Lecom At Snyder Memorial
Inspection history, citations, penalties and survey trends for this long-term care facility in Marienville, Pennsylvania.
- Location
- 156 Snyder Memorial Rd, Marienville, Pennsylvania 16239
- CMS Provider Number
- 395728
- Inspections on file
- 25
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lecom At Snyder Memorial during CMS and state inspections, most recent first.
Several residents with complex medical conditions had their MDS assessments inaccurately coded regarding the use of restraints and documentation of falls. Although bed rails and a pelvic safety device were observed in use according to physician orders, the MDS did not accurately reflect their status. The DON and Nursing Home Administrator confirmed these discrepancies after review of records, observations, and staff interviews.
A resident with chronic respiratory conditions did not have their oxygen saturation routinely monitored or documented as required by physician orders for continuous oxygen therapy. Facility policy required such monitoring and documentation, but the clinical record lacked evidence of compliance, as confirmed by the DON.
Three residents were kept on droplet isolation precautions despite negative lab tests for transmittable diseases and no fever, contrary to facility policy. Staff interviews revealed a lack of awareness about when to discontinue isolation, and the Infection Preventionist confirmed that isolation should have ended. The residents, who had conditions such as dementia and anxiety, experienced unnecessary restrictions on socialization and activities.
A resident with chronic respiratory conditions had physician orders for continuous oxygen at 2-3LPM via nasal cannula, but the care plan only reflected oxygen at 2LPM and was not updated to match the current orders. The DON confirmed the care plan was not reviewed or revised as required.
The facility did not ensure that the DON and Infection Preventionist attended two of four required quarterly QAPI Committee meetings, as shown by missing signatures on attendance records and confirmed by the NHA.
Snyder Memorial Health Care Center failed to conduct 12 required fire drills, lacking documentation of fire alarm signals and emergency simulations. The facility also conducted silent drills outside the NFPA-defined time intervals. These deficiencies were confirmed by the maintenance supervisor.
A facility failed to properly administer medications when an LPN left a medication cup containing Eliquis and Celexa unattended on a resident's bedside tray. The resident was asleep, and the LPN was not present to ensure the medications were taken, contrary to the facility's policy.
The facility failed to provide necessary morning care assistance for grooming and personal hygiene to five residents, as observed and confirmed by staff interviews. Residents with various medical conditions, including stroke, dementia, and intellectual disabilities, reported not receiving their A.M. care by the afternoon. Staff interviews confirmed that all residents required assistance, and the Director of Nursing stated that residents should be cleaned up by 10:30 a.m. daily.
The facility failed to maintain sanitary food service operations due to improper dishwashing procedures. The dish machine's final rinse temperatures were consistently below the required 180 degrees Fahrenheit, as revealed by temperature logs for May and June 2024. The Dietary Manager confirmed that staff were not properly trained on recording dish machine temperatures, violating state codes on licensee responsibility and dietary services.
The facility did not address or resolve concerns raised by the Resident Council over several months. Issues such as delayed call bell response times, ill-fitting dentures, and missing clothing were documented but not resolved or communicated back to residents. Interviews confirmed that residents were not informed about the outcomes of their concerns.
The facility did not obtain a physician's order for a resident with multiple sclerosis, heart problems, anxiety, and bipolar disorder to smoke, as required by their Tobacco and Vaping Policy. The resident was observed smoking outside without the necessary order, and the DON confirmed the oversight.
The facility failed to maintain proper documentation for drug regimen reviews for two residents, as required by their policy. Despite having diagnoses such as dementia and psychotic disorders, the residents' records lacked additional pharmacy reports and physician communication forms since the last survey. This was confirmed by the DON, indicating a failure to ensure medication regimens were free of unnecessary medications.
Inaccurate MDS Assessment Documentation for Restraints and Falls
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments to reflect the actual status of seven residents. Specifically, the MDS Section P0100A, which documents the use of restraints such as bed rails, was incorrectly coded for several residents. Although the MDS indicated that bed rails were used daily as restraints, observations revealed that only quarter-sized rails were present, which staff confirmed were not used as restraints. Additionally, for one resident, the MDS Section J1900 was incorrectly coded to show zero falls with major injury, despite documentation of a fall resulting in a head injury and hospital transfer. Another resident was coded as not using a trunk restraint, even though a pelvic safety device was observed in use per physician order. These inaccuracies were confirmed through review of clinical records, physician orders, incident reports, direct observations, and staff interviews. The Director of Nursing and the Nursing Home Administrator both acknowledged the incorrect MDS coding for the affected residents. The deficiencies involved residents with complex medical histories, including epilepsy, bipolar disorder, anxiety, heart disease, paraplegia, pressure ulcers, hemiplegia, diabetes, psychotic disorder, and profound intellectual disabilities. The failure to accurately document the use of restraints and falls in the MDS assessments constitutes a violation of medical records requirements.
