Longwood At Oakmont
Inspection history, citations, penalties and survey trends for this long-term care facility in Verona, Pennsylvania.
- Location
- 500 Route 909, Verona, Pennsylvania 15147
- CMS Provider Number
- 395882
- Inspections on file
- 24
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Longwood At Oakmont during CMS and state inspections, most recent first.
A facility failed to communicate necessary resident information to a receiving health care provider during a transfer. A resident with surgical aftercare, muscle weakness, and venous insufficiency was transferred to a hospital without documented evidence of communicated care plan goals, advanced directives, or specific care instructions. The DON confirmed this lapse.
The facility failed to notify the Office of the LTC Ombudsman Division about the hospital transfers of two residents. One resident with dementia, diabetes, and hyperlipidemia was transferred and returned without notification, while another with surgical aftercare and muscle weakness was transferred and did not return, also without notification. The DON confirmed the oversight.
The facility failed to notify two residents or their representatives about the bed-hold policy during hospital transfers. One resident with dementia, diabetes, and hyperlipidemia was transferred and returned without receiving written notification. Another resident with surgical aftercare needs and muscle weakness was transferred and did not return, also without notification. The DON confirmed the oversight.
The facility failed to complete significant change MDS assessments for two residents who were placed under hospice care, as required when there is a significant change in condition. This oversight was confirmed by an LPN and the DON.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident, admitted with dementia, benign prostatic hyperplasia, and depression, was observed with a Foley catheter, but the care plan lacked interventions for its management. An LPN confirmed the omission.
The facility failed to provide appropriate respiratory care for three residents, as their oxygen and CPAP equipment were not properly dated or stored. A resident's nasal cannula and humidification bottle lacked dates, and CPAP masks for two residents were not stored in bags when not in use. Additionally, a resident's nebulizer tubing was undated and improperly stored. These deficiencies were confirmed by staff and acknowledged by the Director of Nursing.
The facility failed to timely dispose of discontinued medications in the Countryside Medication room. Unsecured medications dated November 2024 were found on the counter, including Atropine, Pantoprazole, and Eliquis. An LPN stated there was no paperwork required before destroying the medications, and the Director of Nursing confirmed the failure to dispose of or reconcile the medications timely.
The facility failed to properly and securely store medications and biologicals in the Riverside medication cart. The cart's fourth drawer contained various creams, ointments, and gels not stored separately from other medications. Further inspection revealed additional storage issues, with medications and treatment supplies commingled in the fifth and bottom drawers. An LPN confirmed these observations, indicating non-compliance with the facility's medication storage policy.
A resident was not provided food items consistent with their prescribed diet order. The resident's physician orders specified a Low Lactose diet, Mechanical Soft Ground Meat texture, and Nectar/Mildly Thick liquids. However, the resident was served turkey vegetable soup and had liquids in a sippy cup, despite no orders for adaptive equipment. The Dietary Director and DON confirmed these findings.
The facility failed to coordinate hospice services for three residents, lacking necessary physician orders and care plans. One resident with dementia and other conditions had hospice services indicated but lacked documentation and care plan details. Another resident with similar issues also had incomplete hospice coordination. A third resident had a hospice consult order without vendor information or a qualifying diagnosis. The DON confirmed these deficiencies.
The facility failed to ensure all required multidisciplinary members attended Infection Control Meetings, missing a community member for all four quarters and laboratory personnel for one quarter. This non-compliance with the MCARE Act was confirmed by the Nursing Home Administrator.
The facility failed to maintain documentation for one of the two required semi-annual Kitchen Fire Suppression Testing/Maintenance sessions within the last 12 months, affecting one of four smoke compartments. This was confirmed during an interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain its automatic sprinkler system, as a drop ceiling grid was improperly wired to a sprinkler pipe, and the system's gauges had not been replaced or recalibrated in over five years. These deficiencies were confirmed by the Facility Administrator and Maintenance Director.
The facility did not conduct five out of twelve required fire drills over the past year, lacking documentation for specific shifts across multiple quarters. This deficiency affects the entire facility's compliance with NFPA 101 fire safety standards.
An unsecured oxygen cylinder was found in the Oxygen Storage Room on the first floor of Countryside, violating NFPA 99 standards for medical gas storage. The deficiency was confirmed by the Facility Administrator and Maintenance Director during a survey.
The facility was found to have a deficiency in maintaining emergency lighting, as an emergency light above the dryers in the laundry room was damaged and missing parts. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to implement appropriate transmission-based precautions for residents with gastrointestinal symptoms treated as Norovirus positive. Despite policy requirements, several residents lacked physician orders for Contact Precautions, and there was a lack of signage indicating precautions outside their rooms. Staff interviews confirmed the absence of necessary precautions, highlighting a significant lapse in infection control measures.
A resident with dementia and a history of falls experienced neglect when a skin tear was not properly treated. The resident's daughter reported the wound to a nurse aide, who applied a bandage without cleansing it due to the nurse's absence and failure to communicate. The Director of Nursing was aware but did not investigate it as neglect.
