Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Linwood Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia had orders for multiple CNS-active medications, including an antidepressant, two antipsychotics, an opioid, a benzodiazepine, and an anticonvulsant. The consultant pharmacist recommended that the attending physician reevaluate the medication combination and consider GDR of quetiapine and/or perphenazine, but the clinical record did not show any physician review, response, GDR, or documented reason that reduction was not attempted. The DON confirmed the facility could not provide documentation of physician action on the recommendation.
Planned pureed menu item not available for residents on pureed diets. A planned lunch menu included a pureed dinner roll for residents with physician-ordered pureed diets, but during meal service no pureed dinner rolls were available on the tray line. Nine residents with pureed diet orders did not receive the menu item, and the CDM confirmed the item was missing and could not explain why it was not prepared or available.
Food and drinks were not consistently served at safe, palatable temperatures for residents receiving meals from the hallway cart. A test tray showed the entree, sides, and coffee were below ideal serving temperatures, and two residents reported they frequently received cold, unappetizing meals, including coffee. The CDM confirmed meals were not being served in accordance with regulatory guidelines.
Care Plan Did Not Address Known Behavioral Needs: A resident with Alzheimer's disease and Bipolar Disorder was severely cognitively impaired and had a known history of sexualized behaviors and inserting objects into body openings. Staff observed the resident pass a blue rubber glove in stool, but the care plan did not identify the behavior or include individualized, measurable goals or interventions despite family and staff awareness.
Failure to Document PICC Line IV Competency: A resident with osteomyelitis and bacteremia had a PICC line and received ordered NS flushes through the line by multiple LPNs. The facility could not produce proof that the LPNs completed required IV therapy education, competency validation, supervision documentation, or PICC-specific training, and the DON and NHA confirmed no such documentation or PICC policy existed.
A resident was observed receiving oxygen by nasal cannula at 3 LPM, but the clinical record did not include a physician order for oxygen. An LPN confirmed the missing order, and the DON and NHA later verified that oxygen was being provided without an order, contrary to facility policy and professional standards.
Pain management documentation was deficient for a resident with osteomyelitis and bacteremia. The PRN oxycodone order lacked the required pain indication or severity level, staff did not document attempted non-pharmacological interventions before four doses of the opioid, and there was no follow-up numeric pain scale within one hour after administration to show effectiveness. The NHA and DON reviewed and confirmed the missing documentation.
Controlled Substance Documentation Discrepancies: A resident with paraplegia and COPD had an order for PRN hydrocodone-acetaminophen, a Schedule II opioid, for thoracic spine pain. Review of the controlled med record and MAR showed multiple mismatches, including doses documented as removed or used without MAR entries and MAR administrations without corresponding controlled med record documentation. The DON reviewed the discrepancies with the surveyor.
Improper Dating and Expired Insulin Pens in Medication Cart: Surveyors found an opened insulin glargine pen on a medication cart that was not dated when opened, and a Tresiba insulin U-100 pen that remained available for use beyond the manufacturer’s 28-day discard period. An LPN confirmed both issues, and the DON was informed of the facility’s failure to follow policy and manufacturer guidance.
The facility failed to develop and maintain an effective training program to ensure LPNs were competent to manage a resident’s PICC line for IV Daptomycin therapy. A resident with osteomyelitis and bacteremia had orders for PICC line flushes and antibiotic administration, and the eMAR showed multiple LPNs accessed the line for flushes and medication. Personnel files did not show PICC-specific education or competency validation for the LPNs, and the DON stated the facility had not implemented PICC line training or included it in annual nursing competency reviews.
A resident who was not safe to self-administer medications was found with multiple unsecured medications, including Tylenol, cranberry tablets, and oxycodone, left in clear plastic cups on the bedside table. The medications were accessible in an open room, contrary to facility policy requiring staff to remain with residents until medications are ingested. The DON confirmed the medications and the policy violation.
A resident with anxiety disorder and chronic pain was repeatedly administered PRN Lorazepam without documented evidence of anxiety-related behaviors or symptoms, and often received the medication alongside opioid pain medication. The facility did not consistently document clinical indications or behavioral monitoring prior to administering the psychoactive medication, as confirmed by the DON.
Two residents experienced actual harm due to staff failures: one was given hot coffee without a required lidded cup, resulting in burns, while another suffered a head injury, hip fracture, and rib fractures after agency staff performed a mechanical lift transfer without properly securing the sling. In both cases, lack of proper documentation, communication, and staff competency contributed to the injuries.
Surveyors found that the dietary department did not label or date several opened and thawed food items, including milk, prepared salads, and nutritional supplements, as required by facility policy. The lack of proper labeling made it impossible to determine safe use or discard dates, increasing the risk of food contamination. The dietary supervisor confirmed these unsanitary practices during the inspection.
A resident with a history of spinal fusion did not receive the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) before Medicare Part A coverage ended. The notice was provided only after coverage had lapsed, as confirmed by facility staff interviews and record review.
A resident's MDS assessment inaccurately documented that insulin was administered during a seven-day period, while medication records showed no insulin was given. The DON confirmed the discrepancy between the MDS and the actual medication administration.
A resident with severe cognitive impairment and a feeding tube experienced significant unplanned weight loss, but staff did not reweigh the resident within 24 hours, complete a timely nutritional assessment, or notify the physician or representative as required by facility policy.
A resident was transferred to a hospital and later readmitted, but the facility did not provide written notification of the transfer to the resident, the resident's representative, or the State LTC Ombudsman as required. Staff confirmed that documentation of these notifications was not available.
Linwood Nursing and Rehabilitation Center failed to investigate an allegation of physical abuse reported by a resident. The resident, who was cognitively intact, reported that a nurse aide was rough with her, but the facility did not conduct a thorough investigation or document the incident as required by their policy. The Director of Nursing confirmed the lack of investigation, leading to a deficiency citation.
A resident at Maplewood Nursing and Rehabilitation, dependent on a mechanical lift for transfers due to multiple health conditions, was transferred by a single nurse aide, contrary to the facility's policy requiring two staff members. Despite training, the second staff member left the room, leading to non-compliance with safety regulations.
A resident at Maplewood Nursing and Rehab Center required a stealth CT scan for prosthetic manufacturing, but the facility failed to submit necessary medical information to the insurance company. Despite multiple attempts by a nurse aide to contact the insurance company, the required imaging studies were not approved due to lack of information. The facility could not provide evidence of submission, and the deficiency was confirmed by the facility's Administrator and Assistant DON.
A facility's call bell system malfunctioned, leaving residents in three halls without a reliable way to call for assistance. Temporary tap bells were insufficient, and staff were not adequately trained on increased safety measures. This led to incidents where residents were unable to alert staff, including one resident found injured on the floor.
The facility failed to protect the personal privacy of three residents by posting signs above their beds with specific care instructions, such as the use of a Hoyer pad and nectar thick liquids. An interview with the NHA revealed an inability to justify the presence of these signs, compromising the residents' privacy rights.
The facility failed to provide adequate supervision, resulting in falls for two residents. One resident, needing assistance for toileting, fell after waiting over 20 minutes for help due to insufficient staff. Another resident, with a history of stroke, fell when the call bell system was non-operational, and staff were unaware of the incident until alerted by another resident. The Nursing Home Administrator confirmed these deficiencies.
The facility was found to have ongoing deficiencies in personal privacy and infection control. Observations revealed signs with personal information in residents' rooms, compromising privacy. The infection control program lacked effective monitoring and investigation, with poor practices observed, such as a catheter bag on the floor. A resident's infection was not tracked, and no intervention plans were in place. The quality assurance plan failed to address these issues.
The facility failed to maintain a comprehensive infection control program, lacking a system to monitor and investigate infections. A resident's persistent cough was not effectively tracked, leading to a diagnosis of Rhinovirus and pneumonia. Observations included improper foley catheter and hygiene equipment handling. The Infection Preventionist confirmed incomplete logs and the need for maintained practices.
