Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mahoning Operating Llc during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and muscle weakness had multiple scheduled medications, including diuretics, pulmonary hypertension treatments, psychotropic medication, and vitamin/mineral supplements, that were not administered within the facility’s required 90‑minute window. Audit reports showed several morning and afternoon doses given significantly late, ranging from just over an hour to several hours past the scheduled time, despite policy and professional standards requiring timely administration and accurate MAR documentation. The NHA acknowledged that medications are expected to be administered in a timely manner consistent with facility policy and nursing standards.
The facility failed to provide written information about advance directives and failed to verify whether advance directives, HCPOAs, or health care representatives were already in place for four sampled residents. The affected residents included individuals with intact or impaired cognition, and one resident later had a Health Care Declaration signed by a representative outlining preferences for CPR, ventilation, tube feedings, hydration, blood products, surgery, dialysis, and antibiotics. The DOSS and NHA confirmed the missing documentation during interview.
A resident with left-sided hemiplegia/hemiparesis and rheumatoid arthritis had a care plan and PT discharge recommendation for restorative ambulation with a platform rollator and 2 caregivers, but documentation showed inconsistent, incomplete, and conflicting restorative nursing entries, including NA, blank, unavailable, refused, and distances that did not match the plan. The resident stated staff had not walked her since PT ended and denied refusing ambulation, while the ADON confirmed the facility was responsible for providing restorative services as planned.
Failure to provide oxygen therapy per physician orders affected three residents. One resident with COPD and dementia was found in the dining room connected to an empty portable O2 tank despite an order for continuous O2 at 2.0 L/min. Another resident with acute respiratory failure was observed in her room with O2 turned off despite an order for continuous O2 at 3.0 L/min. A third resident with acute and chronic respiratory failure and asthma had O2 tubing that was not changed per the physician’s order and facility policy.
Quarterly MDS assessments were not completed within the required timeframe for two residents. The RNAC signed both assessments late, and the RNAC confirmed the delay during interview.
Failure to Involve Resident Representative in Care Planning: The facility failed to ensure a comprehensive care plan was developed and revised with resident and representative participation for a resident with HF and DM. The resident had moderate cognitive impairment (BIMS 9), and the record contained no documentation that the resident or representative were invited to or participated in care conferences; the representative stated she had not been invited, and the SSD and NHA could not provide evidence otherwise.
Failure to Document and Monitor Skin Integrity: A resident with a care plan for skin impairment and a physician order for weekly skin checks had ongoing arm irritation, erythema, inflammation, abrasions, and bleeding, but the MAR lacked documentation of the skin check findings and the clinical record did not show ongoing monitoring of the issue. An LPN confirmed the missing documentation, and the NHA could not provide evidence that the resident’s skin was being monitored per policy.
A resident with dementia and major depressive disorder received PRN Ativan multiple times for anxiety or agitation, but the record did not document specific behavioral symptoms, distress, or other clinical indicators supporting each dose. The chart also lacked evidence that nonpharmacological interventions such as redirection, reassurance, or therapeutic communication were attempted before the medication was administered, despite facility policy requiring documentation of ineffective non-pharm interventions before psychoactive drug use.
A resident with CKD and moderate cognitive impairment experienced burning and discomfort after an aide mistakenly applied muscle rub cream to a wound area instead of the ordered zinc oxide paste. The cream had been left at the bedside, and the record lacked documentation of pain assessment, nursing intervention, or MD notification after the medication error.
A resident with diabetes, HTN, and moderately impaired cognition had a UA and C&S ordered, and the final urine culture showed abnormal E. coli growth. Nursing staff did not notify the physician of the abnormal result in a timely manner, with the result communicated several days after it was available; the ADON confirmed the delay.
A resident with dementia, decreased mobility, and incontinence developed multiple pressure ulcers on the buttocks and sacrum despite having a care plan that included skin assessments and preventive interventions. Staff documented the resident's resistance to repositioning and the progression of wounds from open areas to deep tissue injuries and unstageable pressure injuries. The facility did not implement timely and adequate preventive measures, and detailed wound information was not provided to the resident's family prior to discharge.