A resident with dementia and a history of falls had a skin tear that was improperly treated by a Nurse Aide, who applied a bandage without cleansing the wound and failed to inform the nurse. The Director of Nursing was aware of the incident but did not investigate or report it as neglect, contrary to the facility's policy requiring thorough investigation and reporting of neglect.
A resident with dementia and a history of falls had a skin tear that was not properly addressed by a NA, who applied a bandage without cleansing the wound and failed to inform a nurse. The DON was aware but did not report the incident as neglect, violating facility policy and state regulations.
A resident with dementia and a history of falls had a skin tear improperly treated by a nurse aide, who applied a bandage without cleansing the wound. The DON was aware of the incident but did not investigate it as neglect, failing to adhere to the facility's policy on abuse and neglect investigations.
A resident, cognitively intact and at risk for wandering, eloped from the facility due to inadequate supervision. Despite having a care plan, the resident was last seen at dinner and was assumed to be in her room. She was later found outside by a personal care employee, having exited through double doors unnoticed by staff. The facility's policy on missing residents was not effectively implemented, leading to this incident.
The facility failed to report an allegation of neglect within the required 24-hour timeframe and did not describe the investigation results within five working days. This involved a resident with a bruise and mass on the left inner thigh. The incident report was initially submitted late and under the wrong event type, leading to further delays.
Failure to Communicate Resident Information During Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer. This deficiency involved a resident who was originally admitted with diagnoses including surgical aftercare, muscle weakness, and venous insufficiency. The resident was transferred to the hospital and did not return to the facility. Upon review, there was no documented evidence that the facility communicated essential information such as the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. The Director of Nursing confirmed this failure during an interview.
Plan Of Correction
The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This plan of correction should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements. Any resident transferred or discharged to the hospital after 1/9/2025 was audited to ensure all required documentation was transferred with the transferred resident. R52 was not affected by the deficient practice of not providing documentation at the time of transfer to the hospital. All discharged residents had the potential to be affected by the deficient practice; however, there were no known negative outcomes. The DON/ Designee will educate nursing staff on including the correct documentation of resident care in the transfer process for the accepting healthcare provider. The DON/Designee will conduct daily audits for four weeks to ensure resident documentation regarding their plan of care is included in the transfer process of all residents who are transferred to another healthcare provider for further care. The results of audits will be submitted to the QAPI committee to review for any trends that require further recommendation follow up.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two residents. Resident R39, who was admitted with diagnoses including dementia, diabetes mellitus, and hyperlipidemia, was transferred to the hospital and returned to the facility without documented evidence of a written transportation notification to the Ombudsman. Similarly, Resident R52, admitted with surgical aftercare, muscle weakness, and venous insufficiency, was transferred to the hospital and did not return, also lacking documented evidence of notification to the Ombudsman. The Director of Nursing confirmed during an interview that the facility did not provide the required transfer notices for these two residents, which is a violation of resident rights as per 28 Pa. Code 201.29(a)(c)(3)(2).
Plan Of Correction
The administrator sent the facility initiated discharge report for the month of December, 2024 to the State Long Term Care Ombudsman at [email protected] on January 10, 2025. All discharged residents from Longwood had the potential to be affected by the deficient practice. There were no known negative outcomes. The administrator and social services director were re-educated by the email guidance given by the office of the long term care ombudsman on January 10, 2025. The Social Services Director or Administrator/designee will submit the discharge report to the state long term care ombudsman before the last day of the following month every month going forward. The reports will be submitted at the next two Quality Assurance Committee meetings to ensure compliance. Any identified non-compliance will be addressed at the time of discovery and reviewed for further recommendations.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital. Resident R39, who has dementia, diabetes mellitus, and hyperlipidemia, was transferred to the hospital on 9/9/24 and returned to the facility later. However, there was no documented evidence that the resident or their representative received written information about the facility's bed-hold policy at the time of transfer. Similarly, Resident R52, who has surgical aftercare needs, muscle weakness, and venous insufficiency, was transferred to the hospital on 10/13/24 and did not return to the facility. The clinical record for Resident R52 also lacked documentation that the resident or their representative was informed in writing about the bed-hold policy. The Director of Nursing confirmed the facility's failure to provide the required notifications for these two hospital transfers.
Plan Of Correction
The bedhold policy is given to all residents upon admission. Residents 39 and 52 were not given a copy of the bed hold policy at the time of their transfer out to the hospital. There were no identified negative outcomes from the deficient practice of the resident/representative not receiving a copy of the bedhold policy at the time of transfer/discharge. The Director of Nursing/designee will educate team members on the need to provide the written bed hold notice before a resident/patient is transferred out of the facility. The Director of Nursing or designee will conduct audits on all discharged residents/residents daily for 4 weeks to ensure the Bed Hold Policy agreement is included with the transfer process and the resident and or the resident's family are aware of the bed hold process. The results of the audits will be presented to the QAPI committee to identify any negative trends toward compliance. The QAPI committee will make further recommendations for improvement, if needed.