A resident with a history of stroke fell in the bathroom after waiting over 20 minutes for assistance, due to insufficient staffing. At the time, only one LPN and one nurse aide were available, both occupied with another resident. The facility's staffing did not meet the required minimum, as confirmed by the DON.
The facility did not correctly post current nurse staffing information. Observations revealed that the posted nursing time was outdated and did not include the current day's staffing details. The Nursing Home Administrator confirmed the information was not posted at the beginning of the shift, and the facility failed to list the total number of staff and actual hours worked.
The facility failed to maintain a hazard-free environment on the second floor, where unsecured air purifiers and plastic containers obstructed access to handrails, creating potential tripping hazards. The nursing home administrator acknowledged these issues during an interview.
The facility failed to implement a comprehensive infection control program, lacking a system to monitor and investigate infections. Monthly logs were inconsistent, missing crucial details, and a resident's Salmonella infection was not tracked or addressed. The facility could not demonstrate effective surveillance or data analysis to prevent infection spread.
A resident's personal privacy was compromised when a sign was posted in her room without her knowledge, indicating restrictions on using her right arm for medical procedures. The resident and her daughter were unaware of the reason for the sign, and the Nursing Home Administrator could not provide an explanation, highlighting a failure in maintaining privacy.
A facility failed to include necessary care for a resident with a broken ankle in their care plan. The resident had a cast on her right leg, but the care plan did not address the need for regular assessment of her exposed toes for color, circulation, sensation, and mobility. This deficiency was identified during an observation and interview.
A resident experienced a delay in treatment for painful urination due to a CRNP's failure to order a urinalysis test promptly. The resident, admitted with a fractured ankle, reported symptoms to the CRNP, who noted the need for a test but did not order it. An LPN later obtained the necessary order, revealing a salmonella infection. Treatment began ten days after the initial complaint.
A resident diagnosed with salmonella infection raised concerns about the facility's food quality, leading her to request meals from her daughter. Despite consuming some facility food, the facility attributed the infection to external meals without conclusive evidence. The facility did not evaluate dietary staff practices or provide food safety training, and no quality improvement activities were initiated.
The facility failed to protect a resident from sexual abuse by another resident with known inappropriate behaviors and neglected to provide necessary care for two other residents, leading to harm and discomfort. Despite multiple incidents, the facility did not report or investigate the abuse, and residents were left in soiled briefs for extended periods, compromising their well-being.
The facility did not ensure comprehensive staff training on its abuse prohibition policy and specific procedures for reporting abuse, neglect, and exploitation. The Nurse Educator confirmed that the educational content lacked facility-specific procedures, and the NHA acknowledged the deficiency in both annual and new hire training programs.
The facility failed to report instances of resident abuse to the State Survey Agency within the required timeframe. A resident with severe cognitive impairment was involved in multiple incidents of sexually inappropriate behavior, which were not reported promptly. The facility's policy requires reporting within 24 hours and submission of completed investigations within five working days, but these requirements were not met.
The facility failed to investigate sexual abuse allegations involving a resident known for inappropriate behavior towards female residents and did not report findings to the State Agency. Additionally, the facility did not thoroughly investigate an ankle fracture of another resident, failing to rule out abuse or neglect. The facility's policies on abuse prevention and incident investigation were not followed, leading to significant lapses in resident safety.
The facility failed to provide written notice of its bed-hold policy to several residents and their representatives upon hospital transfer. This deficiency was identified for six residents, with no documentation of notification found in their clinical records. The NHA and DON could not provide evidence of compliance during an interview.
The facility failed to assess and implement individualized toileting care plans for three residents, leading to deficiencies in their care. A resident with dementia and a history of falls was not consistently checked and changed every two hours, resulting in hospitalization for sepsis and a UTI. Another resident with heart failure and frequent UTIs was also not consistently checked and changed as planned. Additionally, a resident with urinary retention and chronic UTIs experienced a decline in bowel continence, which the facility failed to address.
The facility failed to monitor and address significant weight changes for three residents, including not evaluating weight accuracy, not following up on significant changes, and not providing ordered nutritional supplements. These deficiencies were confirmed by the NHA and DON.
A resident with rheumatoid arthritis, Alzheimer's, and osteoporosis experienced inadequate pain management due to the facility's failure to implement an individualized pain management program. Despite ongoing complaints of pain and a subsequent ankle fracture, the facility did not perform a pain evaluation or adjust the pain medication regimen, leading to continued discomfort.
A resident with rheumatoid arthritis, Alzheimer's, and osteoporosis experienced swelling in the left leg. Despite multiple calls to the physician, there was a four-day delay in response, leading to a late diagnosis of ankle fractures. The facility did not contact an on-call physician or medical director, resulting in the resident's hospitalization for a fractured leg and exacerbated cardiac condition.
The facility failed to provide adequate nursing staff, resulting in delayed medication administration and personal care for residents. A resident with multiple medical conditions did not receive timely medications, while another was left in a soiled state for hours. Additionally, a resident's medical appointment was rescheduled due to staffing shortages. Interviews confirmed these deficiencies, highlighting the facility's inability to meet residents' needs.
A facility failed to provide adequate staff competency and supervision for a resident with severe cognitive impairment and inappropriate sexual behaviors. Despite a care plan with interventions like frequent checks, the resident engaged in inappropriate conduct with female residents. Staff documented incidents but lacked consistent supervision and training, failing to prevent further occurrences.
The facility failed to conduct a comprehensive assessment to identify necessary resources for residents with behavioral health and dementia care needs. The assessment lacked evaluation of residents' conditions and did not address staffing, training, and competency requirements. The Nursing Home Administrator confirmed the need for enhanced training for staff to meet the needs of residents requiring increased supervision.
The facility did not ensure that the QA/QAPI committee, including the NHA, DON, Medical Director, and department heads, met quarterly as required. Only one meeting was documented between the last and current annual surveys, and the NHA could not provide evidence of additional meetings due to missing signature sheets.
A facility failed to ensure accurate MDS assessments, as a resident's quarterly MDS inaccurately indicated receiving anticoagulant medication for 7 days. However, records showed no such medication was ordered or administered during the look-back period. The RN Assessment Coordinator confirmed the inaccuracy.
A medication cart was left unattended and unlocked in a resident care unit hallway by an LPN during medication administration. The cart, containing keys to access medications and narcotics, was out of the nurse's view, while multiple residents were independently mobile in the area. The DON confirmed the potential hazard and risk of unauthorized access.
A resident with cognitive intactness and heart-related diagnoses did not receive timely dental services as required. Despite a care plan intervention for dental consults, the resident's scheduled dental appointment for a tooth extraction was canceled and not rescheduled, with no further documentation of dental services provided. Interviews revealed the resident was aware of the cancellation and awaiting a new appointment, which the facility failed to schedule.
Physician Did Not Respond to Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to ensure the attending physician reviewed and responded to a consultant pharmacist’s medication regimen review recommendation for one resident with dementia. The resident had orders for multiple CNS-active medications, including venlafaxine, quetiapine, perphenazine, oxycodone hydrochloride, clonazepam, and primidone. In the consultant pharmacist communication to the physician, the pharmacist identified that the resident had three or more CNS medications and noted that quetiapine and perphenazine were due for gradual dose reduction (GDR). The pharmacist recommended that the attending physician reevaluate the combination of CNS medications and consider GDR of quetiapine and/or perphenazine, or document why reduction would be medically inappropriate. Review of the clinical record did not reveal written documentation that the attending physician reviewed, acknowledged, or responded to the pharmacist’s recommendation. The record also did not show documentation that the physician evaluated the medication combination, implemented a GDR, or documented a clinical reason why a reduction could not be attempted. During interview, the DON confirmed the facility could not provide documentation showing the attending physician reviewed or acted upon the consultant pharmacist’s recommendation.