The facility failed to provide proper oxygen administration and infection control for three residents. A resident had an empty humidifier bottle and undated oxygen tubing, while another had outdated nebulizer equipment. A third resident was not receiving prescribed oxygen therapy, with no physician order for discontinuation. These issues were confirmed by staff and management.
The facility failed to ensure medications were administered according to physician's parameters for two residents. One resident received Humalog injections despite low blood glucose levels, and another received Midodrine despite high blood pressure. These incidents were confirmed by the DON and Nursing Home Administrator.
The facility did not ensure the Medical Director or designee attended the quarterly QAPI meetings for two quarters. This was confirmed through sign-in sheets and an interview with the DON, revealing non-compliance with the requirement for quarterly attendance.
The facility did not send copies of written notices of facility-initiated hospital transfers to the Ombudsman for a resident transferred twice in September 2024. The social services director confirmed the lack of documentation for these and other transfers in previous months.
The facility failed to provide person-centered pain management for two residents by not consistently attempting non-pharmacological interventions before administering opioid medication and not documenting pain levels prior to administration.
The facility failed to timely report an incident of physical abuse involving two residents to the State Survey Agency. A nurse aide observed one resident hitting another in the mouth, and although the incident was reported to supervisory staff and documented, it was not reported to the State Survey Agency within the required time frames.
The facility failed to develop a comprehensive care plan for a resident with heart failure and an AICD. The care plan lacked necessary checks, monitoring for complications, and emergency procedures for the AICD device. This deficiency was confirmed through a clinical record review and staff interview.
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the resident's safety and well-being. Despite documented behavioral issues such as incessantly calling out, yelling, and physical aggression, the resident's care plan did not address these behaviors or include individualized non-pharmacological approaches, purposeful activities, or environmental modifications.
The facility failed to provide written notice of facility-initiated transfers to the hospital for four residents. Clinical record reviews and staff interviews revealed that the required written notices, including the reason for the transfer and contact information for the Ombudsman, were not provided. The Nursing Home Administrator confirmed the absence of these notifications.
Failure to Administer Medications Within Required Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses administered medications within the facility’s required timeframes and in accordance with professional standards of practice and state nursing regulations. Facility policy titled “Medication Administration,” last reviewed on September 1, 2025, required that medications be administered within 90 minutes of the scheduled time. Pennsylvania Code provisions for RNs and LPNs require that nurses carry out nursing care actions that promote, maintain, and restore well-being, exercise sound judgment, and document and maintain accurate records. The American Nurses Association principles for nursing documentation further emphasize timely documentation of medication records in the EHR to support informed decisions and continuity of care. The clinical record for one resident (CR1) showed the resident was admitted with chronic respiratory failure and muscle weakness and had multiple prescribed medications, including several scheduled for administration at 9:00 AM. These medications included Vitamin D3, Oyster Shell Calcium, Vitamin C, a multivitamin, aspirin, bumetanide, biotin, ropinirole, potassium, sildenafil, Lexapro (escitalopram), and Tyvaso (treprostinil) inhalation solution. The resident’s medication regimen included drugs for pulmonary hypertension, edema, anxiety, restless leg syndrome, and various vitamin and mineral supplements, all of which were to be administered according to the times and frequencies ordered and documented on the MAR. A review of the February 2026 medication administration audit report revealed multiple instances where this resident’s medications were administered outside the facility’s 90‑minute window. On one date, a 9:00 AM biotin dose was given at 2:18 PM, 318 minutes late. On another date, multiple 9:00 AM medications, including Tyvaso, Lexapro, Vitamin D3, potassium, Oyster Shell Calcium, bumetanide, aspirin, and ropinirole, were administered between 10:41 AM and 10:56 AM, 101 to 116 minutes after the scheduled time. Additionally, a 1:00 PM Tyvaso dose was given at 2:35 PM (95 minutes late), and a 1:00 PM sildenafil dose was given at 4:22 PM (202 minutes late). In an interview, the Nursing Home Administrator confirmed review of these late medication administrations and acknowledged that medications are expected to be administered timely in accordance with professional standards of practice and facility policy.