Failure to Complete Significant Change MDS Assessments for Residents
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for two residents, which is required when there is a significant change in a resident's condition. According to the Resident Assessment Instrument 3.0 User's Manual, a comprehensive assessment must be conducted within 14 days after determining a significant change in a resident's physical or mental condition. Resident R3, who was admitted to the facility with diagnoses of high blood pressure, depression, and dementia, was placed under hospice care as indicated by a physician order dated 11/11/24. However, a significant change MDS assessment was not completed to reflect the inclusion of hospice services. Similarly, Resident R8, who was admitted with high blood pressure, dementia, and Parkinson's disease, was also placed under hospice care as per a physician order dated 2/20/24. The facility again failed to complete a significant change MDS assessment to include hospice services for this resident. These deficiencies were confirmed during interviews with the Licensed Practical Nurse Assessment Coordinator and the Director of Nursing, who acknowledged the oversight in completing the necessary assessments for these residents.
Plan Of Correction
The Director of Nursing/designee will complete an audit of any resident admitted to hospice since Jan 1, 2025, to ensure that their MDS significant change includes documentation of hospice services. There were no negative outcomes from resident R3 or R8 not having a significant Change MDS prior to being admitted to hospice. The Director of Nursing/designee will educate the appropriate nursing staff on the appropriate documentation needed before a resident admits to hospice services. The LNAC/designee will conduct weekly audits for four weeks after any significant change MDS is completed to ensure the required documentation is present. The audit results will be submitted to the QAPI committee for review for any trends that may require further improvement plans.
Failure to Develop Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a baseline care plan for Resident R156 within 48 hours of admission, as required by their policy. Resident R156 was admitted with diagnoses of dementia, benign prostatic hyperplasia, and depression. An observation revealed that the resident was in his room sitting in a wheelchair with a Foley catheter bag attached to the chair. However, the baseline care plan did not include interventions for the care of the Foley catheter. This omission was confirmed during an interview with an LPN, who acknowledged that the baseline care plan for Resident R156 was incomplete.
Plan Of Correction
The R156 care plan was updated to indicate that the resident has a Foley catheter. R156 was not affected by the deficient practice of failure to include a Foley catheter in the line care plan. The LNAC/designee will educate team members on the need to include catheters in the baseline care plan. The LNAC/designee will conduct weekly audits for four weeks of baseline care plans for newly admitted residents to ensure necessary resident care information is present on the care plan. The audit results will be submitted to the QAPI committee for review for any trends and the need for any performance improvement plans.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as evidenced by observations and staff interviews. Resident R9, who had diagnoses including hypertension, diabetes, and sleep apnea, was observed receiving oxygen therapy without a date on the nasal cannula and humidification bottle. Additionally, the CPAP mask was not stored in a bag when not in use. Licensed Practical Nurse (LPN) Employee E8 confirmed these observations. Resident R20, diagnosed with respiratory failure, hypertension, and diabetes, also had a CPAP mask that was not properly stored in a bag, as confirmed by LPN Employee E1. Resident R205, with diagnoses of pneumonia, anemia, and asthma, was observed with a nebulizer on the nightstand, but the nebulizer tubing was not dated and not stored in a bag when not in use. Registered Nurse (RN) Employee E2 confirmed these observations. The Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care for these residents, which is a violation of the facility's policies on oxygen administration and infection prevention and control.
Plan Of Correction
The director of nursing/designees completed an audit of Oxygen Tubing/Bipap/ Nebulizers to review all respiratory equipment currently in use to ensure that each required item is properly dated and stored as per infection control guidelines. Any items undated or improperly stored were removed and replaced at the time of discovery. All residents with oxygen tubing or nebulizers had the potential to be affected by the alleged deficient practice. There were no known negative outcomes. The DON/Designee will provide training for nursing and respiratory therapy staff on the proper procedure for dating and storing respiratory equipment. This training will include the appropriate technique for labeling oxygen tubing, nebulizer equipment, and storing bipap masks with the correct date of use and the recommended duration for tubing replacement according to infection control policies. The DON/Designee will conduct weekly audits of respiratory equipment to ensure proper labeling and storing is completed for four weeks. Results of audits will be submitted to the QAPI committee to review and identify any trends that may require further follow-up recommendations.
Failure to Timely Dispose of Discontinued Medications
Penalty
Summary
The facility failed to dispose of or reconcile discontinued medications in a timely manner in one of the two medication rooms reviewed, specifically the Countryside Medication room. During a review, two plastic basins containing various medications were found unsecured on the counter. These medications, dated November 2024, included Atropine, Pantoprazole, Calcium, Eliquis, Tums, Centrum, Scopolamine patches, Nitroglycerin, Simethicone, Albuterol, Tylenol, Aspirin, Lisinopril, Metoprolol, Zoloft, Tylenol Cold and Flu, Vitamin D, Atorvastatin, Montelukast, Senna, Melatonin, Seroquel, Carvedilol, Depakote, Fluoxetine, Remeron, Simvastatin, Ferrous Sulfate, and a Multivitamin. The medications were accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During an interview, an LPN stated that these were old medications and that there was no paperwork required before destroying them. The LPN mentioned that they were instructed to destroy the medications when time allowed using a solution called 'med buster.' However, there was no accountability paperwork that went into the residents' medical records. The Director of Nursing confirmed the facility's failure to dispose of or reconcile the discontinued medications in a timely manner, as observed in the Countryside Medication room.
