Luther Woods Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hatboro, Pennsylvania.
- Location
- 313 County Line Road, Hatboro, Pennsylvania 19040
- CMS Provider Number
- 395370
- Inspections on file
- 19
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Luther Woods Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to promptly investigate a suspected diversion of narcotic medication after a resident with chronic pain syndrome was found to have discrepancies in their oxycodone administration records. The issue was reported to the DON, but no investigation was initiated until a second, similar allegation arose involving the same nurse.
A resident with Alzheimer's Disease and moderate cognitive impairment, identified as at risk for elopement, was able to exit the facility when the receptionist released the front door lock for visitors. The resident was found outside in the parking lot by staff, and the wander guard alarmed only upon re-entry. This incident demonstrates a failure to provide adequate supervision and prevent elopement.
The facility failed to maintain accurate records and reconciliation of controlled substances for two residents, resulting in medication discrepancies and diversion by an LPN. In both cases, oxycodone was signed out and administered without proper documentation or resident request, and required dual signatures for narcotic counts were missing across multiple shifts.
A resident with Alzheimer's Disease and moderate cognitive impairment was incorrectly documented as having no dementia or cognitive impairment on the Elopement Evaluation Assessment tool, despite their care plan identifying elopement risk and the use of a wander prevention band. An LPN confirmed the documentation error.
The facility failed to maintain and inspect its emergency generator, lacking documentation for an annual fuel quality test and a 3-year load test. The generator was also in alarm for 'over-cranking.' A revisit confirmed the missing documentation for the fuel quality test.
The facility failed to obtain required occupancy inspection approval for its emergency power generator and did not update policies per the 2016 Act 48. Additionally, it lacked a carbon monoxide alarm evacuation policy and accurate portable floor plans, as confirmed during interviews and document reviews.
The facility failed to maintain and inspect the kitchen hood suppression system, affecting the entire facility. The required semi-annual testing was not conducted within six months, and monthly quick checks were not performed throughout the survey year. This was confirmed by the facility's administrative staff during an exit interview.
The facility failed to maintain its fire alarm system components, affecting the entire facility. A document review revealed two deficiencies: the inability to use the Xaap device for inspection due to lack of reception in the basement, and a repeat functional failure of a pull station on the first floor. Additionally, there was a high priority recommendation to update smoke detectors for better sensitivity testing. These issues were confirmed during an exit interview with facility leadership.
The facility failed to maintain and inspect its emergency generator, lacking documentation for an annual fuel quality test and a 3-year load test. Additionally, the newly installed generator was in alarm for 'over-cranking,' indicating potential malfunction. These issues were confirmed during an exit interview with facility leadership.
The facility did not obtain necessary approvals for emergency power generator replacements and failed to update policies per the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. Additionally, it lacked accurate floor plans for the Life Safety Code Survey, as confirmed by administrative staff.
The facility failed to maintain self-closing doors on both levels, with several doors found propped open or not functioning correctly. Issues included doors propped open with wedges, chairs, and door stops, as well as a door that did not latch and another with a large gap when latched. These deficiencies were confirmed during an exit interview with the Facility Administrator and other staff.
The facility was found to have a deficiency in maintaining emergency lighting, as the emergency spot lighting in the loading dock/maintenance shop was damaged and detached from its housing. This was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility did not maintain proper hazardous area enclosures, with laundry room doors propped open and lacking door closers, and maintenance area doors also propped open, compromising fire safety standards.
The facility did not properly maintain and inspect its sprinkler systems, impacting the entire facility. Damage was observed in the C wing supply closet to the ceiling grid and sprinkler escutcheon around the sprinkler head. This issue was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as required by NFPA 101 standards. Observations revealed unsealed penetrations above smoke barrier doors next to a room due to a newly run data line, compromising the smoke barrier's integrity. This was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility was found to be non-compliant with NFPA 70, National Electric Code, due to a non-GFCI outlet located within 6 feet of a sink in the women's room/locker room. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance.
The facility did not conduct fire drills once per shift per quarter, impacting the entire facility. A document review revealed the absence of accurate documentation for fire drills from July to November 2024. An exit interview confirmed the reuse of documentation for these months.
The facility did not maintain its electrical system as required by NFPA standards. An observation revealed an electrical panel in the basement's electrical room without a cover. This deficiency was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility was cited for improper use of electrical equipment, including extension cords powering Christmas trees, a refrigerator plugged into a power strip in the laundry room, and a heat/blower hand dryer using an outlet multiplier. These issues were confirmed during an exit interview with facility leadership.