Planned Pureed Menu Item Not Available for Residents on Pureed Diets
Penalty
Summary
The facility failed to follow the planned menu for residents who required a pureed consistency diet, affecting 9 of 9 residents reviewed with physician-ordered pureed diets: Residents 18, 23, 28, 45, 47, 61, 81, 9, and 92. The planned cycle menu for the lunch meal on March 5, 2026, included a dinner roll to be provided in pureed form for residents on a pureed diet. During observation of lunch meal service on March 5, 2026, between 12:00 P.M. and 12:45 P.M., there were no pureed dinner rolls available on the tray line where meals were prepared and distributed. Continued observation showed that the nine residents with physician orders for a pureed consistency diet did not receive a pureed dinner roll with their lunch meal as listed on the planned menu. During interview at 12:45 P.M., the CDM confirmed that pureed dinner rolls were not available on the lunch tray line, confirmed that the planned menu included pureed dinner rolls for residents receiving pureed consistency diets, and was unable to explain why they were not prepared or available for service.
Food Served at Unsafe and Unpalatable Temperatures
Penalty
Summary
The facility failed to ensure food and drinks were served at safe and palatable temperatures for residents receiving meals on the 300 hallway cart. A review of food committee minutes dated January 9, 2026 showed complaints that meal trays were left on food carts in the hallway while waiting for staff to deliver them to resident rooms, resulting in cold food. The minutes did not identify which residents attended the meeting or made the complaints. The facility’s posted meal service schedule for March 5, 2026 showed lunch for the 300 rooms hall cart was scheduled for delivery at 12:20 PM, but observation of the kitchen tray line at 12:22 PM showed cart three leaving the kitchen at that time, and the last tray on the 300 nursing unit was not served until about 12:30 PM. A test tray evaluated at 12:31 PM showed food temperatures of 134.8 F for onion sage chicken, 133.1 F for carrots, 127.5 F for au gratin potatoes, 121.5 F for coffee, 122.2 F for hot water, and 57 F for a purple cold drink. The chicken entree was described as cool and not palatable, the carrots were bland and mushy, and the au gratin potatoes were dry, hard, and difficult to chew. Two residents who ate in the small hallway dining room stated they frequently received cold, unappetizing food, including coffee, and one said nursing staff could reheat the coffee but he just drank it cold. The Certified Dietary Manager confirmed the facility failed to ensure meals were served at temperatures that are palatable and in accordance with regulatory guidelines.
Care Plan Did Not Address Known Behavioral Needs
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan that included individualized and measurable interventions for a resident with known behavioral needs. Resident 88 was admitted with diagnoses including Alzheimer's disease and Bipolar Disorder and was severely cognitively impaired on the annual MDS, with a BIMS score of 0. Facility policy required comprehensive care plans to address each resident's identified needs, including behavioral needs, based on assessment findings and interdisciplinary input. A nursing progress note documented that staff observed Resident 88 defecate a blue rubber glove into the toilet, with the glove intact and intertwined in stool. The resident had no rectal redness, swelling, irritation, blood, pain, or discomfort, and the RN notified the on-call medical provider. During interview, the DON stated family members had previously informed staff that the resident had a history of sexualized behaviors and inserting objects into body openings. However, the resident's care plan, originally initiated in 2015 and most recently updated in January 2026, did not identify these behaviors as a problem and did not include individualized goals or interventions to address or monitor them, despite staff awareness of the behavior.
Failure to Document IV Therapy Competency for PICC Line Administration
Penalty
Summary
The facility failed to ensure nursing services met professional standards of quality by not implementing appropriate nursing practices for administration of IV medication through a PICC line for one resident. The resident was admitted with osteomyelitis and bacteremia and had a PICC line in the left arm. A physician ordered 10 mL normal saline flushes through the PICC line prior to and after daily antibiotic administration, and the eMAR showed that three LPNs documented normal saline administration through the PICC line on multiple occasions. The facility could not produce documentation showing that the three LPNs had completed the IV therapy education required under Pennsylvania Code Chapter 21.145(b). There was also no evidence of current competency validation, supervision documentation, or internal training specific to PICC line administration. During interview, the DON and NHA confirmed the facility had no documentation of required IV therapy education or competency for LPNs regarding medication administration through PICC lines, and the facility did not maintain a policy specific to PICC line medication administration or documented competencies for RNs or LPNs.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
Failure to provide oxygen therapy consistent with professional standards of practice occurred for one resident. Facility policy for Oxygen Administration by Nasal Cannula and mask stated that residents requiring oxygen must have a physician order specifying the flow rate, how oxygen is to be administered, and whether humidified air is needed if necessary. The policy also stated that oxygen tubing and bag are to be changed monthly and dated when changed. Resident 43 was admitted with diagnoses including unspecified convulsions and was cognitively intact on a significant change MDS assessment with a BIMS score of 13. On March 3, 2026, the resident was observed in bed receiving oxygen by nasal cannula attached to an oxygen concentrator at 3 liters per minute, and later the same day was observed sitting in a chair still receiving oxygen at 3 liters per minute. Review of the clinical record did not include a physician order for oxygen. An LPN confirmed there was no physician order for oxygen, and the DON and NHA later confirmed there was no order for the resident's oxygen in accordance with professional standards and facility policy.
Pain Management Documentation Deficiencies
Penalty
Summary
Safe, appropriate pain management was not provided for Resident 102, who was admitted with osteomyelitis and bacteremia. The facility’s pain management policy required staff to attempt and document non-pharmacological measures before giving PRN pain medication, and to use a numeric pain scale before administration and again one hour afterward to evaluate effectiveness. The policy also required PRN pain medication orders to include the medication name, strength, frequency, indication or location of pain, and pain scale category such as mild, moderate, or severe. A nurse practitioner order dated February 27, 2026, prescribed oxycodone HCL 5 mg, one tablet every four hours as needed for pain, but the order did not include the required pain indication or severity level. The March 2026 MAR showed four administrations of the PRN narcotic pain medication for documented pain levels of 7, 7, 6, and 7, but the record did not show that non-pharmacological interventions were attempted or documented before any of those doses. The record also did not contain a follow-up numeric pain scale within one hour after administration to evaluate whether the medication relieved the resident’s pain.
Controlled Substance Documentation Discrepancies
Penalty
Summary
The facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for one resident. The facility policy titled Controlled Substances stated it would comply with laws, regulations, and requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled medications. Resident 1 was admitted with diagnoses including paraplegia and COPD, and had a physician order dated November 16, 2025 for hydrocodone-acetaminophen 5 mg/325 mg, a Schedule II opioid, to be given one tablet every 4 hours as needed for moderate to severe pain related to thoracic spine pain. A review of Resident 1’s Controlled Medication Utilization Record and MAR from November 2025 through February 2026 showed documentation discrepancies for hydrocodone-acetaminophen. There were 8 entries on the controlled medication record showing the medication was removed or utilized with no corresponding MAR documentation that it was administered, and 5 MAR entries showing the medication was administered with no corresponding controlled medication record showing it was removed from inventory. The surveyor reviewed these findings with the DON during an interview on March 5, 2026, regarding the facility’s failure to reconcile the resident’s controlled substance medications.
Improper Dating and Expired Insulin Pens in Medication Cart
Penalty
Summary
The facility failed to ensure medications were properly dated when opened and failed to discard a multi-dose medication after the manufacturer’s recommended use-by period on one of four medication carts, specifically 300 Hall, Cart 2. Review of the facility policy titled Storing and Expiration Dating of Medications and Biologicals showed that staff were expected to record the date a medication container was opened and that multi-dose injectable medications were to be dated and discarded within 28 days unless the manufacturer specified otherwise. During observation of the medication cart on 300 Hall, Cart 2, surveyors found one multi-dose insulin pen of Insulin Glargine that had been opened and was available for use, but it was not dated when initially opened. Surveyors also observed one multi-dose insulin pen of Tresiba Insulin U-100 that had been labeled with an opening date, and manufacturer guidance showed it should have been discarded 28 days after opening; based on the labeled date, it should have been discarded on February 11, 2026, but it remained in the cart and available for use more than three weeks past that discard date. An LPN confirmed both findings during interview, and the DON was later informed of the facility’s failure to follow its policy and manufacturer guidance.