Plan Of Correction
The Director of Nursing/designees conducted an audit on the date of discovery of all medications left behind after resident discharge/death. The medications were immediately discarded according to policy. Any medications that have not been properly destroyed have been securely stored pending destruction. NS medication disposition will be completed. DON/designee will audit residents that have been discharged since January 20, 2025, weekly for 4 weeks to ensure medication disposition forms have been completed and medication has been destroyed. DON/Designee will train nursing and pharmacy team members on the proper procedures for medication destruction following a resident's death or discharge. The training will include: - The importance of timely medication destruction. - Procedures for identifying medications that need to be destroyed. - Documentation and verification requirements for destruction. - Compliance with state and federal regulations regarding the disposal of medications. Results of audits will be submitted to the QAPI committee for review of any trends and further recommendations.
Improper Storage of Medications in Riverside Medication Cart
Penalty
Summary
The facility failed to store medications and biologicals properly and securely in one of its medication carts, specifically the Riverside medication cart. The facility's policy on the storage of medications, dated 11/5/24, requires that medications and biologicals be stored safely, securely, and properly, with orally administered medications kept separate from externally used medications and treatments. However, during an observation and interview on 1/7/25, it was found that the fourth drawer of the Riverside medication cart contained dividers labeled with room numbers and various creams, ointments, and gels, which were not stored separately from other medications. LPN Employee E1 confirmed that the facility did not have a separate treatment cart and referred to this drawer as the treatment drawer. Further inspection of the Riverside medication cart revealed additional storage issues. The fifth drawer contained an open box of paper tape, a container of antifungal powder, a box of vaginal cream mixed with seven oral Tussin liquid medication bottles, and a Ventolin inhaler and three nasal sprays commingled with dry dressing supplies. The bottom drawer contained a tube of antifungal cream, a tube of Voltaren gel, a tube of hydrocortisone cream, and two containers of Silvadene ointment, all mixed with respiratory treatment agents. LPN Employee E1 confirmed these observations, indicating a failure to adhere to the facility's medication storage policy.
Plan Of Correction
The Director of Nursing and designees organized the medication carts in all neighborhoods on the date of discovery to include a labeled drawer designated for topical medications. There were no known negative outcomes from the deficient practice of not properly storing biological medications separately from other medications. The Director of Nursing/ Designee will educate nursing staff on the proper storage of biological medications on medication carts/treatment carts by the compliance date. The Director of Nursing /Designee will conduct weekly audits for 4 weeks of medication carts/treatment carts to ensure biological items are stored properly in designated drawers. The results of audits will be submitted to the QAPI committee to determine if any negative trends exist that may require further intervention for improvement.
Failure to Provide Prescribed Diet to Resident
Penalty
Summary
The facility failed to provide food items consistent with the prescribed diet order for Resident R4. The physician's orders for Resident R4, dated 11/18/24, specified a Low Lactose diet, Mechanical Soft Ground Meat texture, and Nectar/Mildly Thick liquids. However, during dining observations on 1/7/24, at 12:15 p.m., Resident R4 was served turkey vegetable soup and had her liquids in a sippy cup, despite having no orders for adaptive equipment. The Dietary Director, Employee E9, confirmed these findings. Additionally, the Director of Nursing (DON) confirmed on 11/8/24, at 2:00 p.m., that Resident R4 should not have been served the soup or the sippy cup.
Plan Of Correction
Resident R4 was not affected by the deficient practice of not providing items consistent with their prescribed diet as the issue was discovered and addressed before the soup was served. There was also no negative effect for resident R4 who did not have orders for the two handle cup adaptive equipment. The Dietician/designee or the Director of Nursing/designee will audit orders for residents with specialty diets and/or adaptive dining equipment to ensure the appropriate orders are in place. The Dining Services Director/designee will educate team members on ensuring residents receive food/diet items as prescribed by physician orders by DON/designee. The Director of Nursing, Dining Services manager, dietician or designee will conduct observation audits at least five times weekly for 4 weeks on residents who are on modified diets to ensure team members are following the MD order. The audits will be completed and presented to the QAPI committee for further review and follow up if there are any negative trends identified.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to obtain a physician order for hospice services and ensure the coordination of hospice services with facility services for three residents. Resident R3, who was admitted with diagnoses including high blood pressure, depression, and dementia, had a physician order indicating hospice services but lacked documentation from the hospice service, including admission details, a plan of care, and communication records. Additionally, the comprehensive care plan for Resident R3 did not include contact information for the hospice agency or instructions on accessing the hospice's 24-hour on-call system. Similarly, Resident R8, diagnosed with high blood pressure, dementia, and Parkinson's disease, had a physician order for hospice services without a related diagnosis. The care plan also failed to include necessary hospice coordination details. Resident R39, with dementia, diabetes mellitus, and hyperlipidemia, had a physician order to consult hospice care but lacked vendor information and a qualifying diagnosis. The Director of Nursing confirmed these deficiencies, which were in violation of several Pennsylvania Code regulations regarding licensee responsibilities, management, staff development, and resident care policies.