The facility failed to maintain proper storage of oxygen and gas cylinders, with freestanding cylinders found in multiple locations, including the C wing oxygen room and the Activities Room. Additionally, a door was propped open using a full oxygen cylinder storage rack, indicating non-compliance with NFPA 101 standards. This was confirmed during an exit interview with facility administrators.
The facility failed to develop and document an Emergency Preparedness Plan addressing its role under a waiver declared by the Secretary, as required by section 1135 of the Act. This deficiency was confirmed during a document review and exit interview, affecting the entire facility's ability to provide care at alternate sites during emergencies.
The facility was found non-compliant with NFPA 101 standards as one of its smoke compartments exceeded the maximum size of 22,500 square feet and the travel distance limit of 200 feet. This was confirmed during an exit interview with the Administrator and Maintenance Director.
A facility failed to obtain a physician's order for a resident's oxygen therapy. The resident was observed using a nasal cannula connected to an oxygen concentrator at 4 liters per minute, which she had been on since a recent hospitalization. The DON confirmed the absence of a physician's order, despite the resident's discharge summary indicating continuous oxygen use.
The facility failed to properly store controlled drugs in the B wing medication room. The door lock code was written on the door jamb, and the medication refrigerator was unlocked, containing an unsecured bottle of Lorazepam. These issues were confirmed by the unit manager during an observation.
The facility did not meet the required nurse aide-to-resident ratios on several occasions, failing to provide the mandated number of nurse aides during day, evening, and night shifts. This deficiency was confirmed through a review of staffing data and an interview with the Scheduler.
In 2024, the facility failed to meet the required LPN staffing ratios during various shifts over several weeks. On multiple occasions, the number of LPNs provided was below the mandated levels, such as on July 4, when only 40.50 LPNs were available during the day shift, while 41.92 were required. These deficiencies were confirmed through a review of staff schedules and punch reports.
The facility failed to provide the required minimum of 3.20 hours of direct nursing care per resident per day on multiple occasions. A review of nursing schedules and punch reports revealed that on several days, the care hours ranged from 2.70 to 3.14, falling short of the mandated requirement. This deficiency was confirmed through staff interviews and documentation review.
The facility failed to maintain a safe, clean, and homelike environment in B and C Units. Observations revealed exposed bedpans, missing tiles, and dirty linen in B Unit, along with an exposed electrical heater in the hallway. In C Wing, shower rooms were cluttered and used for storage, making them non-functional. A resident reported unfinished repairs in their bathroom.
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with specific communication needs. Despite the resident's preference for using paper and pen to communicate, the care plan did not reflect this, leading to frustration and ineffective communication. This deficiency was confirmed through staff interviews and a review of the facility's policy and clinical records.
The facility failed to monitor and address significant weight loss for two residents. One resident experienced a weight drop from 190.2 pounds to 141.0 pounds over several months, while another resident's weight dropped from 170.4 pounds to 143 pounds. Despite documented weight loss, timely interventions were not implemented, and the Registered Dietitian could not explain the lack of timely assessment and intervention.
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in acquiring, receiving, and administering Pregabalin. The resident missed multiple doses due to the medication being unavailable, and there was no documented evidence that the physician was informed or that backup pharmacy procedures were activated. The Director of Nursing confirmed the nursing staff did not follow the facility's policy and procedure.
The facility failed to ensure that residents and their representatives understood the terms of binding arbitration agreements. Four residents signed the agreements without proper explanation in a language they could understand. The agreements were missing key elements, and the Admission Director confirmed that they were read to residents without ensuring comprehension.
