bowel movement for seven days. Similarly, another resident did not receive the prescribed Milk of Magnesia and Dulcolax suppository on the third and fourth day without a bowel movement, as ordered by the physician, leading to extended periods without bowel movements. Additionally, the facility did not follow physician's orders for a third resident regarding the administration of a Salonpas patch. The patch was applied multiple times without documented evidence of its removal within the prescribed 12-hour period. These failures were confirmed through interviews with the Nursing Home Administrator, highlighting a lack of adherence to established protocols and physician's orders for these residents.
Plan Of Correction
(Bowel) An Immediate Remedy could not occur for Resident 4 and 41 in this situation as the events occurred in the past. A audit/review of all other current residents in the facility shows that all residents have had appropriate administration of all bowel protocols where necessary. The Bowel Protocol Policy was reviewed and updated by Nursing Administration and Medical Director. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated on the bowel protocol policy. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with the Bowel Protocol Policy three times a week for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting. (Patch) An Immediate Remedy could not occur for Resident 27 as this situation as the events occurred in the past. An audit/review of orders was completed with no other resident prescribed as needed topical patches. The Transdermal Patch Policy was reviewed and updated by the Nursing Administration and Medical Director. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated on the bowel protocol policy. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with the documentation of removal of as needed transdermal patches three times a week for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Repeated Deficiencies in Physician Orders, Catheter Care, and Nutrition
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in a recent survey. The survey, which concluded on April 16, 2025, highlighted recurring issues that were previously noted in a survey ending May 23, 2024. These issues included failures to follow physician's orders, provide proper care of urinary catheters, and maintain nutrition for residents. The deficiency related to following physician's orders was initially identified in the May 2024 survey. The facility had developed a plan of correction that involved conducting audits and reporting the results to the QAPI committee. However, the recent survey found that the QAPI committee was ineffective in addressing these issues, as the same deficiency was cited again under F684. Similarly, the facility's plan to address deficiencies in catheter care and nutrition maintenance, which also involved audits and QAPI committee reviews, proved ineffective. The recent survey cited the facility under F690 for failing to maintain compliance with catheter care regulations and under F692 for nutrition maintenance. These repeated deficiencies indicate that the QAPI committee's efforts to correct and monitor these issues were insufficient.
Plan Of Correction
The current Quality Assurance Performance Improvement program has been reviewed by the Director of Quality and Compliance. The repeat deficiencies have been reviewed, and audits have been developed to provide accurate data collection and process improvement. The Director of Quality and Compliance will review Quality Assurance and Performance Improvement Minutes. Education has been provided to the Interdisciplinary Team regarding repeat deficiencies. Audits for repeat deficiencies will be completed per their individual plan of corrections. All audits will be reviewed at the Quality Assurance and Performance Improvement Quarterly meeting, where a Root Cause Approach will evaluate new and recurrent deficiencies. Revision or extension of audits will be discussed with the Interdisciplinary Team. Any audits that need to be reviewed will be done at that time.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
Laurel View Village was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the accuracy of Minimum Data Set (MDS) assessments for four residents. The facility failed to accurately code the administration of specific medications in the MDS assessments. For Resident 15, the MDS assessment did not reflect the administration of a diuretic medication, Valsartan-hydrochlorothiazide, despite physician orders and Medication Administration Records (MARs) indicating daily administration. Similarly, Resident 23's MDS assessment failed to indicate the administration of lorazepam, an antianxiety medication, which was ordered and documented as administered four times daily. Resident 28's MDS assessment inaccurately reflected the administration of Silver Sulfadiazine cream, a topical antibiotic, which was applied daily as per physician orders and Treatment Administration Records (TARs). Additionally, Resident 38's MDS assessment did not accurately reflect the administration of carbamazepine, an anticonvulsant medication, despite documentation of its administration. These inaccuracies were confirmed through staff interviews, including with the Registered Nurse Assessment Coordinator, who acknowledged the coding errors in the MDS assessments for these residents.