Plan Of Correction
The Director of Nursing/designee completed a whole house audit on 1/1/25 of active hospice residents to ensure MD orders were updated and plans include resident diagnoses for hospice and hospice contact information. Each resident has a form of internal communication from the assigned hospice. R3, R8, and R39 were not affected by the deficient practice of not having all the required documentation of hospice services on resident charts. The Director of Nursing/Designee will educate team members on the required documentation for the clinical record for resident hospice services admission. Each hospice resident has an internal communication process from the assigned hospice. The DON/designee will conduct weekly audits for 4 weeks of hospice residents to ensure they have a hospice order, diagnosis for hospice, and contact information for the resident's selected hospice service. The Director of Nursing/designee(s) will audit for four weeks the communication books for each hospice resident to ensure the internal communication process is in place for residents served by the identified hospice. The results of audits will be submitted to the QAPI committee to review for any trends for which further improvement plans may need to be considered.
Infection Control Meeting Attendance Deficiency
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by the Medical Care Availability and Reduction of Error (MCARE) Act. Specifically, the facility did not ensure that all required multidisciplinary members were present at the Infection Control Meetings. The absence of a community member was noted for all four quarters of the year, and laboratory personnel were missing for one quarter. This deficiency was identified through a review of the facility's Infection Control Meeting attendance records for the entire year of 2024. During an interview, the Nursing Home Administrator confirmed the absence of the required members at the meetings. The regulation requires a multidisciplinary committee to include representatives from medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plant personnel, a patient safety officer, a community member, and a member of the infection control team. The failure to include these members, particularly a community member and laboratory personnel, indicates non-compliance with the infection control plan requirements as outlined in the MCARE Act.
Plan Of Correction
The 2025 infection control meetings have been established. Communication about scheduled infection control meetings will be sent to all committee members prior to each meeting. Committee members who do not RSVP or participate in the scheduled meeting will be asked to connect with the infection preventionist to review the summary of the meeting. The missing committee member may also view a securely recorded version of the meeting to share their feedback. The infection preventionist will ensure that attendance is documented for all meetings and whether the committee member participated in person, via Zoom, or via recording. The sign-in sheets will be shared with the QAPI committee to verify infection control committee required participation at least quarterly in 2025. Any identified trends by the QAPI or infection control committee will be addressed for performance improvement.
Deficiency in Kitchen Fire Suppression Documentation
Penalty
Summary
The facility failed to maintain proper documentation for the kitchen hoods' fire suppression system, as required by NFPA 101 standards. During a review on January 8, 2025, it was discovered that the facility did not have records for one of the two mandatory semi-annual Kitchen Fire Suppression Testing/Maintenance sessions conducted within the past 12 months. This deficiency was identified in one of the four smoke compartments. The absence of documentation was confirmed during an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The kitchen fire suppression system was tested by Firefighters on January 9, 2025. There were no identified issues with the test. The maintenance director has scheduled our kitchen fire suppression system test for July 2025 to ensure we are in compliance with semi-annual testing. A recurring work order will be created electronically to serve as a reminder to the maintenance team that this test will be completed within the scheduled time frame. The maintenance director will educate all maintenance team members on the appropriate fire safety and testing of the fire suppression system by the compliance date. The maintenance director will present fire suppression testing records at the quality assurance meetings twice annually to ensure compliance. Any issues identified with fire suppression testing compliance will be addressed by the QAPI committee to ensure compliance is maintained.
Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in compliance with NFPA 25 standards, as evidenced by two specific deficiencies. Firstly, during an observation on January 8, 2025, it was found that a drop ceiling grid was improperly wired to a sprinkler pipe in the Countryside hallway next to Room 312. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director later that day. Additionally, the facility did not replace or recalibrate the gauges for the automatic sprinkler system within the last five years, affecting the entire facility. This was discovered during an inspection on the same day. The Facility Administrator and Maintenance Director confirmed this deficiency during an interview. These findings indicate a lapse in the regular maintenance and testing of the sprinkler system, as required by the relevant standards.
Plan Of Correction
Note that room 312 is Gardenside. The identified attached wire to the sprinkler pipe near room 312 was removed on the date of discovery. An inspection of the building will occur to identify non-compliant wires attached to sprinkler pipes and any issues will be corrected. Maintenance staff will receive training conducted by the maintenance director or designee related to areas of noncompliance related to sprinkler heads. Each neighborhood area will be randomly audited in several locations weekly for four weeks and then monthly for three months to ensure there are no issues of non-compliance related to sprinkler head violations. Results of audits will be presented to the QAPI committee each quarter for review to ensure any negative trends of non-compliance are addressed through a performance improvement plan. Firefighters are scheduled to do a sprinkler head inspection on January 21, 2025. Firefighters will replace all sprinkler head gauges during this inspection. Firefighters acknowledged the need to replace the sprinkler head gauges in advance of the five-year threshold. A recurring work order will be placed in the electronic work order system as a reminder to ensure sprinkler head gauges are replaced by January of 2030 unless issues arise. The maintenance manager will educate all maintenance team members on the sprinkler head inspection and gauge replacement schedule. The maintenance manager will submit Firefighters' completion report/invoice to the QAPI committee. Any identified issues will be reviewed by the committee for further review and recommendations.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct the required number of fire drills, as mandated by NFPA 101, which requires fire drills to be held at least quarterly on each shift. Upon review of the documentation on January 8, 2025, it was found that the facility did not have records for five out of the twelve required fire drills over the past year. Specifically, there was no documentation for the first and third shifts during the second quarter, the second shift during the third quarter, and the first and third shifts during the fourth quarter. An interview with the Facility Administrator and Maintenance Director confirmed the absence of documentation for these fire drills. This deficiency affects the entire facility, as the drills are essential for ensuring staff familiarity with emergency procedures and maintaining safety standards. The lack of documentation indicates that the facility did not meet the regulatory requirements for fire safety preparedness.