Failure to Investigate Suspected Narcotic Diversion
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of missing potential narcotic medication for one resident. According to the facility's policy, all discrepancies, suspected loss, or diversion of medications must be immediately investigated and reported. A review of clinical records showed that a resident with chronic pain syndrome had an order for oxycodone as needed for migraines. The Medication Administration Record (MAR) and controlled substance inventory sheets revealed that a single licensed nurse was signing out and administering the medication, with discrepancies noted on specific dates. The resident later stated they had not requested the medication, prompting suspicion of possible diversion. The unit manager identified inconsistencies between the narcotic book and the MAR and reported the issue to the DON when the medication was discontinued. Despite the suspicion of medication diversion, the DON confirmed that no investigation was initiated at the time the concern was reported, as the administrator was out of the office and the nurse in question was not scheduled to return for several days. An investigation was only started after a subsequent, similar allegation involving another resident. The failure to promptly investigate the initial suspicion of narcotic diversion constituted a violation of facility policy and state regulations.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with Alzheimer's Disease and moderate cognitive impairment. Upon admission, the resident was assessed for elopement risk and scored as low risk, but the care plan identified the resident as being at risk for elopement due to dementia and included a wander prevention band. Despite these measures, the resident was able to exit the building when the receptionist released the front door lock, allowing multiple visitors and the resident to leave the premises. The incident report and staff witness statements confirm that the resident left the building and was later found in the parking lot near the road by a nurse aide. The wander guard alarmed only when the resident re-entered the building. The event was confirmed by the DON, who provided the timeline of the resident's exit and subsequent recovery. The deficiency was cited under regulations related to the responsibility of the licensee, resident care policies, and nursing services.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an accurate account of all controlled substances was kept for two residents. Facility policy required special handling, storage, disposal, and recordkeeping for controlled substances in accordance with federal and state regulations. However, discrepancies were identified in the narcotic count sheets and Medication Administration Records (MARs) for two residents who had orders for PRN oxycodone. In both cases, the controlled substance inventory did not match the documented administration, and doses were signed out without corresponding physician orders or resident requests. For one resident with chronic pain syndrome, the MAR indicated that oxycodone was administered multiple times by a single nurse, despite the resident stating he had not requested or taken the medication for nearly two months. The medication was discontinued by the physician after this was discovered. For another resident with chronic migraines, the controlled substance count decreased by two tablets during a night shift, but only one dose was documented as given. The resident confirmed she had not requested the medication during that time. In both cases, the nurse responsible admitted to diverting the narcotics for personal use. Additionally, the facility failed to maintain proper dual signatures for narcotic counts during shift changes, as required by policy. Multiple interviews with nursing staff confirmed that several shifts lacked the required signatures in the controlled substance inventory count books across different wings of the facility. This lack of proper documentation and reconciliation of controlled substances contributed to the inability to promptly detect and prevent the diversion of medications.
Inaccurate Documentation of Elopement Risk Assessment
Penalty
Summary
The facility failed to ensure complete and accurate documentation for a resident assessed for elopement risk. Upon admission, the resident, who had a diagnosis of Alzheimer's Disease and a BIMS score indicating moderate cognitive impairment, was required to be evaluated for elopement risk using the facility's Elopement Risk Tool Assessment. The resident's care plan identified them as being at risk for elopement due to dementia and noted the use of a wander prevention band. However, the Elopement Evaluation Assessment tool incorrectly indicated that the resident had no diagnosis of dementia or cognitive impairment. This discrepancy was confirmed during an interview with an LPN, who acknowledged that the resident did have a standing diagnosis of Alzheimer's dementia and that the assessment tool was coded incorrectly.
Emergency Generator Maintenance and Inspection Deficiency
Penalty
Summary
The facility failed to maintain and inspect its emergency generator, which affected the entire facility. During a document review on December 18, 2024, it was found that the facility could not provide documentation for an annual fuel quality test and a 3-year, 4-hour load test. Additionally, an observation on the same day revealed that the newly installed generator was in alarm for 'over-cranking.' These findings were confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance. A follow-up onsite revisit conducted on February 11, 2025, confirmed that the facility still could not provide documentation for the annual fuel quality test. This was verified during an exit interview with the Maintenance Director. All other deficiencies listed under this tag were corrected, but the lack of documentation for the annual fuel quality test remained unresolved.
Plan Of Correction
The annual fuel test is scheduled to be completed on 2/26/25. Results take up to 2 weeks to receive, so they will be available to us by 3/12/25. Maintenance will keep the date and the results logged in our Generator Binder and will ensure the fuel quality test is completed in February every year ongoing.
Deficiencies in Emergency Power Generator Approval and Policy Updates
Penalty
Summary
The facility failed to obtain the required Pennsylvania Department of Health Final Occupancy Inspection approval for the replacement of the facility's emergency power generator and other essential electrical system components. This deficiency was identified during an observation, interview, and documentation review conducted on December 18, 2024. The facility did not notify the Norristown Department of Safety Inspection in writing about the approved PA DOH Stamped Drawing Index of H-22-0230, indicating when construction started and was completed. This lack of notification was confirmed during an exit interview with the Administrator, Administrator in training, and Maintenance Director. Additionally, the facility did not update its policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. The document review revealed the absence of a carbon monoxide alarm evacuation policy plan and associated staff in-service training. Furthermore, the facility failed to provide accurate portable floor plans, which are required for the Life Safety Code Survey. The provided floor plans lacked indications of smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. These deficiencies were confirmed during an exit interview with the facility's administration and maintenance staff.
Plan Of Correction
We notified Norristown Department of DSI on 1/30/2025. We needed to gather more documentation for DSI. This documentation will be completely acquired and submitted by 2/28/25.