Failure to Monitor and Document Oxygen Saturation per Physician Orders
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with physician's orders for one resident. The resident had a history of chronic obstructive pulmonary disease, chronic respiratory failure, and sleep apnea, and had a physician's order for continuous oxygen via nasal cannula at 2-3 liters per minute, with a goal oxygen saturation of 88-92%. Facility policy required staff to check the physician's order for oxygen flow and to document care provided according to the resident's needs. Review of the resident's clinical record showed that there was no evidence that oxygen saturation levels were routinely obtained or documented to ensure the resident was within the prescribed oxygen saturation range. During an interview, the DON confirmed that the clinical record lacked documentation of oxygen saturation percentages and acknowledged that monitoring was necessary to ensure compliance with the physician's orders.
Failure to Discontinue Unnecessary Droplet Isolation Precautions
Penalty
Summary
The facility failed to discontinue droplet isolation precautions for three residents after laboratory testing confirmed that they did not have transmittable diseases. According to facility policy, isolation and transmission-based precautions should be used only as necessary to prevent the spread of infection and should be the least restrictive possible. For the three residents involved, clinical records showed that all relevant tests for COVID-19 and influenza were negative, and the residents remained afebrile. Despite these negative results, droplet precautions were not removed, and the residents continued to be isolated. Staff interviews revealed a lack of awareness regarding the need to discontinue isolation precautions when no transmittable disease was present. One RN was unaware of any positive test results that would require ongoing droplet isolation, and an LPN confirmed that the residents were kept in isolation, which limited their ability to socialize and participate in activities. The Infection Preventionist also confirmed that isolation should have been discontinued based on the negative test results. The affected residents included individuals with diagnoses such as neuralgic amyotrophy, dementia, anxiety, depression, and dysphagia, and at least one resident expressed dissatisfaction with the unnecessary isolation.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident to reflect current care and services as required by facility policy. Specifically, a resident with chronic obstructive pulmonary disease, chronic respiratory failure, and sleep apnea had physician orders for continuous oxygen via nasal cannula at 2-3 liters per minute with a goal oxygen saturation of 88-92%. However, the resident's care plan only included interventions for oxygen at 2 liters per minute, either as needed or continuously, and did not reflect the updated physician order. The Director of Nursing confirmed that the care plans were not reviewed or revised to match the current orders and acknowledged that care plans should be updated as necessary.
Required QAPI Committee Members Absent from Meetings
Penalty
Summary
The facility failed to ensure the required attendance of the Director of Nursing (DON) and the Infection Preventionist at two of four quarterly Quality Assurance and Performance Improvement (QAPI) Committee meetings. Review of the facility's policy indicated that the QAPI steering committee must include the Administrator, DON, Infection Control, and Medical Director, in accordance with CMS regulations. Examination of the QAPI Committee attendance records showed that the DON was not present at the October 2024 meeting, and the Infection Preventionist was not present at the February 2025 meeting, as evidenced by the absence of their signatures on the attendance sheets. During an interview, the Nursing Home Administrator confirmed that there was no evidence of attendance for these required members at the specified meetings and acknowledged that their presence was required.
Failure to Conduct Required Fire Drills
Penalty
Summary
Snyder Memorial Health Care Center was found to be non-compliant with the Life Safety Code requirements for an existing health care occupancy during an Abbreviated Survey conducted as part of a Complaint Investigation. The facility, a one-story, Type V (111), protected, wood frame building that is fully sprinklered, failed to conduct the required fire drills. Document review revealed that the facility did not perform 12 out of 12 required fire drills, as there was no documentation of the sending/receiving of a fire alarm signal or the simulation of emergency fire conditions. Additionally, the facility conducted silent drills outside the defined NFPA time intervals, specifically between 9:00 p.m. and 6:00 a.m. An interview with the maintenance supervisor confirmed these deficiencies.
Plan Of Correction
A fire drill was immediately held in the facility on 1/8/2025 at 1400 during the 1st shift. A test of the pull station was completed and documentation of successful check obtained. The Director of Maintenance was educated by the facility Administrator on the requirements of conducting fire drills and maintaining documentation of fire drills in accordance with NFPA 101. An all staff education on fire prevention policy will be completed by January 31, 2025. The education will be conducted by the facility administrator designee. A calendar of scheduled fire drills has been completed for the calendar year and shared only by the Director of Maintenance and the facility administrator to facilitate unexpected times and varying conditions. The facility Director of Maintenance will be responsible for performing the fire drills in accordance with requirement. The Facility Administrator will audit fire drills monthly to ensure completion and compliance with the requirement. The results of the audit and the fire drill will be reviewed by the facility Quality Assurance and Performance Improvement Committee at a minimum of the next 3 scheduled meetings.
Medication Administration Deficiency
Penalty
Summary
The facility failed to properly safeguard and administer medications for one of the six residents reviewed. The facility's policy on medication administration, dated 10/11/23, requires that all medications be given by the person who prepared the dose, ensuring the resident has enough fluids to swallow their medication, and that no medication is left at the bedside. However, during an observation on 10/01/24, a medication cup containing two pills, Eliquis 2.5 mg and Celexa 10 mg, was found on the bedside tray table of Resident R1, who was asleep. The LPN who prepared the medication was not present in the room, having left the medication unattended. A Registered Nurse confirmed that the medications should not have been left alone in the room and that the LPN should have ensured the resident took the medications before leaving.