Plan Of Correction
An audit of fire drills at Longwood Skilled Nursing noted 12 fire drills in 2024. However, there was one night shift in the second quarter, one evening shift in the third quarter, and a night shift drill in the fourth quarter that were missed. The maintenance manager will create a quarterly fire drill schedule to ensure each shift is covered every quarter. There were no identified issues related to the deficient practice of the missed fire drills. The maintenance manager educated the maintenance team on the need to conduct drills on every shift and every quarter. Completed drills will be submitted to the QAPI team prior to the end of the quarter to ensure that all shifts participated in a fire drill during the quarter. Any missed drills will be completed by the maintenance team before the end of the quarter. Documentation reports from the monthly drills will be presented at the QAPI meeting to identify and address any issues of non-compliance.
Unsecured Oxygen Cylinder Found in Storage Room
Penalty
Summary
The facility failed to maintain medical gas storage requirements, as evidenced by an unsecured oxygen cylinder found in the Oxygen Storage Room on the first floor of Countryside. This observation was made during a survey on January 8, 2025, at 9:50 a.m. The deficiency was noted in one of the four smoke compartments, indicating a lapse in adherence to the National Fire Protection Association (NFPA) standards for gas equipment storage. During an interview conducted on the same day at 1:30 p.m., the Facility Administrator and Maintenance Director confirmed the deficiency related to medical gas storage. The unsecured cylinder represents a failure to comply with the NFPA 99 requirements, which mandate that storage locations for medical gases be designed, constructed, and ventilated according to specific guidelines to ensure safety and compliance.
Plan Of Correction
The improperly stored oxygen cylinder was chained on the date of discovery to ensure compliance. All rooms in the building where oxygen is located will be audited for proper storage of oxygen cylinders. The nursing and maintenance team will be reeducated before the compliance date about the storage of oxygen in the oxygen storage locations. The oxygen rooms will be audited weekly for four weeks and monthly for three months to ensure oxygen cylinders are stored properly. The audits will be presented at the quarterly QAPI committee for review of any negative trends that may require performance improvement plans.
Emergency Lighting Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain emergency lighting in operable condition, as observed during an inspection. Specifically, an emergency light located above the dryers in the laundry room was found to be damaged and missing parts. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This plan of correction should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements. The emergency light for dryer side of the laundry was replaced on 1/14/2025. The maintenance director/designee will complete a review by January 17 of all emergency lights. Any identified emergency lights found to not be operational will be addressed at time of discovery. The maintenance team will be re-educated by the maintenance director on the need to test all emergency lights and report any issues with proper function immediately upon discovery. The emergency lights are on a monthly service check and an annual 90-minute test. The maintenance director/designee will submit results of the audits to the Quality Assurance Performance Improvement Committee for the next two quarters. Any identified negative trends will be addressed by the committee for further follow up.
Failure to Implement Transmission-Based Precautions for Norovirus
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for 11 out of 16 residents who were reviewed. These residents exhibited symptoms of gastrointestinal illness, such as nausea, vomiting, and diarrhea, which were being treated as positive for Norovirus. Despite the facility's policy requiring residents with infections to be placed on transmission-based precautions, several residents did not have physician orders for Contact Precautions, and for those who did, there was a lack of signage indicating the precautions outside their rooms. Observations revealed that residents with symptoms of Norovirus were not consistently placed on Contact Precautions as required by the facility's policy and CDC guidelines. For instance, residents with symptoms starting from various dates did not have corresponding physician orders for Contact Precautions, and even when orders were present, there was no signage outside their rooms to indicate the need for such precautions. This lack of signage was confirmed during interviews with staff, who acknowledged that signs should be present to indicate isolation precautions. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) further confirmed the deficiency. The DON admitted that the facility failed to implement the necessary precautions for the affected residents, and the RN noted that isolation signs were not consistently placed on the doors of residents who were supposed to be on isolation precautions. The facility's failure to adhere to its own policies and CDC guidelines resulted in a significant lapse in infection control measures for residents with gastrointestinal symptoms.
Plan Of Correction
All residents who were experiencing diarrhea or vomiting symptoms as of 12/26/2024 were reviewed and any missing orders were added to the resident's medical record. Appropriate isolation signage was placed to the door of any resident with orders for isolation if signage was found to be missing. Setup for all residents who had an isolation setup ensured to have an order for isolation and contact isolation signs in place. Any resident who has illness or symptoms that require isolation has the potential to be affected by this alleged aberrant practice. Team members will be educated by the Director of Nursing/designee before the compliance date on the appropriate isolation protocols and setup to include physician orders for the isolation and isolation precaution signage at the resident's door while the isolation is in place. An isolation checklist will be developed to help guide the nursing team any time a resident is placed in isolation precaution. The Director of Nursing/designee will complete audits weekly for six weeks to ensure all isolation precaution protocols including physician orders and appropriate signage are in place for residents who are ordered isolation. Audits will be reviewed by the QAPI committee until such time consistent substantial compliance has been achieved as determined by the QAPI committee.