Failure to Maintain Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system, which affected the entire facility. During a document review on December 18, 2024, it was revealed that the facility did not conduct the required semi-annual testing of the kitchen hood suppression system within six months of February 27, 2024. This was confirmed during an exit interview with the Administrator, Administrator in training, and Maintenance Director, who acknowledged the lack of documentation. Additionally, an observation and interview conducted on the same day at 12:40 p.m. revealed that the kitchen hood suppression system did not undergo the necessary monthly quick checks throughout the entire survey year. This was also confirmed during the exit interview with the facility's administrative staff.
Plan Of Correction
Kitchen Hood Fire Suppression system was inspected on December 19th, 2024, by an outside vendor. The equipment has been placed on an automatic inspection schedule with this vendor. Maintenance will monitor the automatic scheduling dates.
Fire Alarm System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on December 18, 2024, it was found that the fire alarm report from December 16, 2024, listed two deficiencies and one high priority recommendation without verification of repair. The first deficiency involved the inability to use the Xaap device for system inspection due to lack of cellular and WiFi reception in the basement where the Fire Alarm Control Panel (FACP) is located. The second deficiency was a repeat issue from the previous year's inspection, involving a functional failure of a pull station located on the first floor, C Wing by the activities room. Additionally, there was a high priority recommendation to update all smoke detectors to a newer model for improved sensitivity testing and troubleshooting. These findings were confirmed during an exit interview with the Facility Administrator, Administrator in training, and the Director of Maintenance.
Plan Of Correction
We have contacted Johnson Controls, who is our service contractor. They are scheduled to come to the facility on January 18th, 2025. We are anticipating that all needed repairs will be completed by January 20th, 2025.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect its emergency generator, which affected the entire facility. During a document review, it was found that the facility could not provide documentation for an annual fuel quality test and a 3-year, 4-hour load test. These tests are essential for ensuring the generator's reliability and compliance with NFPA standards. The absence of these records indicates a lapse in the facility's maintenance and testing protocols for its emergency power systems. Additionally, an observation revealed that the newly installed generator was in alarm for 'over-cranking.' This issue was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance. The alarm condition suggests a potential malfunction or improper setup of the generator, further highlighting the facility's failure to ensure the emergency generator's operational readiness and compliance with required safety standards.
Plan Of Correction
An outside vendor was brought in to do required testing on our generator: Annual Fuel Quality and 3 year, 4 hour load test. We were told the report would be given to us by January 22nd, 2025. The over cranking was repaired the same day as the survey.
Facility Fails to Obtain Required Approvals and Update Policies
Penalty
Summary
The facility failed to obtain the required Pennsylvania Department of Health Final Occupancy Inspection approval for the replacement of the facility's emergency power generator and other essential electrical system components. This deficiency was identified during an observation, interview, and documentation review conducted on December 18, 2024. The facility did not notify the Norristown Department of Division of Safety Inspection in writing about the approved PA DOH Stamped Drawing Index of H-22-0230, indicating when construction started and when it was completed. This lack of notification was confirmed during an exit interview with the Administrator, Administrator in training, and Maintenance Director. Additionally, the facility did not update its policies in accordance with the 2016 Act 48 - Care Facility Carbon Monoxide Alarms Standards Act. The document review revealed the absence of a carbon monoxide alarm evacuation policy plan and associated staff in-service training. Furthermore, the facility failed to provide portable, accurate floor plans required for the Life Safety Code Survey. The provided floor plans lacked indications of smoke barrier walls, fire barrier walls, horizontal exits, rated rooms, required exits, and shaft walls. This deficiency was also confirmed during the exit interview with the facility's administrative staff.
Plan Of Correction
1. The initial notification in writing of the generator had been completed. The addition of the Docking Station on 12/17/24 was just completed the day before the annual Life Safety survey, so we had not had the time yet to write a notification. Upon the exit interview, there was confusion on our part that the notification needed to be done in writing. That is being submitted today, 1/8/25. 2. The Carbon Monoxide alarm evacuation policy plan has been attained and staffing education will be completed by Friday, January 10th, 2025. 3. Maintenance will update the floor plan to include the items that are needed to make the floor plan correct. The following will be added: a. Smoke Barrier Walls (outside wall to outside wall) b. Fire Barrier Walls (2-hour walls) c. Horizontal Exits d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan. e. Required Exits should be clearly noted; and f. Shaft Walls This will be completed by January 15th, 2025.
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain doors with self-closing devices on both levels of the building, as observed during a survey conducted on December 18, 2024. Several doors intended to be self-closing were found propped open or not functioning correctly. Specifically, the staff lounge ice room door was propped open with a door wedge, the A Wing lining closet door did not latch, and the B wing break room door was held open with a trash bag tied from the door handle to a handrail. Additionally, the chapel door was propped open with a chair, the sprinkler/janitor room door had a large gap between the door and frame when latched, the basement storage door was propped open with an installed kick down door stop, and the C wing clean lining door was propped open with a door stop. These deficiencies were confirmed during an exit interview with the Facility Administrator, Administrator in training, and the Director of Maintenance.