Failure to Provide Advance Directive Information and Verify Existing Directives
Penalty
Summary
The facility failed to ensure that residents were informed in writing of their right to formulate advance directives and failed to determine whether advance directives were already in place upon admission for four of 27 sampled residents: Residents 15, 26, 54, and 111. The facility policy titled Advance Directives stated that residents and/or their representatives should be provided written information about the right to complete an advance directive for health care and to appoint a health care agent or representative, and that resident advance directive documents should be requested at admission and intermittently. Resident 15 was admitted with an admission MDS showing a BIMS score of 13, indicating intact cognition, and later had a quarterly MDS with a BIMS score of 9, indicating moderate cognitive impairment. The clinical record included a Health Care Declaration form signed 30 days after admission by the resident's representative, identifying treatment preferences for CPR, mechanical ventilation, tube feedings or other artificial nutrition, artificial or invasive hydration, blood or blood products, surgery or invasive tests, renal dialysis, and antibiotics. Resident 26 was admitted with acute respiratory failure and had an admission MDS showing a BIMS score of 12, indicating moderate cognitive impairment. Resident 111 was admitted with chronic kidney disease and had a quarterly MDS showing a BIMS score of 10, also indicating moderate cognitive impairment. Resident 54 was admitted with acute kidney failure and dementia and had a quarterly MDS showing a BIMS score of 13, indicating intact cognition. Review of the clinical records for Residents 15, 26, 54, and 111 showed no documented evidence that written information about advance directives was provided on admission and no documented evidence that the facility determined whether they had existing advance directives, health care powers of attorney, or health care representatives. The Director of Social Services and the Nursing Home Administrator confirmed these findings during interviews.
Failure to Provide Consistent Restorative Ambulation Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident. Resident 57 was admitted with diagnoses including left-sided hemiplegia/hemiparesis and rheumatoid arthritis, was cognitively intact with a BIMS score of 13, and had a care plan dated September 25, 2025, that required restorative programs for muscle weakness with goals for safe, consistent ambulation using a rollator walker. A physical therapy discharge summary recommended that nursing implement a restorative ambulation program using a platform rollator walker with assistance from two caregivers and a wheelchair follow for safety. The resident’s task report directed ambulation in a straight path for 30 to 50 feet with two caregivers and assistance to place and remove the left upper extremity on and off the walker platform. However, the Documentation Survey Report v2 for November and December 2025 showed inconsistent, incomplete, and conflicting documentation of restorative ambulation, including multiple entries marked NA, blank entries, entries showing the resident was unavailable, and ambulation distances that did not align with the restorative plan. Documented ambulation ranged from 0 feet to 50 feet, and some entries recorded ambulation on dates when the resident later denied that it occurred. During interview, Resident 57 stated that after physical therapy ended, no staff had provided restorative ambulation services and that no one had walked with her since therapy was discontinued. The resident also denied refusing ambulation services and stated she did not ambulate the night before despite documentation showing 15 minutes of ambulation and 50 feet. The Assistant Director of Nursing confirmed that the facility was responsible for ensuring restorative nursing services were implemented and provided as planned after therapy ended to maintain or improve resident function.