Plan Of Correction
Minimum Data Set (MDS) assessment for Residents 28, 38, 23, 15 was updated and resubmitted. Residents who have a Minimum Data Set (MDS) completed and require coding related to care needs have the potential to be affected. These individuals' Minimum Data Set were reviewed for accuracy. Education will be obtained for both Nursing Home Administrator, Registered Nurse Assessment Coordinator (RNAC), the Employee responsible for completion of the assessment, and any other individuals responsible for coding and/or auditing of the Minimum Data Set. Registered Nurse Assessment Coordinator reviewed the accuracy of assessments related to coding residents' abilities and care needs via Resident Assessment Instrument (RAI) manual. Registered Nurse Assessment Coordinator (RNAC) will reference the 3.0 Drug Class Index to confirm drug class when completing Section N (N0415. High risk Drug Classes: Use and Indication) of the Minimum Data Set Version 3.0 to assist and ensure accuracy of the Minimum Data Set. Updated 3.0 Drug Class Index obtained to ensure all classifications are accurate and reflective of any new medications. Director of Compliance or Designee will ensure Compliance going forward through auditing of the Minimum Data Set. The auditing will occur at the following schedule: 2 Clinical Records weekly for 4 weeks, followed by 4 clinical records twice monthly for 2 months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Provide Restorative Nursing Programs
Penalty
Summary
The facility failed to ensure that restorative nursing programs were provided according to the resident's plan of care for one resident. The deficiency was identified through a review of facility policies, clinical records, and interviews with residents and staff. The facility's policy on restorative nursing programs required individualized programs with measurable goals, overseen by a restorative nursing coordinator, and documented by restorative aides. However, documentation for the resident's restorative active range of motion and ambulation programs was missing on multiple dates. The resident involved was cognitively intact and required substantial assistance with lower body dressing, moderate assistance with upper body dressing, and substantial assistance with transfers and ambulation. The resident had a diagnosis of Parkinsonism, which affects movement. The care plan included a restorative active range of motion program using weights and a restorative ambulation program with a walker, both of which were not consistently documented as completed. Interviews with staff confirmed the lack of documentation and completion of the restorative programs as per the care plan. The Nursing Home Administrator acknowledged the absence of documented evidence for the completion of the resident's restorative programs on the specified dates and shifts. This lack of adherence to the care plan and documentation requirements led to the identified deficiency.
Plan Of Correction
An immediate remedy could not be implemented for Resident 29 as events occurred in the past. To ensure compliance and accuracy going forward, active range of motion for the certified nursing assistant to complete was added to this resident. An audit/review of all other residents' restorative nursing plans was completed. Active range of motion for the certified nursing assistant was added to those residents who had an active range of motion program assigned to the Restorative Nursing Assistant. The Restorative Nursing Program policy was reviewed by Nursing Management and the Medical Director; the policy was updated. This policy will be educated and reviewed with all current Healthcare Nursing Staff, and acknowledgements will be obtained and documented. All newly hired staff, as well as temporary (agency) staff, are to be educated on the Restorative Nursing Program/Policy Schedule and Execution of Tasks. An additional Restorative Nursing Assistant to fill in when the Restorative Nurse Aide is absent has been identified and trained. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with documentation of the Restorative Nursing Program daily for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Ensure Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling urinary catheter, as evidenced by the catheter bag and tubing being observed in direct contact with the floor, without a privacy bag or barrier. This was confirmed by a nurse aide and the Nursing Home Administrator, who acknowledged that the catheter bag should have been placed in a basin, which was found under the resident's bed. The resident, who was cognitively intact and required assistance with care needs, had a diagnosis of obstructive uropathy and a physician's order for a suprapubic catheter. Additionally, the facility did not adhere to its policy of measuring and documenting urinary output for residents with indwelling catheters every shift. A review of the resident's records revealed multiple instances where urinary output was not documented across various shifts from February to April. The Nursing Home Administrator confirmed the lack of documentation for the specified dates and shifts, indicating a failure to comply with the facility's policy on intake and output measurement.
Plan Of Correction
The remedy could not be immediate as the events occurred in the past. All residents with Urinary Catheters were identified and a documentation Audit was completed. The Input and Output Measurement policy was reviewed and updated. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff and Hospice Agencies that provide care are to be educated on the documentation of output. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with documentation of output in indwelling catheters three times weekly for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting. (Catheter Bag touching the Floor) Upon immediate investigation it was determined that all necessary supplies were in place to ensure that residents Urinary Catheter and any accompanying tubing were not in direct contact with the floor, however due to the residents bed being placed in the appropriate care Planned position, the bed frame had inadvertently crushed the basin allowing for the tubing and bag to be in contact with the floor. As this facility considers this a random unusual occurrence, the following will be completed in efforts to ensure that staff continue to remain educated and diligent in ensuring the mentioned deficiency does not occur. Policy was reviewed for accuracy and appropriateness. The Director of Nursing, Assistant Director of Nursing (Infection Preventionist), Healthcare Nursing Leadership, or designee will conduct visual audits for staff compliance with ensuring urinary Catheter Bags and Tubing are meeting Infection Control Standards three times weekly for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Implement Recommended Nutritional Interventions
Penalty
Summary
The facility failed to implement recommended nutritional interventions for a resident identified as being at nutritional risk. The dietician had recommended that the resident, who had cognitive impairment and unplanned weight loss, be provided with ice cream twice a day to address her weight loss and decreased food intake. However, there was no documented evidence that the ice cream was provided as recommended. The resident's weight decreased from 130.7 pounds to 125.5 pounds over a period of approximately one month. Interviews with the dietician and dietary manager revealed that the ice cream was not included in the resident's meal ticket, and there was no order in the clinical record for the ice cream to be provided twice a day. The dietician believed the resident was receiving the ice cream or an equivalent supplement, but this was not the case. The dietary manager confirmed that the usual process of adding nutritional support items to a resident's diet was not followed, resulting in the resident not receiving the recommended nutritional intervention.