Plan Of Correction
All doorways will be kept closed at all times. Maintenance will do daily audits each day times 30 days. Then they will do weekly checks times 60 days. All stops whether portable or installed have been removed. A new door latch has been installed on the door on A Wing. A door will be installed at the Sprinkler Room as we have been unable to fix the gap. This will be completed by 1/30/25.
Emergency Lighting Deficiency in Maintenance Area
Penalty
Summary
The facility failed to maintain emergency lighting in operable condition, as observed during a survey. On December 18, 2024, at 11:37 a.m., an inspection of the loading dock and maintenance shop revealed that the emergency lighting and exit sign combination device had damaged emergency spot lighting. The spot lighting was found detached from the sign housing and hanging from the combination device. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
All emergency signs will be repaired by January 31st, 2025. They will be audited weekly times one month. After one month they will be checked monthly. All auditing will be done by Maintenance and logged in an audit book.
Deficiency in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures on one of its two levels, as observed during a survey. Specifically, all laundry room doors, approximately four in total, were found propped open with door wedges, compromising their ability to function as fire barriers. Additionally, the C wing soiled laundry room lacked a door closer, further failing to meet the required standards for hazardous area enclosures. The maintenance area also had double doors propped open with door wedges, which was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance.
Plan Of Correction
All door wedges have been removed and proper door closures will be installed by January 15th, 2025. The fire doors will be kept closed. Maintenance will audit the fire doors daily for one month, then quarterly thereafter. All audits will be kept in an audit binder.
Failure to Maintain Sprinkler Systems
Penalty
Summary
The facility failed to maintain and inspect the sprinkler systems as required, affecting the entire facility. During an observation on December 18, 2024, at 12:40 p.m., physical damage was noted in the C wing supply closet, specifically to the ceiling grid and the sprinkler escutcheon surrounding the sprinkler head. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
C Wing closet repairs have been completed. Maintenance will check sprinkler heads for damage monthly times 6 months then quarterly on going. All audits will be logged in the Maintenance Audit Binder.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, as required by NFPA 101 standards. During an observation on December 18, 2024, at 12:15 p.m., it was noted that there were unsealed penetrations above the smoke barrier doors next to room 110. This issue arose due to the installation of a newly run data line, which compromised the integrity of the smoke barrier. The deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
Fire caulk has been used to fill in the opening created by the installation of the data line. Maintenance will check smoke barriers on a routine monthly basis and document findings in the Maintenance Audit Book. All penetrations have been and will be corrected moving forward using a UL approved stop gap penetration system.
Non-GFCI Outlet Near Sink in Women's Room
Penalty
Summary
The facility failed to comply with NFPA 70, National Electric Code, specifically regarding electrical wiring and equipment. During an observation on December 18, 2024, at 11:43 a.m., it was found that there was a non-GFCI outlet located within 6 feet of a sink in the women's room/locker room. According to NFPA 70 210.8(B)5, a GFCI outlet is required in such locations to ensure safety. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance on the same day at 1:45 p.m.
Plan Of Correction
A GFCI has been installed in the Ladies Locker Room. Maintenance will check quarterly to make sure all GFCIs are working properly. All checks will be documented in the Maintenance Audit Log.
Failure to Conduct Quarterly Fire Drills on Each Shift
Penalty
Summary
The facility failed to conduct fire drills once per shift per quarter, affecting the entire facility. During a document review on December 18, 2024, it was found that the facility could not provide correct and accurate documentation of shift and staff participation in monthly fire drills for the months of July 2024 through November 2024. An exit interview with the Facility Administrator, Administrator in training, and the Director of Maintenance confirmed the reuse of shift and participation documentation for these months.
Plan Of Correction
While paperwork was present, there was missing information. Fire Drill paperwork will be completely redone by January 15th, 2025, to fill in the missing information. Information will be checked monthly for accuracy.
Electrical Panel Cover Missing in Facility
Penalty
Summary
The facility failed to maintain and inspect its electrical system requirements according to NFPA 70 and NFPA 99 standards. During an observation on December 18, 2024, at 11:43 a.m., in the basement's electrical room, it was found that an electrical panel was missing its cover. This deficiency was confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance later that day at 1:45 p.m.
Plan Of Correction
The electrical panel has been replaced. Maintenance will check all electrical panels quarterly to make sure all covers in place. Findings will be documented in the Maintenance Audit Log.