Failure to Provide Oxygen Therapy Per Physician Orders
Penalty
Summary
The facility failed to ensure oxygen therapy was administered according to physician orders for three residents. The facility policy required oxygen to be given under a physician’s order, with care plans identifying the oxygen delivery system, monitoring of oxygen saturation and vital signs, and monitoring for complications. The policy also required hand hygiene and gloves when administering oxygen or handling oxygen equipment, and required oxygen tubing and masks/cannulas to be changed and dated every two weeks and as needed. Resident 1 had diagnoses including COPD and dementia and had a physician’s order for continuous oxygen at 2.0 L/min by nasal cannula/mask. On observation, the resident was seated in the dining room connected to a portable oxygen tank via nasal cannula, and the tank was empty. An LPN confirmed the tank was empty and stated the resident had orders for continuous oxygen and that the tank should have been checked before the resident left the room. The LPN then replaced the tank and measured the resident’s oxygen saturation at 96%. Resident 26 had diagnoses including acute respiratory failure and a physician’s order for continuous oxygen at 3.0 L/min via nasal cannula. On observation, the resident was sitting in her room with her oxygen turned off. An LPN stated the resident’s oxygen should always be in use and that staff had not informed her that the resident had returned to the room and needed oxygen reapplied or adjusted. Resident 26’s oxygen saturation was measured at 92%. Resident 38 had diagnoses including acute and chronic respiratory failure and asthma, with a physician’s order for oxygen at 2.0 L/min via nasal cannula and for oxygen tubing to be changed every two weeks on Monday night and as needed. On observation, the oxygen tubing attached to the concentrator was dated November 20, 2025, and an ADON confirmed the tubing had not been changed in accordance with the physician’s order and facility policy.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
Quarterly MDS assessments were not completed within the required time frame for two residents reviewed. The RAI User's Manual dated October 2024 stated that a quarterly MDS assessment's ARD must be no more than 92 days after the ARD of the most recent assessment and that the completion date must be no later than 14 calendar days after the ARD. For Resident 48, the quarterly MDS had an ARD of November 8, 2025, but was signed as completed by the RNAC on December 3, 2025, 25 days after the ARD. For Resident 105, the quarterly MDS had an ARD of November 10, 2025, but was signed as completed by the RNAC on December 10, 2025, 30 days after the ARD. During interview on December 11, 2025, the RNAC confirmed that these quarterly MDS assessments were not signed as completed within the required time frames.
Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and revised with the participation of the resident and the resident's representative for one resident sampled, Resident 89. Facility policy required a comprehensive care plan to be developed by the interdisciplinary team in conjunction with the resident and/or the resident's responsible party, surrogate, or family, and the care conference policy required residents and/or resident representatives to be invited to participate, with any declination or inability to attend documented. Review of Resident 89's record showed no documented evidence that Resident 89 or the resident representative were invited to participate in or participated in the development of the person-centered care plan. Resident 89 was admitted with diagnoses including heart failure and diabetes and had a quarterly MDS assessment dated August 14, 2024, showing moderate cognitive impairment with a BIMS score of 9. During interview, the resident representative stated she had not been invited to participate in care plan development or revision and had not been invited to any care plan meetings at the facility. The SSD and NHA both confirmed that care planning conferences were completed and that it was the facility's responsibility to ensure residents and resident representatives were provided the opportunity to participate, but neither could provide documented evidence that Resident 89 or the resident representative had been offered that opportunity.
Failure to Document and Monitor Skin Integrity
Penalty
Summary
The facility failed to ensure Resident 54 received treatment and care in accordance with the resident’s care plan, physician orders, and facility policy for skin integrity. Resident 54 was admitted with diagnoses including acute kidney failure and dementia, and a quarterly MDS dated September 9, 2025, indicated the resident was cognitively intact with a BIMS score of 13. The care plan identified the resident as having a potential for skin impairment and being prone to bruising with slight pressure, with interventions to assess skin integrity and report findings to the charge nurse. A physician’s order required weekly skin checks every Thursday day shift and documentation of whether there were no new areas of skin impairment, new areas of skin impairment, or existing areas of skin impairment. During an observation and interview on December 9, 2025, Resident 54 stated her arms had been irritated for weeks, were very itchy, and she believed she might be allergic to the facility detergent. Her left arm had erythema and inflammation along the forearm, eight abrasions with dried blood measuring under 0.5 inches, and bright red blood from a scratch measuring 0.25 inches. The resident reported she had told nursing staff, but they only provided moisturizer that did not help. The MAR showed weekly skin checks were performed on December 4 and December 11, 2025, but there was no documentation of the skin status findings on either date. The clinical record also lacked documentation of an ongoing issue with upper extremity skin irritation, inflammation, or injury, and an LPN confirmed the missing documentation. The NHA was unable to provide documented evidence that the facility was monitoring the resident’s skin consistent with facility policy.