Lack of PICC Line Training and Competency Validation for Licensed Nursing Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for licensed nursing staff to ensure competency in managing a PICC line for Resident 102, who was admitted with osteomyelitis and bacteremia and had a PICC line in place for IV antibiotic therapy. Orders required daily Daptomycin administration through the PICC line, along with normal saline flushes before and after the antibiotic and during evening and night shifts to maintain catheter function. Review of the resident’s eMAR showed that in February 2026 the antibiotic was documented as administered one time and normal saline flushes were documented four times through the PICC line by licensed nursing staff. In March 2026, the antibiotic was documented as administered two times and normal saline flushes were documented eleven times through the PICC line. The eMAR also showed that multiple LPNs accessed the PICC line to administer normal saline flushes, including Employee 2, Employee 3, and Employee 4. Review of personnel records for these LPNs did not show documentation of education, training, or competency validation related to PICC line management before they provided PICC line care. Employee 2’s file showed hire and orientation completion on January 15, 2026; Employee 3’s file showed hire on November 12, 2024, orientation completion on November 16, 2024, and annual licensed nursing education on November 16, 2024; and Employee 4’s file showed hire and orientation completion on April 11, 2025. During interview, the DON stated the facility had not developed or implemented a PICC line training program for licensed nursing staff and had not included PICC line management in annual nursing competency or skills reviews. The NHA and DON also stated the facility should have developed and implemented PICC line training based on the resident population and facility assessment before staff provided PICC line care.
Unsecured Medications Left at Bedside in Resident Room
Penalty
Summary
The facility failed to ensure that the resident environment was free from potential accident hazards on one of its nursing units. Specifically, in one resident's room, five clear plastic cups containing a total of seven tablets and two capsules were found unsecured on the bedside table. These medications were accessible in an open room, which could have allowed other residents to access them. The medications included Tylenol 325 mg tablets, a cranberry 300 mg tablet, and oxycodone HCl 5.0 mg capsules. The presence of these medications at the bedside was in direct violation of the facility's policy, which requires that a nurse or qualified staff remain with the resident until medications are ingested. A review of the resident's clinical record indicated that the individual was not deemed safe to self-administer medications, as they required nursing assistance and could not state the purpose, dosage, or timing of their medications. The medications were supposed to be maintained and administered by nursing staff. The DON confirmed both the presence of the medications and that the oxycodone was dispensed in a different form than ordered. These findings were corroborated by facility policy and staff interviews.
Failure to Document Indications for Psychoactive Medication Administration
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of behaviors and clinical indications prior to administering psychoactive medications for a resident with diagnoses including anxiety disorder, encephalopathy, and chronic pain. Clinical record review showed that the resident received multiple doses of PRN Lorazepam without documented evidence of anxiety-related behaviors or symptoms to justify its use. On several occasions, the Medication Administration Record (MAR) indicated that Lorazepam was administered even when the resident was not exhibiting anxiety, and the Documentation Survey Report confirmed no anxiety behaviors were present on those dates. The resident also reported not requesting Lorazepam and stated that staff administered it in addition to pain medication to help with sleep, rather than for anxiety. Further review revealed that Lorazepam was frequently given in combination with a prescribed opioid pain medication, Hydrocodone/Acetaminophen, without proper documentation of clinical need for the psychoactive medication. The facility was unable to provide supporting documentation for the administration of Lorazepam, and the Director of Nursing confirmed that monitoring of behaviors and clinical indications was not consistently documented. This lack of documentation and monitoring led to the administration of psychoactive medication without appropriate indication, as required by regulation.
Failure to Implement Adaptive Device and Ensure Safe Mechanical Lift Transfers Resulting in Resident Harm
Penalty
Summary
The facility failed to implement a physician-ordered adaptive device for a resident with severe cognitive impairment, resulting in actual harm. The resident, who had dementia and required set up and clean up assistance for meals, had an active physician order for lidded cups for all liquids. Despite this, the resident was provided with hot coffee in a regular cup without a lid, which was not documented on the resident's Kardex. A nurse aide, unaware of the order, placed the coffee in front of the resident and turned away, during which time the resident spilled the hot liquid into her lap, causing multiple burns and blisters to the upper thigh area. The coffee was documented at 139 degrees Fahrenheit at the time of the incident. In a separate incident, the facility failed to ensure that nurse aides demonstrated the necessary skills and competencies to safely perform mechanical lift transfers for another resident with severe cognitive impairment and total dependence for transfers. The resident required a mechanical lift for all transfers per physician order. During a transfer, an agency nurse aide and an agency LPN used a universal sling but failed to cross the leg straps as required by manufacturer instructions. As a result, the resident slid out of the sling, first onto the bed and then onto the floor, striking her head. The resident sustained a scalp hematoma, a left periprosthetic hip fracture, and multiple rib fractures. Documentation revealed that the agency LPN had no evidence of mechanical lift training or competency validation prior to assisting with the transfer. Both incidents demonstrate failures in communication, documentation, and staff competency. In the first case, the adaptive device order was not properly linked to the resident's Kardex, leading to staff being unaware of the requirement. In the second case, improper use of the mechanical lift sling and lack of documented training for agency staff directly resulted in significant injuries to the resident. These failures resulted in actual harm to both residents involved.
Failure to Label and Date Opened and Thawed Food Items in Dietary Department
Penalty
Summary
Surveyors observed that the facility failed to maintain proper food storage and labeling practices in the dietary department, which increased the risk of food contamination and food-borne illness. During an initial tour of the dietary area, it was found that several food items inside the reach-in tray line refrigerators, including opened containers of chocolate milk, a prepared plated tossed salad with chicken, an opened gallon of milk, and an opened can of cola, did not have use by dates or thaw dates as required by facility policy. Additionally, thawed nutritional supplements such as juice drinks and Magic Cup supplements were found without any indication of thaw or discard dates, making it impossible to determine if they were still safe for consumption. The facility's own policy, last reviewed in February 2025, requires that all time/temperature control foods and ready-to-eat foods prepared on site and held for longer than 24 hours must be properly labeled and dated. The dietary supervisor confirmed these observations and acknowledged that the lack of labeling on opened and thawed items was not in accordance with safe food handling practices. No information about specific residents or their medical conditions was provided in the report.
Failure to Timely Issue SNF-ABN Prior to End of Medicare Coverage
Penalty
Summary
The facility failed to provide timely notification to a resident regarding the end of Medicare Part A coverage for skilled nursing services. The resident, who had been admitted with a diagnosis including spinal fusion, had their last day of covered Medicare Part A services on February 24, 2025. However, the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) was not issued until February 25, 2025, after the coverage had already ended. This deficiency was confirmed through clinical record review and interviews with the Director of Social Services and the Nursing Home Administrator, both of whom acknowledged the delay in providing the required notice.
Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment indicated that the resident received one insulin injection during the seven-day look-back period. However, a review of the resident's medication administration record for the same period showed no documented evidence that the resident received any insulin injections. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the resident did not receive insulin as recorded in the MDS assessment. The inaccurate documentation in the MDS assessment did not accurately reflect the resident's medication administration status during the specified period.
Failure to Timely Respond to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by the lack of timely response to significant weight loss. A resident with severe cognitive impairment and a history of dysphagia requiring a gastronomy tube experienced a weight loss of over 6% within 30 days. Facility policy required reweighing within 24 hours of a significant weight change and notification of the registered dietician, physician, family, and assessment coordinator. However, there was no documented evidence that the resident was reweighed within 24 hours after significant weight losses were identified on two separate occasions. Additionally, there was no documentation of a nutritional assessment being completed or of the physician or resident representative being notified following the significant weight loss events. The registered dietician confirmed that the significant weight loss was not reviewed until 10 days after it was identified, and that required notifications were not made. These failures were in direct violation of the facility's policies and state regulations regarding monitoring and responding to changes in residents' nutritional status.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to a resident and the resident's representative regarding a facility-initiated transfer to a community hospital, as well as failed to send copies of the written transfer notice to the Office of the State Long-Term Care Ombudsman. Clinical record review showed that the resident was transferred to a hospital and later readmitted, but there was no documented evidence that the required notifications were given in writing or in a language and manner understood by the resident and representative. Staff interviews, including with the nursing home administrator, confirmed the absence of documentation for both the resident/representative notification and the Ombudsman notification related to the transfer event.