Improper Use of Electrical Equipment in Facility
Penalty
Summary
The facility was found to have several deficiencies related to the improper use of electrical equipment, as observed during a survey on December 18, 2024. Specifically, the surveyors noted that two lighted decorative Christmas trees in the lobby were powered by extension cords running through windows, which is not compliant with the regulations. Additionally, an orange extension cord was in use in the environmental services area, and a refrigerator in the laundry room was plugged into a power strip, both of which are against the established guidelines for electrical safety. Further observations revealed that a heat/blower hand dryer in the main office bathroom was powered by an outlet multiplier located in an adjacent hallway, and both a refrigerator and a microwave in the administrator's office were plugged into a power strip. These findings were confirmed during an exit interview with the Administrator, Administrator in training, and the Director of Maintenance, indicating a failure to adhere to the required standards for electrical equipment use within the facility.
Plan Of Correction
All extension cords were removed from Holiday decorations the day of the survey. Power strips were removed and replaced with hospital grade outlet extenders. Office hand dryer will be removed and replaced with paper towels by Friday, January 10th, 2025. Maintenance will do random audits to check facility for continued compliance.
Improper Storage of Oxygen and Gas Cylinders
Penalty
Summary
The facility failed to maintain proper storage of oxygen and gas cylinders, as observed during a survey on December 18, 2024. Freestanding oxygen and gas cylinders were found in several locations, including the C wing oxygen room, the Activities Room, and the B Wing oxygen room. Specifically, three oxygen cylinders were observed in the C wing oxygen room, and two helium tanks were found in the Activities Room. Additionally, the door to the B Wing oxygen room was propped open using a full oxygen cylinder storage rack, indicating improper storage practices. During the exit interview with the Administrator, Administrator in training, and the Director of Maintenance, it was confirmed that the freestanding cylinders and the propped door were indeed present. This deficiency highlights the facility's failure to adhere to the NFPA 101 standards for gas equipment storage, which require specific storage conditions to ensure safety and compliance. The improper storage of these cylinders poses potential safety risks, as they were not secured or stored according to the required guidelines.
Plan Of Correction
All observations were corrected the same day as the survey. Maintenance will check weekly times one month for compliance and then will check quarterly. All audits will be documented in the Maintenance Log.
Deficiency in Emergency Preparedness Planning
Penalty
Summary
The facility was found deficient in its emergency preparedness planning, specifically in failing to develop and document policies and procedures concerning its role under a waiver declared by the Secretary of the Department of Health, in accordance with section 1135 of the Act. This deficiency was identified during a document review conducted on December 18, 2024, which revealed that the facility did not have an Emergency Preparedness Plan that included the necessary provisions for care and treatment at an alternate care site as identified by emergency management officials. During the exit interview with the Administrator, Administrator in training, and Maintenance Director, it was confirmed that the facility lacked the required documentation. This deficiency affects the entire facility, as it does not have the necessary policies and procedures in place to guide its actions under a waiver declared by the Secretary, potentially impacting its ability to provide care and treatment at alternate care sites during emergencies.
Plan Of Correction
Paperwork has been downloaded regarding the waiver of the Secretary of State regarding section 1135 of the Act. This will be implemented and added to our Emergency Preparedness plan by January 1st, 2025.
Non-compliance with Smoke Compartment Size Requirements
Penalty
Summary
The facility failed to comply with the NFPA 101 requirements for smoke compartments on one of its four smoke compartments. During an observation and document review conducted on December 18, 2024, it was found that the smoke compartments, specifically the front and back hallways, exceeded the maximum allowable size of 22,500 square feet. Additionally, the travel distance within these compartments surpassed the 200-foot limit from any point in the compartment to a door in the smoke barrier. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, where it was acknowledged that the B Wing smoke compartment exceeded the specified size limit.
Plan Of Correction
Ken Walters, Director of Maintenance, will contact the Department of Health to request a FSES.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that physician's orders were obtained for oxygen therapy for one resident. During an initial tour, it was observed that the resident was using a nasal cannula connected to an oxygen concentrator at 4 liters per minute. The resident confirmed that she had been on oxygen since a recent hospitalization. Subsequent observations confirmed the continued use of oxygen at the same rate. A review of the resident's medical record revealed no physician's order for the oxygen therapy. The Director of Nursing confirmed that the resident returned from an emergency room visit on continuous oxygen, as noted in the hospital discharge summary, but the nurse had not obtained a physician's order for the therapy.
Plan Of Correction
Education provided to all licensed nurses regarding Policy #1901- Respiratory Care and Oxygen Equipment. Nurse Managers will conduct Oxygen Order Audit weekly times four weeks, then biweekly times two months, then monthly times three months to ensure that all residents receiving Oxygen have appropriate physician orders per policy. All data will be reported at QAPI. Other residents who potentially could be affected by not having an order in place will be identified through the audit. R45 had a physician's order put into place immediately on discovering that her readmission orders did not have her previous O2 order in place.