PRN Ativan Given Without Documented Medical Necessity
Penalty
Summary
The facility failed to ensure that one resident’s psychotropic medication regimen was supported by adequate clinical justification and documentation of behavioral symptoms and nonpharmacological interventions before PRN administration. Facility policy stated that psychoactive medications are to be used to add quality of life for residents who require them and that drug therapy should begin only after non-pharmacological interventions have been attempted and documented as ineffective. Resident 2 was admitted with unspecified dementia with other behavioral disturbance and major depressive disorder, and a quarterly MDS dated November 5, 2025, showed severe cognitive impairment with a BIMS score of 3. The resident had an order for Ativan 0.5 mg by mouth every 12 hours PRN for anxiety or agitation for 3 months, and the eMAR showed eight PRN doses given between October 5 and October 26, 2025. For each administration, the clinical record lacked documentation of specific behavioral symptoms, distress, or other clinical indicators supporting the need for Ativan, and it also lacked documentation that nonpharmacological interventions were attempted before the medication was given. The DON was interviewed on December 11, 2025 regarding the missing documentation supporting medical necessity and prior nonpharmacological interventions.
Medication Left at Bedside and Applied to Wrong Area Caused Resident Burning
Penalty
Summary
The facility failed to ensure medications were properly stored and administered in accordance with physician orders and accepted nursing practice, resulting in a medication error that caused pain and discomfort for Resident 82. Resident 82 was admitted with chronic kidney disease and was moderately cognitively impaired, with a BIMS score of 10 on the most recent MDS assessment. Physician orders included zinc oxide paste for the groin, abdominal folds, buttocks, thighs, and muscle rub external cream for the right knee. A progress note documented a chronic open wound under the right abdominal fold with exposed subcutaneous tissue and moderate serosanguineous drainage. Resident 82 stated that a male nurse aide applied muscle rub cream to her wound area, causing immediate burning and requiring an ice pack. She reported that the aide cleaned the cream off with water and she remained in bed for about an hour until the pain subsided. The clinical record contained no documented evidence that the muscle rub was administered, that the resident’s pain or discomfort was assessed or monitored, that nursing interventions were implemented after the event, or that the physician was notified. The DON stated the nurse aide applied cream from a cup and that the resident reported burning; the aide was educated that topical medications are to be applied from original containers and only those identified on the resident’s Kardex. The aide stated the medication had been left at the resident’s bedside and that he mistakenly applied muscle rub to the abdominal folds and peri-area, believing it was zinc oxide paste.
Delayed Physician Notification of Abnormal Lab Results
Penalty
Summary
The facility failed to timely notify the physician of abnormal lab results for one resident out of 27 sampled, Resident 119. The facility policy on Laboratory Testing and Notification stated that physicians will be notified of abnormal laboratory results in a timely fashion, and that nursing staff who receive lab results are responsible for notifying the resident's physician of abnormal or critical results and documenting the notification in the medical record. Resident 119 was admitted with diagnoses including diabetes and hypertension and had moderately impaired cognition with a BIMS score of 9. A physician ordered a UA and C&S, and the final urine culture results showed abnormal findings of greater than 100,000 colonies per milliliter of E. coli. The nursing progress notes showed that these abnormal C&S results were not communicated to the physician until three days after the result was available. The Assistant Director of Nursing confirmed that lab results are sent to the nursing department and that nursing staff are responsible for timely physician notification, and also confirmed that the urine culture results were not relayed in a timely manner for Resident 119.
Failure to Prevent and Manage Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to consistently provide care and services in accordance with professional standards to prevent the development of pressure ulcers for one resident. The resident, who had multiple risk factors including dementia, decreased mobility, incontinence, and a history of falls, was identified as being at risk for impaired skin integrity. The care plan included interventions such as regular skin assessments, keeping the skin clean and dry, applying protective creams, and using a mechanical lift for transfers. Despite these interventions, the resident developed multiple open and discolored areas on the buttocks and sacrum, which were identified by staff during routine care. Clinical documentation and staff witness statements revealed that the resident was resistive to repositioning and required significant assistance with activities of daily living. Initial assessment found a new open area on the left inner gluteal fold, followed by the discovery of additional open and non-blanchable areas on the buttocks and sacrum. The wounds progressed to deep tissue injuries and unstageable pressure injuries, with the presence of slough and eschar. The facility's investigative reports and nursing notes documented the progression of these wounds and the resident's combative behavior during care, which further complicated wound management. Although the care plan addressed the resident's risk factors, the facility did not implement timely and adequate preventive measures to prevent the development of pressure ulcers. The documentation also indicated that detailed wound descriptions and measurements were not provided to the resident's wife prior to discharge. Interviews with the DON and NHA confirmed the failure to prevent the development of pressure ulcers in this resident, as required by professional standards and regulatory requirements.