Failure to Provide Morning Care Assistance
Penalty
Summary
The facility failed to provide necessary assistance for grooming and personal hygiene to five residents, as observed and confirmed by staff interviews. The facility's policy on A.M. Care, dated 8/09/23, outlines the importance of morning care for cleanliness, comfort, and psychosocial well-being. However, observations on 6/15/24 revealed that several residents had not received their morning care by the afternoon. Resident R15, with a history of stroke and dementia, was found in the hallway in street clothes, stating they had not been cleaned up yet. Similarly, Resident R22, with psychotic disorder and intellectual disabilities, was in their room and had not been washed up. Resident R5, with traumatic brain injury and intellectual disabilities, also reported not having completed their A.M. care. Further observations showed Resident R2, with multiple sclerosis, lying in bed with a soiled shirt, expressing a preference for being cleaned before breakfast. Resident R16, with schizophrenia and bipolar disorder, was in their wheelchair and had not been washed up, expecting it to happen only before bed. Interviews with staff, including a nurse aide and an LPN, confirmed that all residents on the hall required assistance with personal hygiene, and none were independent. The Director of Nursing confirmed that all residents should be cleaned up by 10:30 a.m. daily, indicating a failure to adhere to this standard.
Failure to Maintain Sanitary Food Service Operations
Penalty
Summary
The facility failed to maintain sanitary food service operations in its kitchen, as evidenced by a deficiency in the dishwashing process. The facility's policy, last reviewed on August 9, 2023, required that dish machine temperatures be checked and documented at all meals, with the high-temperature dish machine wash ranging from 150 to 160 degrees Fahrenheit and the final rinse temperature at least 180 degrees Fahrenheit. However, observations and a review of the dish machine temperature logs for May and June 2024 revealed that the final rinse temperatures were consistently below the required 180 degrees Fahrenheit, with most temperatures recorded between 160 and 170 degrees Fahrenheit. During an interview, the Dietary Manager confirmed that the documented temperatures did not meet the required standards for proper sanitization and acknowledged that staff had not been properly trained on recording dish machine temperatures. This deficiency was identified as a violation of 28 Pa. Code 201.14(a) and 28 Pa. Code 211.6(f) regarding the responsibility of the licensee and dietary services, respectively.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and resolve concerns raised by the Resident Council over a three-month period. During the months of March, April, and May 2024, the Resident Council Meeting Minutes revealed that previous concerns were not discussed with the council, and new concerns were not assigned to a department for investigation. Issues raised included the use of chewing tobacco in resident rooms, locked dining room doors, delayed call bell response times, ill-fitting dentures, inconsistent smoke break times, dirty bathrooms, inability to fully utilize wheelchairs, and missing clothing. Despite documentation of these concerns in facility Grievance Concerns forms, there was no evidence of resolutions being communicated back to the residents. Interviews with Resident Council members confirmed that they were not informed about how their concerns were being resolved, and there was a lack of evidence that the repeated education provided to staff was effective. The Director of Nursing, Nursing Home Administrator, and Registered Nurse Assessment Coordinator acknowledged the absence of evidence showing that previous concerns were discussed at Resident Council Meetings or that residents were informed of the outcomes. This lack of communication and resolution led to the deficiency identified in the report.
Failure to Obtain Physician's Order for Smoking
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for Resident R9, who was admitted with diagnoses including multiple sclerosis, heart problems, anxiety, and bipolar disorder. The facility's Tobacco and Vaping Policy requires a physician's order for smoking to ensure compliance with Federal and State regulations and guidelines. However, a review of Resident R9's clinical record revealed a lack of evidence that a physician's order was obtained for smoking. Observations confirmed that Resident R9 was seen smoking outside in a gathering area on two separate occasions. During an interview, the Director of Nursing confirmed the absence of a physician's order for Resident R9 to smoke, which is necessary to ensure the resident's safety in participating in smoking activities.
Failure to Maintain Drug Regimen Review Documentation
Penalty
Summary
The facility failed to ensure that medication regimens were free of potentially unnecessary medications for two residents. The facility's policy on Drug Regimen Review, dated 8/09/23, requires that completed pharmacy reports be maintained, and that prescribers act upon the Drug Regimen Review findings within 21 days, documenting any disagreements with recommendations. However, for Resident R38, who has diagnoses including alcohol abuse with alcoholic-induced psychotic disorder, dementia with behavioral disturbances, and stroke, the clinical record only contained one Physician's Communication Form dated 4/26/24, with no additional pharmacy reports or communication forms available since the last full health survey on 7/25/23. This was confirmed by the Director of Nursing during an interview on 6/17/24. Similarly, Resident R69, diagnosed with dementia with behavioral disturbance, anxiety, major depression with psychotic symptoms, and stroke, also had only one Physician's Communication Form dated 1/31/24 in their clinical record, with no further pharmacy reports or communication forms since the last survey. The Director of Nursing confirmed this during an interview on 6/18/24. The lack of documentation and follow-up on pharmacy recommendations for these residents indicates a failure to comply with the facility's policy and regulatory requirements, potentially leading to the continuation of unnecessary medications.
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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