Failure to Investigate Alleged Abuse
Penalty
Summary
Linwood Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding the investigation of alleged abuse. The facility failed to conduct a thorough investigation into an allegation of physical abuse reported by a resident. The resident, who was cognitively intact, reported to a social worker that a nurse aide had been rough with her during the night shift, causing discomfort. Despite the resident's disclosure, the facility did not collect written statements from staff on duty, nor did they conduct interviews with other alert and oriented residents. Additionally, there was no documentation in the resident's clinical record regarding the incident. The Director of Nursing confirmed that no thorough investigation was completed or documented, which is a violation of the facility's abuse prohibition policy. The policy requires immediate reporting and investigation of any allegations of abuse, including notifying appropriate personnel and documenting the incident. The failure to adhere to these procedures resulted in a deficiency citation for not promptly and thoroughly investigating the allegation of abuse as required by both federal and state regulations.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Resident 4 was reassessed and re-interviewed by the Director of Nursing for signs and symptoms of physical or mental abuse. The allegations were unsubstantiated. The NHA/designee will audit current residents to ensure there are no other allegations. The Director of Nursing/designee conducted interviews of staff and residents. The resident's clinical record was updated. The Director of Nursing/designee in-serviced the nursing staff and the social services department regarding the facility's abuse policy/procedures. The NHA/designee will perform an audit 1x/day for 30 days to ensure allegations of abuse are investigated and reported per the facility policy and procedures. The results of the audit will be presented to the QA committee for review and recommendation.
Non-Compliance in Resident Transfer Procedure
Penalty
Summary
Maplewood Nursing and Rehabilitation was found to be non-compliant with federal and state regulations regarding accident hazards and supervision during an abbreviated survey. The deficiency was identified when a nurse aide, Employee E2, was observed transferring a resident, who was totally dependent on assistance for transfers, using a mechanical lift without the required second staff member present. The facility's policy mandates that two staff members are necessary to safely operate the mechanical lift, ensuring one controls the lift and the other assists with the resident. However, during the transfer, Employee E2 was left alone as the second staff member, Employee E3, left to attend to another resident. The resident involved, admitted in 2016, had multiple diagnoses including atrophy, dysphasia, dementia, and malnutrition, and was assessed as needing a mechanical lift for transfers. Despite the facility's inservice training on proper mechanical lift usage, which both Employee E2 and Employee E3 attended, the policy was not adhered to during the incident. Employee E2 acknowledged awareness of the two-person requirement, and Employee E3 confirmed that leaving a single staff member to perform the transfer was against policy.
Plan Of Correction
Immediate Corrective Action: Employee 2 was re-educated and counseled regarding the policy. House wide corrective action: Current CNA's will have lift competencies completed. Education: Licensed nursing staff will be re-educated on the facility's policy regarding use of the mechanical lift. Performance Monitoring: DON or designee will complete 10 random observations weekly x 4 weeks to ensure staff are using the mechanical lift per facility policy. The results of the audits will be reviewed during the facilities monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.
Failure to Submit Required Information for Imaging Study
Penalty
Summary
Maplewood Nursing and Rehab Center failed to ensure that necessary information was submitted to obtain an imaging study for one resident, identified as Resident R4. Resident R4 was admitted to the facility with a complex medical history, including a left basal ganglia intraparenchymal hemorrhage, status post craniectomy, stroke, cognitive communication deficit, and other conditions. On April 16, 2024, a neurosurgery consult recommended a 'stealth CT ordered for prosthetic manufacturing.' However, the facility did not submit the required medical information to the resident's insurance company to approve the necessary imaging studies. The facility's documentation revealed that on May 7, 2024, a nurse aide attempted to contact the insurance company multiple times to check on the approval status of the stealth CT scan, but the insurance company had not received the required information. Further attempts on May 24, 2024, to obtain approval for a CT scan of the abdomen/pelvis were also denied due to a lack of medical information. Interviews with the insurance company confirmed that no medical information had been submitted for Resident R4, and the facility was unable to provide evidence of submission. The facility's Administrator and Assistant Director of Nursing confirmed these findings during an interview on December 11, 2024.
Plan Of Correction
Immediate corrective action: Placed a call to POA regarding care conference and follow up on resident's procedure. Discussed that medical records were able to retrieve additional information and will ask for a new script to get the scan necessary for Hershey medical. On 12.12, authorization for release of information was signed and faxed to Hershey medical Department of Neurosurgery for medical record release of information for insurance purposes. Appointment and scan approved by insurance. Stealth scan to take place on January 10th @10am. Family aware. House wide corrective action: Auditing all current residents to ensure follow up appointments/testing has been completed as requested. NHA or designee will complete weekly audits x4 to ensure timely appointments and follow-up if applicable. QA meeting will determine the need for continued monthly auditing.
Call Bell System Failure Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that the call bell system was fully functional in three out of four areas, specifically the 100, 200, and 300 Halls, placing residents in an Immediate Jeopardy situation. The malfunction was caused by a possible lightning strike, which led to the call bell system being inoperable. As a temporary measure, tap bells were provided to residents, but these were not sufficient as they could not be heard throughout the facility or over long distances. Observations revealed that some residents did not have tap bells in their rooms, and staff were not adequately informed about the frequency of safety checks or how to manage the situation effectively. Interviews with staff members, including a maintenance director and nursing staff, highlighted a lack of communication and training regarding the nonfunctional call bell system. Staff were not instructed to increase the frequency of resident rounding, and there was confusion about how residents could alert staff if they needed assistance, particularly in the bathrooms where no call bells were accessible. Some staff members assumed they would hear residents yell for help, but this was not a reliable method of ensuring resident safety. The deficiency was further underscored by specific incidents involving residents. One resident, who was cognitively intact but had physical impairments, was found on the floor with injuries after being unable to call for assistance due to the nonfunctional call bell. Another resident expressed frustration with the tap bell system, noting that staff could not determine the source of the call. These incidents illustrate the immediate risk to resident safety due to the facility's failure to maintain a functional call bell system and adequately address the situation with effective interim measures.
Failure to Protect Residents' Personal Privacy
Penalty
Summary
The facility failed to protect the personal privacy rights of three residents. During observations, signs were found taped above the beds of these residents, revealing specific care instructions. For Resident A1, a sign indicated the use of a Hoyer pad while in a wheelchair. Resident A2 had a sign specifying the use of nectar thicken liquids only. Similarly, Resident A3's sign indicated the need for nectar thick fluids and the absence of an over-the-bed table. An interview with the Nursing Home Administrator revealed that they could not provide a reason for the presence of these signs, which compromised the residents' personal privacy. This failure to maintain confidentiality of personal and medical information is a violation of resident rights as per 28 Pa. Code 201.29 (a).
Inadequate Supervision and Non-Operational Call Bell System Lead to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls and ensure resident safety for two residents. Resident B1, who was admitted with a diagnosis of cerebral infarction, was cognitively intact and required assistance for transferring and toileting. On the day of the incident, Resident B1 rang the call bell for over 20 minutes without receiving assistance. Due to the urgency of needing to use the bathroom, the resident attempted to self-transfer, resulting in a fall and a scrape on the right elbow. At the time, only one LPN and one nurse aide were on duty, both occupied with another resident requiring two-person assistance, which delayed their response to Resident B1's call bell. Resident A10, admitted with a history of cerebral vascular accident and hemiplegia, was also cognitively intact and required assistance for daily activities. The resident was found on the floor with a bump and abrasion above the left eyebrow after being alerted by another resident. The call bell system was not operational at the time, and it was unclear if Resident A10 had any means to alert staff. The resident was sent to the emergency room for evaluation after a CT scan revealed a hematoma. The Nursing Home Administrator confirmed the facility's failure to provide timely assistance to Resident B1 and acknowledged the non-operational call bell system during Resident A10's fall. These deficiencies highlight the lack of adequate supervision and timely response to residents' needs, contributing to the incidents involving both residents.