Deficiency in Oxygen Administration and Infection Control
Penalty
Summary
The facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for three residents. For Resident 2, the humidifier bottle was found empty, and the oxygen tubing was not dated as per facility policy. Resident 16 had nebulizer tubing and a mask that had not been replaced for over 25 days, exceeding the recommended timeframe. These observations were confirmed by a licensed practical nurse. Resident 82 was observed with the oxygen concentrator on, but the nasal cannula was not applied to the resident and was instead placed in a clear bag. The oxygen tubing was also not dated. An interview with a licensed practical nurse revealed that the resident was being evaluated for discontinuation of oxygen therapy, but there was no physician order to withhold oxygen therapy. The nursing home administrator and the Director of Nursing confirmed that the nursing staff failed to adhere to facility policies concerning oxygen administration and infection control practices, and that Resident 82 was not receiving oxygen as prescribed.
Failure to Administer Medications According to Physician's Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring that licensed nurses accurately administered prescribed medication according to physician's parameters for two residents. Resident 75, who had diagnoses including diabetes and chronic kidney disease, received Humalog injections outside the prescribed parameters on two occasions. The medication was administered despite blood glucose levels being below the threshold specified by the physician's order. This was confirmed by the Director of Nursing during an interview. Resident 11, diagnosed with Parkinson's disease, benign prostatic hyperplasia, and a history of COVID-19, was also affected by improper medication administration. The resident received Midodrine for hypotension despite having a systolic blood pressure exceeding the physician-ordered threshold. This incident was confirmed by both the Nursing Home Administrator and the Director of Nursing. The facility's failure to adhere to professional standards of nursing care resulted in medications being administered contrary to specific physician-ordered parameters.
Medical Director's Absence at QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or their designee attended the quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two out of four quarters, specifically in April 2024 and January 2025. This deficiency was identified through a review of the QAPI Committee meeting sign-in sheets, which showed the absence of the Medical Director or designee at the meetings held on April 25, 2024, and January 30, 2025. An interview with the Director of Nursing on February 21, 2025, confirmed the absence of the Medical Director or designee at these meetings, indicating a failure to meet the regulatory requirement for quarterly attendance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide copies of written notices of facility-initiated hospital transfers to a representative of the Office of the State Long-Term Care Ombudsman for one resident. Specifically, Resident 56 was transferred to the hospital on two occasions in September 2024, and although written notices were provided to the resident and their representative, there was no documented evidence that these notices were sent to the Ombudsman. An interview with the social services director confirmed the absence of documentation for these transfers and additional facility-initiated transfers in previous months, including April, June, July, and September 2024.
Failure to Provide Person-Centered Pain Management
Penalty
Summary
The facility failed to provide person-centered pain management consistent with professional standards of practice for two residents. Resident 43, who was admitted with cervical and intervertebral disc disorders, experienced almost constant pain as indicated in the MDS assessment. Despite having a care plan that included non-pharmacological interventions, the facility did not consistently attempt these methods before administering oxycodone. The MAR for March 2024 showed that Resident 43 received oxycodone 18 times without documentation of pain levels prior to administration, and the resident confirmed that non-pharmacological interventions were not offered consistently. Similarly, Resident 8, admitted with pyogenic arthritis and spondylosis, had a physician's order for oxycodone for severe pain. The MAR for February and March 2024 revealed that the resident received the medication 48 times in February and 12 times in March, with non-pharmacological interventions not attempted prior to administration in almost all instances. Interviews with the DON and NHA confirmed the lack of consistent non-pharmacological interventions and pain level assessments before administering pain medication.