Improper Storage of Controlled Drugs in Medication Room
Penalty
Summary
The facility failed to ensure that controlled drugs subject to abuse were stored and labeled in accordance with professional standards in the B wing medication room. During an observation, it was found that the door to the medication room had a coded lock, but the code was written on the door jamb, making it easily accessible. This was confirmed by the unit manager, Employee E8, during an interview at the time of the observation. Additionally, the medication refrigerator inside the B wing medication room was not locked, and it contained a transparent plastic box with an opened bottle of Lorazepam 2m/ml with 30 ml of liquid inside. The plastic box was not permanently affixed to the refrigerator, which was also confirmed by Employee E8 during the observation. These findings indicate a failure to adhere to the facility's policy on the safe, secure, and proper storage of medications and biologicals.
Plan Of Correction
Education provided to all licensed nurses regarding policy #4.2 the Storage of Controlled Substances. Nurse Managers will conduct audits on all units of the facility medication rooms to ensure that the narcotic box located in each medication refrigerator remains secured and locked as per above policy. The audits will be conducted daily times 4 weeks, then bi-weekly times two months, then monthly times 3 months. Door codes have been removed from door jams and included in above audit to ensure compliance.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift on multiple occasions across three separate weeks. These deficiencies were identified through a review of facility census data, nursing schedules, and staff punch reports. The specific dates of non-compliance included July 3, 5, 6, and 7, 2024; October 31, 2024, through November 2, 2024; and December 5, 7, 8, and 9, 2024. An interview with the Scheduler, Employee E7, confirmed the failure to meet the required staffing ratios on these dates.
Plan Of Correction
Director of Nursing will conduct a random audit of 15 days throughout the quarter. Findings will be reported quarterly at QAPI.
LPN Staffing Deficiencies in 2024
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) during various shifts over several weeks in 2024. Specifically, the facility did not meet the minimum LPN staffing requirements during the day, evening, and overnight shifts on multiple occasions. For instance, on July 4, 2024, during the day shift, the facility provided only 40.50 LPNs, while the required number was 41.92. Similar deficiencies were noted on other dates, such as July 6, 2024, and November 3, 2024, where the facility consistently fell short of the required LPN staffing levels. The review of nursing staff schedules and punch reports confirmed these deficiencies, as discussed with the facility's Scheduler, Employee E7. The report highlights specific dates and shifts where the facility did not meet the mandated LPN-to-resident ratios, indicating a pattern of non-compliance with staffing regulations. These findings were based on a comprehensive review of the facility's staffing data over the specified periods.
Plan Of Correction
Director of Nursing will conduct a random audit of 30 days throughout the quarter and findings will be reported quarterly at QAPI. Scheduler and Nursing Leadership were educated as to the need for full staffing requirement for all three shifts, seven days each week at a 3.20 HPPD. Our issue is call-outs so we have been following our disciplinary process as well as putting extra staff on.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.20 hours of direct nursing care per resident per day on 11 out of 21 days reviewed. This deficiency was identified through a review of nursing time schedules, punch reports, and staff interviews. Specific dates where the facility did not meet the required staffing levels include July 2, July 4, July 5, July 6, July 7, October 28, October 31, November 1, November 2, November 3, and December 8, 2024. On these dates, the facility's census ranged from 127 to 135 residents, and the direct nursing care hours provided per resident varied from 2.70 to 3.14 hours, all falling short of the mandated 3.20 hours. The deficiency was confirmed during a review with the Scheduler, Employee E7, on December 12, 2024. The review of staffing calculations, nursing staff schedules, and staff punch reports corroborated the finding that the facility did not meet the required staffing minimum on the specified dates. This failure to provide adequate nursing care hours is a direct violation of the regulation effective July 1, 2024, which mandates a minimum of 3.20 hours of direct nursing care per resident per day.
Plan Of Correction
Director of Nursing will conduct a random audit of 30 days throughout the quarter and findings will be reported quarterly at QAPI. Scheduler and Nursing Leadership were educated as to the need for full staffing requirement for all three shifts, seven days each week at a 3.20 HPPD. Our issue is call-outs so we have been following our disciplinary process as well as putting extra staff on.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents on two of its nursing units, B Unit and C Unit. During an observation on August 21, 2024, several deficiencies were noted. In B Unit, multiple rooms had exposed bedpans and basins stored improperly, missing tiles, and dirty linen, with a strong odor of feces present. Additionally, an exposed electrical baseboard heater was found in the hallway leading to the C Wing resident area. These issues were confirmed by the unit manager, Employee E1, and maintenance staff, Employee E3, who admitted that the work in one of the rooms had been started but left incomplete. In C Wing, the first shower room was cluttered with various personal and medical items, rendering it unusable. The second shower was being used as a storage space, filled with a mattress, wheelchair, commode, and other items, making it non-functional as a shower. These observations were also confirmed by the unit manager. A resident residing in one of the affected rooms reported that the bathroom floor and baseboard had been ripped out two months prior and never finished, highlighting the prolonged nature of the deficiencies.