Ongoing Deficiencies in Privacy and Infection Control
Penalty
Summary
The facility was found to have ongoing deficiencies related to personal privacy and infection control, as identified during a survey ending on September 5, 2024. Despite having developed a plan of correction following a previous survey on July 23, 2024, the facility failed to implement effective measures to address these issues. Observations revealed that signs containing personal information were posted in residents' rooms, compromising their privacy. Specifically, signs were noted above residents' beds indicating specific care instructions, such as the use of a Hoyer pad and dietary restrictions, which were visible to anyone entering the room. In terms of infection control, the facility's program was found lacking in its ability to monitor and investigate infections effectively. The infection control data provided during the survey did not reflect a functional system for tracking and analyzing infections, such as healthcare-acquired infections and community-acquired infections. An example of this deficiency was the case of a resident diagnosed with Rhinovirus infection and pneumonia, whose infection was not included in the facility's data, and no intervention plans were in place to prevent similar occurrences. Additionally, observations noted poor infection control practices, such as a catheter bag lying on the floor and an uncovered bedpan in a bathroom, which could increase the risk of infection transmission. The facility's quality assurance plan was deemed ineffective in identifying and addressing these ongoing deficiencies. The Nursing Home Administrator acknowledged the expectation that no signs should be posted on resident walls and that infection control practices should be maintained. However, the facility failed to demonstrate a functioning system for surveillance and corrective action, leading to the recurrence of similar quality deficiencies in resident privacy, fall prevention, and infection control.
Inadequate Infection Control Program and Practices
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, as evidenced by the lack of a functional system to monitor and investigate infections. The infection control tracking log was incomplete, and there was no evidence of a system to analyze infection clusters, changes in prevalent organisms, or increases in infection rates. The facility was unable to demonstrate how it tracks infections or addresses areas needing corrective action. This deficiency was highlighted by the case of a resident who developed a persistent cough, which was not effectively tracked or managed, leading to a diagnosis of Rhinovirus infection and pneumonia after being sent to the emergency room. Additionally, the facility did not maintain proper infection control practices, as observed with a resident's foley catheter bag placed directly on the floor and an unbagged bedpan and wash basin left on the bathroom floor. The newly appointed Infection Preventionist confirmed the incomplete infection logs and acknowledged the need for maintained infection control practices. These observations and the lack of a comprehensive infection control program indicate a failure to prevent the spread or recurrence of infections within the facility.
Insufficient Staffing Leads to Resident Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, resulting in a deficiency in care for a resident who required assistance with toileting. The resident, who was cognitively intact and had a history of cerebral infarction, was admitted to the facility and required staff assistance for transferring and toileting. On the day of the incident, the resident used the call bell for over 20 minutes without receiving assistance, leading him to attempt to use the bathroom independently. This resulted in a fall, causing a small scrape to his right elbow. At the time of the incident, only one LPN and one nurse aide were on duty, and they were occupied with another resident who required the assistance of two staff members. This staffing level was insufficient to respond to call bells in a timely manner, as confirmed by the Director of Nursing. The facility's staffing records indicated that the nurse aide staffing did not meet the minimum required for the facility's census, contributing to the delay in assistance and the subsequent fall of the resident.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to correctly post nurse staffing information as required. Upon entrance to the facility at two different times, it was observed that the posted nursing time was outdated, showing a date of September 5, 2024. The form included the resident census but did not reflect the current day's staffing details, such as the number of staff and the hours worked by the nursing staff. During an interview, the Nursing Home Administrator confirmed that the nursing time was not posted at the beginning of the shift, and the facility did not list the total number of staff and actual hours worked by the staff.
Facility Failed to Maintain Hazard-Free Environment
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards on the second floor, as observed during a survey conducted on July 23, 2024. Residents were seen moving around the hallways, both walking and using wheelchairs, where two air purifier units were plugged into wall outlets near specific resident rooms. These units were not secured, were moveable, and obstructed access to the handrails, creating potential tripping hazards due to their cords and plugs. Additionally, a plastic container with three drawers containing personal protective equipment was found in the hallway, further obstructing access to the handrails. The survey also noted similar issues in other hallways on the second floor, where air purifiers and plastic containers with drawers were placed near resident rooms, again obstructing access to handrails and creating potential hazards. During an interview, the nursing home administrator acknowledged that the air purifiers were placed in the corridors before her employment and agreed that these items impeded access to the handrails and created obstacles to residents' mobility in the hallways.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, as evidenced by a review of their infection control tracking log and staff interviews. The facility's infection control policies, which were intended to maintain a safe and sanitary environment, did not reflect an operational system to monitor and investigate causes of infection or the manner of spread. The infection control data provided during the survey did not show a functional system for analyzing clusters, changes in prevalent organisms, or increases in infection rates in a timely manner. The monthly infection control logs for June and July 2024 were found to be inconsistent, lacking details such as the type of infection, pathogen, start date and length of antibiotic treatment, precaution type, and resolution date. The facility was unable to demonstrate a functioning system for routine surveillance, data analysis, and dissemination to identify infections, infection risks, or communicable disease outbreaks. A specific case involved a resident diagnosed with Salmonella, which was not included in the data, and no intervention plans were made to prevent similar infections. The limited data compiled was not evaluated to prevent the spread or recurrence of infections within the facility.
Failure to Protect Resident's Personal Privacy
Penalty
Summary
The facility failed to protect the personal privacy rights of a resident, as observed during a survey. A handwritten sign was taped to the back of the resident's bed, indicating that the resident's right arm should not be used for IVs, lab draws, blood pressures, or tight clothing. However, during an interview, the resident and her daughter were unaware of the reason for the sign and stated that they did not place it there. The resident mentioned that there was no known reason for the restriction on her right arm and requested the sign's removal. A review of the clinical record confirmed that the right arm should not be used for blood draws, but did not provide a clinical reason or diagnosis. The Nursing Home Administrator was unable to explain the reason for the sign, indicating a failure to ensure the resident's personal privacy.
Care Plan Deficiency for Resident with Cast
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident with a displaced fracture of the right lower leg and a history of falls. Upon review, it was found that the resident, who was admitted with a broken ankle, had a blue hard cast on her right leg extending from the base of her toes to just below her knee. However, the care plan, dated May 30, 2024, did not include the presence of the cast or the need for regular assessment of the exposed toes to monitor color, circulation, sensation, and mobility, as well as to check for swelling. This omission was identified during an interview and observation of the resident on July 23, 2024.
Delayed Treatment for Resident's Urinary Discomfort
Penalty
Summary
The facility failed to provide timely and necessary treatment for a resident's complaints of painful urination, which led to a delayed diagnosis and treatment of a salmonella infection. The resident, who was admitted with a fractured ankle, muscle weakness, and high blood pressure, reported symptoms of burning, pressure, and discomfort during urination to a CRNP. The CRNP noted the need for a urinalysis culture and sensitivity test but did not order it at the time of the resident's complaint. The urine test was not conducted until several days later, after the resident voiced her continued discomfort to an LPN, who then contacted the physician to obtain the necessary order. The test results revealed a salmonella infection, and antibiotic treatment was initiated ten days after the resident's initial complaint. The delay in addressing the resident's symptoms resulted in a significant gap between the onset of symptoms and the start of treatment.