Plan Of Correction
(Magic Cup) Immediately for Resident 12, Order was obtained for Magic Cup and added to resident tray ticket. An audit/review of all other current residents in the facility ordered supplements/interventions were reviewed for accuracy and appropriateness. Policy was Reviewed by Dietary Management, Medical Director, Nursing Administration and Dietician for accuracy. This Policy will be educated and reviewed with All current Registered Nurses and Dieticians; acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated, as necessary. Dietary Management or Designee will inspect the supplements provided at meal service. Audits will be completed with one meal per day x 7 days for two weeks. Then one meal per day x 3 days for two weeks. Finally, one meal a day x 1 day for one week and/or as needed. Dietitian or Designee will Audits items ordered in Care plans, physician orders and tickets/labeled snacks as appropriate. The Dietician is the responsible Dietary staff member who reviews and accepts orders in Electronic Medical Record (EMR) to know if supplements are being consumed. Dietician Audits for Care plans, physician orders and tickets/labeled snacks as appropriate Audits need to be completed once weekly x 5 weeks and/or with changes to supplement orders. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices as ordered by the physician for a resident, identified as Resident 23, who was moderately cognitively impaired and required set-up assistance with eating. The resident had a physician's order to use a divided plate to facilitate easier access to food, as indicated in the resident's meal ticket for the noon meal. However, during an observation on April 15, 2025, at 12:02 p.m., it was noted that the resident did not have the divided plate while eating in the dining room. This was confirmed by an interview with a Licensed Practical Nurse at the time of the observation.
Plan Of Correction
Licensed Practical Nurse on the unit immediately provided Resident 23 with fresh food and appropriate divided plate. Immediately after meal services, the Dietary Aid, which was responsible for providing the plate, was re-educated on the order for residents' adaptive equipment and noted that it was present on the meal ticket to ensure compliance. The Adaptive Equipment Policy was reviewed with no change needed. It will be educated and reviewed with all current staff which assist with meal service. Acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff and Hospices which assist with meals are to be educated, as necessary. An audit/review was completed for all Adaptive equipment ordered for residents with a visual analysis on the equipment being noted on residents' meal tickets as well as successful execution on providing appropriate equipment to the residents. Dietary Management or Designee will inspect the use of adaptive equipment at meal service. Audits to ensure compliance will occur at the following Schedule: Initially, one meal per day x 7 days for two weeks, followed by one meal per day x 3 days for two weeks and finally one meal a day x 1 day for one week and/or as needed. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Follow Physician Orders and Notify Physician
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents. For Resident 7, who was cognitively intact and had a colostomy, there was a failure to discontinue a previous wound care order after new orders were received. On May 20, 2024, a new order was issued for the resident's periostomy wound care, but the previous order from April 29, 2024, was not discontinued. As a result, both wound care orders were documented as administered on May 20, 21, and 22, 2024, which was confirmed by the Director of Nursing. For Resident 28, who was cognitively intact and had diabetes, the facility did not notify the physician when insulin was held due to low blood sugar levels. The resident's blood sugar levels were recorded as low on several occasions, and the bedtime dose of insulin was held on those dates. However, there was no documented evidence that the physician was notified, which was confirmed by the Director of Nursing. This failure to follow protocol for notifying the physician when insulin was held constitutes a deficiency in care.
Failure to Follow Catheter Care Orders
Penalty
Summary
The facility failed to follow physician's orders for the care of an indwelling urinary catheter for one resident. Resident 30, who was rarely or never understood or able to understand and was dependent on staff for daily care tasks, had an indwelling suprapubic catheter. A urology consult ordered the catheter to be changed every four weeks. However, a review of the resident's clinical records, including Treatment Administration Records and nursing notes, showed no documented evidence that the catheter was changed between January 30, 2024, and March 2, 2024. An interview with the Nursing Home Administrator confirmed the lack of documentation for the catheter changes as ordered during this period.
Failure to Maintain Therapeutic Diet for Resident
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident, identified as Resident 51, who was cognitively intact and required extensive assistance for daily care needs. The resident had a diagnosis of kidney failure and was initially on a No Salt Added diet with regular texture and thin liquids, as per physician's orders dated February 29, 2024. On May 4, 2024, a nurse's note indicated that the resident was experiencing prolonged chewing, leading to a referral to speech therapy and a precautionary downgrade of the diet to mechanical soft. A subsequent speech therapy note on May 7, 2024, confirmed the resident's difficulty in chewing, resulting in a physician's order for a regular diet with mechanical soft ground texture and thin liquids. However, there was no documented evidence that the therapeutic No Added Salt diet was continued when the texture was downgraded, which was confirmed by the Nursing Home Administrator on May 21, 2024.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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