Failure to Implement Person-Centered Care Plan for Communication
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 75, who has diagnoses including Corticobasal degeneration, paralysis of the vocal cords and larynx, and a rare progressive neurological disorder. Despite the resident's intact cognition, as indicated by the BIMS score, the care plan did not address the resident's strong preference for using paper and pen to communicate. This preference was confirmed through interviews with the resident, the unit manager, a nursing aide, and a speech therapist. The resident became frustrated and screamed when alternative communication methods, such as a communication board or an iPad, were attempted, indicating a clear need for the care plan to reflect her preferred communication method. The deficiency was identified through a review of the facility's policy on Resident Assessment & Care Planning, clinical records, and staff interviews. The policy mandates that a licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan to provide effective, person-centered care. However, the care plan for Resident 75 did not include any interventions to support her preferred method of communication, leading to frustration and ineffective communication. This oversight was confirmed by multiple staff members, including the unit manager and the speech therapist.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify, implement, monitor, and modify interventions consistent with the residents' assessed needs to maintain acceptable parameters of nutritional status for two residents. Resident R65 experienced significant weight loss beginning in November 2023, with a documented weight drop from 190.2 pounds to 141.0 pounds by March 2024. Despite the critical weight loss, timely interventions were not implemented. The dietary note on December 20, 2023, recommended adding a nutritional supplement, but the weight loss continued, and the Registered Dietitian was unable to explain the lack of timely assessment and intervention. Resident R30, who had diagnoses of dementia and dysphagia, also experienced significant weight loss. The resident's weight dropped from 170.4 pounds in September 2024 to 143 pounds by January 2024. Weekly weights were ordered but not documented, and the resident's nutritional status was not reassessed or addressed in a timely manner. The Registered Dietitian did not reassess the resident and modify interventions until 16 days after the identified weight loss in both October 2024 and January 2024. Interviews with the Registered Dietitian revealed an inability to explain why the weights and nutritional status were not being monitored or addressed in a timely manner. The facility's failure to follow its policy on weight monitoring and tracking, as well as the lack of timely interventions, contributed to the significant weight loss experienced by both residents.
Failure to Provide Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident R45, specifically in acquiring, receiving, and administering medications. The facility's policy on Medication Management/Medication Unavailability requires that if medications are unavailable, the licensed nurse must notify the provider and request an alternate treatment, document the notification, and activate backup pharmacy procedures. However, Resident R45 did not receive Pregabalin 50 mg on multiple occasions due to the medication being unavailable and awaiting delivery from the pharmacy. There was no documented evidence that the physician was informed of the missed doses or that an alternate treatment was requested. Additionally, the backup pharmacy process and procedures were not activated by the nursing staff. The Director of Nursing confirmed that Resident R45 missed doses of Pregabalin and that the nursing staff did not follow the facility's policy and procedure to acquire and administer the medication. This deficiency was identified through a review of the facility policy, clinical records, and interviews with staff. The failure to follow the established procedures resulted in Resident R45 not receiving the necessary medication for pain caused by nerve damage on several occasions.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents and their representatives had the capacity to understand the terms of a binding arbitration agreement. This deficiency was identified for four residents (R35, R48, R93, R113) who were found to have signed the arbitration agreements without a proper explanation in a language they could understand. The review of the facility's policy on Binding Arbitration revealed that the agreements were missing key elements, such as the statement that arbitration is not a condition of admission, the right to rescind the agreement within 30 days, and the prohibition of language that discourages communication with federal, state, or local officials. During the Resident Council meeting, four residents reported that the facility did not explain the arbitration agreement in a manner they could comprehend, leading them to wish to revoke their signatures. Interviews with the Admission Director confirmed that the arbitration agreements were read to the residents or their representatives without ensuring they understood the terms. Additionally, the Admission Director was unaware of the time frame to rescind the arbitration agreement. The facility's failure to provide a clear and understandable explanation of the arbitration agreements to the residents and their representatives resulted in a lack of informed consent. This oversight was confirmed through document reviews, resident interviews, and staff interviews, highlighting a significant lapse in the facility's responsibility to ensure residents' rights and understanding of legal agreements.
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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