Failure to Investigate Salmonella Infection Source
Penalty
Summary
The facility failed to demonstrate that its quality assurance program fully investigated and analyzed the causes of adverse events, specifically a resident's diagnosed salmonella infection. The clinical record review revealed that the resident was admitted with a fractured ankle and later expressed concerns about the food served at the facility, describing it as extremely salty and not to her liking. She also reported receiving greasy silverware. Consequently, she requested her daughter to bring her meals. The resident experienced stomach discomfort and burning on urination, leading to a urinalysis that eventually confirmed a salmonella infection. Despite the resident consuming some facility food and beverages, the facility attributed the infection to the meals brought by her daughter without conclusive evidence. The facility did not evaluate staff practices in the dietary department or ensure awareness of food safety practices, such as proper handwashing and food preparation procedures. Additionally, the facility failed to assess the storage practices for the food brought by the resident's daughter, including storage duration and temperatures. No training or education regarding the prevention of foodborne illness was provided to the staff following the salmonella infection. The Nursing Home Administrator confirmed that no quality improvement activities were initiated in response to the infection, and the facility did not consider itself as a potential source of the infection.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from sexual abuse and neglected to provide necessary care and services to prevent harm and discomfort for two other residents. One resident, with severe cognitive impairment due to Alzheimer's disease, was sexually abused by another resident known for sexually inappropriate behaviors. Despite multiple incidents of inappropriate behavior by the perpetrator, the facility did not report, investigate, or protect the victims as required by their abuse prohibition policy. The facility's failure to implement its policy resulted in the continued risk of abuse for female residents. Another resident, who was cognitively intact but dependent on staff for toileting hygiene, was left in a soiled brief for several hours despite requesting assistance. The resident communicated her need for care, but staff failed to provide timely assistance, resulting in physical discomfort and emotional distress. The facility's neglect in providing necessary care and services compromised the resident's well-being. A third resident, also cognitively intact and requiring assistance for toileting, reported that staff did not respond promptly to her call bell when she was wet. The staff's failure to check and change the resident in a timely manner led to her feeling disappointed and neglected. The facility's inaction in addressing the resident's needs further demonstrated a lack of adherence to care standards, impacting the resident's physical and emotional health.
Incomplete Staff Training on Abuse Prohibition Policy
Penalty
Summary
The facility failed to ensure that all employees received comprehensive training on the facility's abuse prohibition policy and specific procedures for identifying and reporting abuse, neglect, exploitation, or misappropriation of resident property. During an interview, the Nurse Educator revealed that the facility uses an online education platform for mandatory education, supplemented by paper materials and various educational methods. However, the educational content provided for the annual abuse prevention program did not include the facility's specific procedures. The Nursing Home Administrator acknowledged that both the mandatory annual abuse training and new hire abuse training were incomplete, lacking the facility-specific abuse prohibition policy and procedures.
Failure to Report Resident Abuse Timely
Penalty
Summary
The facility failed to promptly report instances of resident abuse to the State Survey Agency and submit completed abuse investigations within the required timeframe. The facility's policy mandates that any report or allegations of abuse, neglect, misappropriation, or exploitation be reported within 24 hours of knowledge of the event to the Pennsylvania Department of Health and other relevant authorities. However, the facility did not adhere to this policy for three out of four allegations of abuse reviewed. One of the incidents involved a resident with severe cognitive impairment and a history of verbally abusive and sexually inappropriate behaviors. The resident was observed by a licensed practical nurse and a CNA engaging in sexually inappropriate behavior with female residents. Despite this, the facility did not report the incident to the State Survey Agency within the required 24-hour period, nor did they submit a completed investigation within five working days. Another incident involved the same resident, who was reported to have inappropriately touched a female resident. The resident's responsible party was informed, and the resident expressed remorse. However, this incident was also not reported to the State Survey Agency within the required timeframe, and the completed investigation was not submitted within five working days. These failures were confirmed during interviews with the Director of Nursing and the Nursing Home Administrator.
Failure to Investigate Sexual Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to promptly conduct a thorough investigation into instances of sexual abuse involving Resident 8, who was known to exhibit sexually inappropriate behaviors towards female residents. Despite documentation by Employee 4, Social Services, and Employee 5, a Licensed Practical Nurse, indicating Resident 8's inappropriate actions, no investigation was initiated to identify the affected female residents or to determine if these actions constituted sexual abuse. The Director of Nursing confirmed that the facility did not initiate an investigation into Resident 8's behavior, nor did they report the results to the State Agency within the required five working days. Additionally, the facility failed to thoroughly investigate an injury of unknown origin involving Resident 48, who sustained an ankle fracture. Despite the resident's severe cognitive impairment and dependency on nursing staff for all activities of daily living, the investigation did not include a demonstration or observation of the mechanical lift used during transfers, nor did it verify that care was provided according to the resident's plan of care. The Director of Nursing confirmed that there was no evidence of a thorough investigation to rule out abuse, neglect, or mistreatment as the potential cause of the injury. The facility's policies on abuse prevention and incident investigation were not followed, as evidenced by the lack of immediate action to protect residents from potential abuse and the failure to conduct comprehensive investigations into reported incidents. These deficiencies highlight significant lapses in the facility's responsibility to ensure resident safety and compliance with regulatory requirements.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and their representatives upon transfer to a hospital, as required by regulations. This deficiency was identified for six residents out of a sample of 21. The clinical records for these residents showed no documentation that they or their representatives were informed of the facility's bed-hold and reserve bed payment policy when they were transferred to the hospital. This lack of documentation was noted for residents who were transferred on various dates throughout 2024. During an interview, the Nursing Home Administrator and Director of Nursing were unable to provide evidence that the facility had informed the affected residents and their representatives about the bed-hold policy. The specific residents involved in this deficiency were transferred to the hospital on multiple occasions, yet there was no evidence of compliance with the notification requirement. This failure to provide the necessary written notice is a violation of resident rights as outlined in the relevant state codes.
Failure to Implement Individualized Toileting Care Plans
Penalty
Summary
The facility failed to fully assess and implement individualized measures for the toileting needs of three residents, leading to deficiencies in their care. Resident 51, who was at risk for urinary incontinence due to a history of falls, dementia, and diuretic use, was not consistently checked and changed every two hours as planned. This inconsistency was confirmed by the Director of Nursing (DON) and was not documented in the resident's survey documentation report. The resident had been diagnosed with sepsis and a urinary tract infection, which required hospitalization and treatment with intravenous antibiotics. Resident 15, who had a history of compression fractures, heart failure, frequent UTIs, and falls, was also not consistently checked and changed every two hours as planned. Despite being identified as a heavy wetter due to diuretics and an overactive bladder, the facility failed to ensure that the planned care was implemented. This was confirmed by the DON, and the lack of documentation in the survey report further highlighted the deficiency in care. Resident 2, who had urinary retention requiring a Foley catheter and a history of chronic UTIs and chronic kidney disease, experienced a decline in bowel continence. The facility did not act upon this decline by evaluating the resident for potential bowel retraining or management programs. The DON confirmed that the facility failed to timely identify and address the resident's decline in bowel continence, resulting in a deficiency in meeting the resident's needs.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for three residents. Resident 21 experienced significant weight fluctuations over a short period, with a 17.8-pound gain in five days, followed by a 35.2-pound gain, and then a 49-pound loss. Despite these significant changes, there was no documented evidence that the weights were evaluated for accuracy, and the registered dietitian did not make any recommendations or changes to the resident's care plan. Resident 7 also experienced significant weight changes, with a 12.4-pound loss in seven days and an 11.7-pound gain in 14 days. The nutrition notes failed to identify a re-weight that confirmed the weight loss, and there was no evidence that the weight gain was evaluated. The registered dietitian did not assess the resident's weight changes, and the facility did not follow its policy to monitor and address significant weight changes. Resident 53 was readmitted to the facility and required weekly weight monitoring, which was not consistently completed. The facility also failed to provide the physician-ordered nutritional supplement, Magic Cup, as observed during a meal. Additionally, staff failed to consistently document the percentage of meals consumed by the resident. These deficiencies were confirmed by the Nursing Home Administrator and Director of Nursing during the survey.
Failure to Implement Individualized Pain Management Program
Penalty
Summary
The facility failed to develop and implement an individualized pain management program for a resident, identified as Resident 48, who required such services. The resident, who had a history of rheumatoid arthritis, Alzheimer's disease, and osteoporosis, was dependent on staff for all activities of daily living and had communication deficits due to Alzheimer's disease. The resident's care plan identified a risk for alterations in comfort related to chronic pain, but the interventions were not effectively implemented. On February 5, 2024, the resident complained of left leg pain, and although Tylenol was administered earlier in the day, there was no evidence of further administration despite continued complaints of pain. The family requested stronger pain management on February 8, 2024, but there was no documented evidence of additional Tylenol administration or a response to the family's concerns. The resident continued to show signs of pain and discomfort during transfers and repositioning, with documented instances of screaming and facial grimacing. Despite the resident's ongoing pain and a subsequent identification of a left ankle fracture, the facility did not perform a pain evaluation to assess the effectiveness of the current pain medication regimen. The Director of Nursing confirmed that the facility failed to implement an effective pain management program to promote the resident's comfort and meet the goals for effective pain relief, consistent with current standards of practice.