Neglect in Wound Care for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by an incident involving a skin tear that was not properly treated. The resident, who had a history of dementia, muscle weakness, and repeated falls, was admitted with a care plan indicating potential for skin integrity impairment. A physician's order required the cleansing and dressing of a skin tear on the resident's right forearm. However, the resident's daughter reported a skin tear near the right elbow to a nurse aide, who applied a bandage without cleansing the wound, as the nurse was unavailable and the aide forgot to inform her. The incident was documented in a facility report, noting a bruise on the resident's head and the untreated skin tear. The Director of Nursing acknowledged awareness of the situation but did not investigate it as neglect. The nurse aide involved provided a statement explaining the circumstances, including the absence of the nurse and the subsequent failure to communicate the issue. This oversight resulted in the resident not receiving the necessary care to prevent potential harm, as required by the facility's policy and state regulations.
Plan Of Correction
The Executive Director of Healthcare Services and Director of Nursing investigated this incident on the evening of the incident. Employee El acknowledged that he placed the bandage on Resident R1's arm and forgot to tell the nurse. The Director of Nursing reviewed the incident with employee El on 12/17/24 and shared that he operated outside of his scope of practice and further failed to report the incident to the nurse. Education and corrective action was issued to Employee El on 12/23/24 to ensure the employee understood his job description and the importance of giving full report to his nurse and the oncoming shift. Resident R1's right elbow is healing properly and there were no negative outcomes as a result of this incident. Employee El was educated on 12/17/24 on appropriate reporting and treatment protocols when a resident health incident occurs. All residents have the potential to be affected by this aberrant practice. The DON/designees will perform a one-time audit of front line team members to ensure they have been educated on timely reporting of incidents involving potential abuse or neglect. The Director of Nursing/designees will observe resident care one time daily five days per week for six weeks. Results of the audits will be presented to the QAPI team for any negative trends and follow up recommendations.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for a resident. The resident, who had a history of dementia, muscle weakness, and repeated falls, was admitted to the facility and had a care plan indicating potential for skin integrity impairment. An incident occurred where the resident's daughter reported a skin tear near the resident's right elbow to a Nurse Aide (NA), who then applied a bandage without cleansing the wound and failed to inform the nurse. This resulted in the wound not being properly treated, as it was not approximated and had moderate bleeding. The Director of Nursing (DON) was aware of the situation but did not investigate or report it as neglect. The facility's policy on abuse requires that reports of neglect be promptly and thoroughly investigated and reported per Federal and State Law. However, in this case, the facility did not follow its policy, as the incident was not investigated or reported as required. The failure to implement these policies and procedures led to the deficiency identified by the surveyors.
Plan Of Correction
1. The incident that occurred with resident #R1 was reported to the Pennsylvania Department of Health and Adult Protective Services on 12/26/2024. A thorough review of all incidents current resident records will be conducted to identify any instances where the failure to report incidents, changes in condition, or abuse/neglect was noted. This review will cover the past 30 days from the date of the citation. 2. All relevant incidents, including changes in a resident's condition, suspected abuse, neglect, or other critical information that should have been reported, will be documented and immediately reported to the appropriate agencies as per state regulations. Staff will also ensure that these incidents are fully documented in resident records. The Senior Director of Clinical Services will re-educate the director of nursing and executive director of health services on the abuse and neglect policy to ensure that instances that may be considered abuse or neglect are reported timely as appropriate to the designated agencies. The Director of Nursing and Executive Director of Health Services or their designees will re-educate team members by the compliance date on the need to report all incidents where there is a need for nursing intervention to ensure if there is any evidence of potential abuse or neglect that it gets reported immediately to nursing supervisors and addressed immediately with the abuse reporting compliance team. The Director of Nursing/designee will audit incidents and accidents weekly for six weeks to ensure a thorough investigation has occurred and if necessary appropriate reporting has been submitted through PA Department of Health's Event Reporting System. The results of these audits will be shared with the Quality Assurance Performance Improvement Committee for review of trends that may require further action.
Failure to Report Allegation of Neglect in Required Timeframe
Penalty
Summary
The facility failed to report an allegation of neglect within the required timeframe for one of four residents. The incident involved a resident with a history of dementia, muscle weakness, and repeated falls, who was admitted to the facility with a care plan indicating potential for skin integrity impairment. On December 16, 2024, the resident's daughter noticed a skin tear near the resident's right elbow and informed a Nurse Aide (NA) about it. The NA, unable to find a nurse, applied a clear bandage without cleansing the wound and forgot to inform the nurse about the incident. The Director of Nursing (DON) was aware of the situation but did not investigate or report it as neglect. The incident was documented in a facility Incident Report by a Licensed Practical Nurse (LPN), who noted a bruise on the resident's head and was informed by the resident's daughter about the skin tear. The DON confirmed that the facility did not report the allegation of neglect in the required timeframe, which is a violation of the facility's policy and state regulations.