Delayed Physician Response to Resident's Acute Condition
Penalty
Summary
The facility failed to provide consistent and timely physician services for a resident who was admitted with rheumatoid arthritis, Alzheimer's disease, and age-related osteoporosis. The resident's family expressed concern over swelling in the resident's left leg, and an x-ray was performed. However, despite multiple calls to the physician's answering service on February 17, 18, and 21, 2024, there was no timely response. It was not until February 21, 2024, that the physician provided orders for an x-ray of the left ankle, which revealed fractures. The facility did not attempt to reach an on-call physician or contact the medical director when the physician failed to respond promptly. As a result, the resident was transferred to the emergency room and subsequently hospitalized for a fractured leg, pain management, and exacerbation of a cardiac condition. The Director of Nursing confirmed that there was a delay of approximately four days before the physician responded to the facility's repeated calls regarding the resident's acute change in condition.
Staffing Shortages Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely and quality care for its residents, as evidenced by the experiences of three residents. Resident 7, who was cognitively intact and had multiple medical conditions including atrial fibrillation and heart failure, did not receive medications on time on numerous occasions throughout June 2024. The medications included Metoprolol, Tramadol, Eliquis, and Cefdinir, all of which were administered late, sometimes by nearly two hours. Resident 7 expressed dissatisfaction during a group interview, stating that the nursing staff frequently administered her medications late. Resident 80, who was also cognitively intact and required substantial assistance for daily activities, experienced neglect in personal care. On June 5, 2024, Resident 80 was left in a soiled state for several hours after requesting assistance, which was not provided until much later. The resident expressed feelings of frustration and distress due to the delay in care. Additionally, Resident 80's scheduled neurosurgery appointment had to be rescheduled because the facility did not have enough staff to accompany her, further indicating staffing inadequacies. Resident 21, with a history of cerebral infarction and hemiplegia, also faced delays in receiving care. On May 22, 2024, Resident 21 reported waiting for two hours for assistance after ringing the call bell, as staff prioritized documentation over immediate care needs. The resident expressed disappointment over the delay in care. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these deficiencies, highlighting the facility's failure to provide adequate nursing services to meet the residents' needs.
Inadequate Staff Competency and Supervision for Resident with Behavioral Issues
Penalty
Summary
The facility failed to provide sufficient staff with the necessary skills and competencies to address the behavioral health needs of a resident with severe cognitive impairment and a history of inappropriate sexual behaviors. The resident, diagnosed with unspecified dementia and adjustment disorder, exhibited sexually inappropriate behaviors towards female residents. Despite having a care plan that included interventions such as every fifteen-minute checks and behavior monitoring, the facility did not consistently implement these measures. On multiple occasions, the resident was observed engaging in inappropriate sexual conduct with female residents, including touching and exposing private areas. Staff members, including a licensed practical nurse and a registered nurse, documented these incidents and attempted to redirect the resident and inform his family. However, the facility lacked evidence of consistent supervision and monitoring as outlined in the care plan, failing to prevent further incidents. Interviews with facility staff, including the Director of Nursing and RN/Staff Development, revealed gaps in training and supervision. The facility's abuse prohibition policy was not included in staff training, and there was no documented evidence of a competency-based approach to managing the resident's behaviors. The facility did not demonstrate effective monitoring or timely adjustments to care plan interventions to ensure the safety and well-being of all residents.
Deficiency in Facility-Wide Assessment for Behavioral and Dementia Care
Penalty
Summary
The facility failed to document a comprehensive facility-wide assessment to determine the necessary resources for adequately caring for residents, particularly those with behavioral health and dementia care needs. The assessment, dated Quarter 1 2024, lacked an evaluation of the diseases, conditions, and cognitive status of residents, which are crucial for planning the services required. It also did not address the need for sufficient nurse staffing, education, training, and competency evaluation for staff providing direct care to residents with behavioral symptoms. During an interview, the Nursing Home Administrator confirmed that the facility assessment did not cover staffing requirements, training, and competencies. The administrator acknowledged that the facility's population included residents requiring increased supervision, such as one-to-one supervision, due to dementia and behavioral issues. The administrator also confirmed that the staff would benefit from enhanced training in dementia care, behavioral health, and abuse to better meet the needs of the resident population.
Failure to Meet QA/QAPI Committee Quarterly
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QA/QAPI) committee met at least quarterly, as required. An interview with the Nursing Home Administrator (NHA) revealed that the committee, which includes the Administrator, Director of Nursing (DON), Medical Director, and department heads, is supposed to meet quarterly. However, a review of the facility's QA/QAPI meeting attendance records from the last annual survey ending July 23, 2023, to the current survey ending June 28, 2024, showed that only one meeting was held on April 30, 2024. The NHA was unable to provide documented evidence of additional meetings, as the signature sheets for the QA/QAPI meetings could not be located.
Inaccurate MDS Assessment for Medication
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident. Specifically, the quarterly MDS assessment for a resident inaccurately indicated that the resident received an anticoagulant medication for 7 days during the 7-day look-back period. However, a review of the resident's physician orders and Medication Administration Records for May and June 2024 revealed no orders or administration of anticoagulant medications during this period. An interview with the Registered Nurse Assessment Coordinator confirmed the inaccuracy of the MDS assessment regarding the medications received by the resident.
Unattended and Unlocked Medication Cart in Resident Care Unit
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards on one of its resident care units, specifically the 300 Hall. During a medication administration observation, a medication cart was found unattended and unlocked in the hallway. The licensed practical nurse, identified as Employee 10, left the cart unsecured while administering medications to a resident in their room. The cart was positioned against the wall, out of the nurse's view, and the keys to the cart, including access to the narcotic drawer, were left on top of the cart. At the time of this observation, multiple residents were seen moving independently in the hallway, increasing the risk of unauthorized access to the medication cart and its contents. The Director of Nursing confirmed the potential accident hazard and acknowledged the presence of independently mobile residents in the area, which could lead to unauthorized access to the medication cart.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a Medicaid Payor source resident, identified as Resident 7, who was part of a sample of 21 residents. Resident 7, who is cognitively intact with a BIMS score of 14, was admitted with diagnoses including atrial fibrillation, cardiomyopathy, and heart failure. The resident's care plan, initiated in July 2021, included interventions to obtain dental consults as ordered. A progress note from May 8, 2023, indicated that Resident 7 had a dental appointment for a tooth extraction scheduled for November 9, 2023. However, this appointment was rescheduled to March 6, 2024, and subsequently canceled on March 3, 2024, with no further documentation of rescheduling or completion of the dental service. During the survey ending June 28, 2024, it was found that there was no documentation of a new dental appointment for Resident 7 after the cancellation. An interview with Resident 7 on June 25, 2024, revealed that she was aware of the cancellation and had been waiting for a new appointment, which had not been scheduled. The facility's Director of Nursing and Nursing Home Administrator were unable to provide evidence that the required dental services were scheduled for Resident 7. This deficiency was noted under 28 Pa. Code 211.12 (d)(3)(5) Nursing services and 28 Pa. Code 211.15 Dental services.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Scranton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Care And Rehabilitation Center | 1 mi | — | 0 | 0 |
| Elan Skilled Nursing And Rehab, A Jewish Senior Li | 1.3 mi | ★★★★★ | 14 | 1 |
| Gino J Merli Veterans Center | 1.4 mi | ★★★★★ | 5 | 0 |
| Scranton Health Care Center | 1.7 mi | ★★★★★ | 11 | 0 |
| Embassy Of Scranton | 1.7 mi | ★★★★★ | 24 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.