Plan Of Correction
The incident that occurred with resident #R1 was reported to the Pennsylvania Department of Health and Adult Protective Services on 12/26/2024. A thorough review of all incidents current resident records will be conducted to identify any instances where the failure to report incidents, changes in condition, or abuse/neglect was noted. This review will cover the past 30 days from the date of the citation. All relevant incidents, including changes in a resident's condition, suspected abuse, neglect, or other critical information that should have been reported, will be documented and immediately reported to the appropriate agencies as per state regulations. Staff will also ensure that these incidents are fully documented in resident records. The Senior Director of Clinical Services will re-educate the director of nursing and executive director of health services on the abuse and neglect policy to ensure that instances that may be considered abuse or neglect are reported timely as appropriate to the designated agencies. The Director of Nursing and Executive Director of Health Services or their designees will re-educate team members by the compliance date on the need to report all incidents where there is a need for nursing intervention to ensure if there is any evidence of potential abuse or neglect that it gets reported immediately to nursing supervisors and addressed immediately with the abuse reporting compliance team. The Director of Nursing/designee will audit abuse and neglect incidents submitted through the PA Department of Health's Event Reporting System for timeliness of investigation and reporting for six weeks. The results of these audits will be shared with the Quality Assurance Performance Improvement Committee for review of trends that may require further action.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of neglect involving a resident with dementia, muscle weakness, and a history of falls. The resident was admitted with a care plan indicating potential for skin integrity impairment due to fragile skin, impaired mobility, bladder incontinence, and a history of skin tears. A physician's order was in place to treat a skin tear on the resident's right forearm. However, an incident report noted a bruise on the resident's occipital bone and a skin tear near the right elbow, which was not properly cleansed before being dressed by a nurse aide. The Director of Nursing acknowledged awareness of the situation but did not investigate or report it as neglect. The nurse aide involved admitted to applying a bandage without cleansing the wound after failing to locate a nurse. The facility's failure to investigate the incident as neglect was confirmed by the Director of Nursing, indicating a deficiency in adhering to the facility's policy on abuse and neglect investigations.
Plan Of Correction
Incident with R1 was investigated and reported to the Department of Health on 12/26/24. The resident had sustained a skin tear, and a team member became aware of the skin tear when the daughter reported it during her visit on 12/16/24. The Executive Director of Health Services confirmed that the CNA did apply a tegaderm dressing and failed to report it to the nurse. A PB22 was completed, and the allegation of neglect was substantiated and addressed internally through corrective action. The skin tear was appropriately treated on 12/16/24 by the RN charge nurse and documented accordingly. The wound is healing properly. An audit of incidents and accidents from the time of this incident will be reviewed to ensure that they have been investigated properly and any potential allegations of abuse or neglect have been properly reported. Any identified issues will be reported at the time of discovery. The Director of Nursing and NHA were reeducated by the Senior Clinical Services Director on January 3, 2025, on the policy to respond to allegations of abuse, neglect, exploitation, or mistreatment. Any alleged violations have been thoroughly investigated with evidence of interventions to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. If the alleged violation is verified, appropriate corrective action must be taken. Audits will be completed monthly for 3 months of any abuse allegations received by the facility to ensure the investigation is thorough and allegations are reported to DOH if appropriate by NHA or designee. Results will be brought to QAPI to determine if further auditing is necessary.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who was cognitively intact with a BIMS score of 13, had a care plan in place to address the risk of wandering or elopement. Despite this, the resident managed to leave the facility unsupervised. The care plan included interventions such as identifying the resident's room and bathroom, monitoring for specific times of wandering, and scheduling regular walks or activities. On the day of the incident, the resident was last seen at dinner and during evening medication rounds. Staff assumed the resident had returned to her room, but no one confirmed her presence there. Approximately 45 minutes later, the resident was found outside the facility by a personal care employee, attempting to navigate a curb in her wheelchair. The employee assisted the resident to the main entrance, where security took over. The resident had managed to exit through double doors leading to a general hallway and then outside, without being noticed by staff. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the lack of adequate supervision. The facility's policy required staff to investigate and report missing residents, but the lapse in supervision allowed the resident to leave the premises unnoticed. The incident report and witness statements highlighted the failure to monitor the resident effectively, leading to her unsupervised departure from the facility.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the appropriate authorities within the required 24-hour timeframe and did not describe the results of the investigation within five working days. This deficiency involved a resident who was admitted with diagnoses including encephalopathy, paroxysmal atrial fibrillation, and hypothyroidism. An incident report noted a bruise on the resident's left inner thigh, which was blackish in color and surrounded by a large, firm mass. The facility initially submitted the incident report late and under the wrong event type, leading to further delays in proper reporting and documentation submission. During interviews, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed the failure to meet reporting requirements. The DON was unable to contact one of the alleged perpetrators due to their resignation the day after the incident. The facility's documentation showed that the initial submission was rejected and resubmitted multiple times, causing further delays in compliance with state law and federal regulations.
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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