Failure to Timely Report Resident Abuse
Penalty
Summary
The facility failed to timely report an incident of physical abuse involving two residents to the State Survey Agency. According to the facility's abuse prohibition policy, staff are required to report any allegations of abuse immediately to their supervisor, and the facility administrator or designee is responsible for follow-up investigation and reporting to the required agencies within five days. However, the facility did not adhere to this policy when a nurse aide observed one resident hitting another resident in the mouth with the back of her hand. The incident was reported to supervisory staff, but the facility did not report the abuse to the State Survey Agency within the required time frames. The incident involved Resident 4 hitting Resident 5 in the mouth after holding her wrist and telling her to shut up. Resident 5 was assessed and found to have no skin impairments, open areas, bruising, swelling, or dental issues. Despite the immediate reporting to supervisory staff and documentation in progress notes, the Nursing Home Administrator and Director of Nursing confirmed that the physical abuse was not reported to the State Survey Agency as required by the facility's policy and state regulations.
Failure to Develop Comprehensive Care Plan for Resident with AICD
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to meet the individualized needs of a resident with heart failure and an automatic implantable cardiac defibrillator (AICD). The resident's care plan did not include necessary checks or monitoring for signs and symptoms of AICD complications, nor did it outline emergency care procedures for the AICD device. This deficiency was identified during a survey ending on March 22, 2024, and confirmed through a review of the resident's clinical record and an interview with the MDS Coordinator. The resident, who was admitted to the facility with diagnoses including heart failure and the presence of an AICD, had a cardiology progress note indicating the need to ensure the move to the skilled nursing facility did not affect the AICD device. Despite this, the care plan lacked specific actions to be taken if the AICD was activated, such as consulting the physician, obtaining vital signs, and ensuring the safety of the resident and staff. The deficiency was confirmed by Employee 1, the RN and MDS Coordinator, who acknowledged the failure to fully address the care and management of the resident's AICD in the care plan.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement individualized plans to manage a resident's dementia-related behavioral symptoms, compromising the resident's safety and well-being. Resident 4, diagnosed with Alzheimer's disease and exhibiting severe cognitive impairment, displayed numerous behavioral issues such as incessantly calling out, yelling, entering other residents' rooms, and physical aggression. Despite these behaviors being documented in nursing progress notes over several months, the resident's care plan did not address these specific behaviors, nor did it include individualized interdisciplinary non-pharmacological approaches to care, purposeful activities, or environmental modifications tailored to the resident's needs. The facility did not provide evidence of specialized services and supports for Resident 4, such as specialized activities, nutrition, and environmental modifications, based on the resident's abilities and dementia-related behaviors. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the lack of an individualized, person-centered care plan for Resident 4's dementia care and behaviors. This failure to provide necessary care and services was a significant deficiency identified during the survey.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to ensure that a written notice of facility-initiated transfer to the hospital was provided to the resident and resident's representative for four residents. Specifically, Residents 47, 8, 18, and 39 were transferred to the hospital on various dates, but there was no evidence that written notices containing all required contents were provided. These contents include the reason for the transfer, the effective date of the transfer, the location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and, if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. An interview with the Nursing Home Administrator confirmed that there was no evidence of written notifications being provided to the residents and their representatives for these facility-initiated transfers. This deficiency was identified through clinical record reviews and staff interviews, which revealed the absence of the required written notices for the transfers of Residents 47, 8, 18, and 39.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lehighton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summit At Blue Mountain Nursing & Rehab Ctr, The | 2.1 mi | — | 0 | 0 |
| St Luke's Rehabilitation And Nursing Center | 7.8 mi | ★★★★★ | 7 | 0 |
| Forest Hills Rehabilitation & Healthcare Center | 8.2 mi | ★★★★★ | 11 | 0 |
| Greenwood Center For Nursing And Rehab | 10.5 mi | ★★★★★ | 17 | 0 |
| Manor At St Luke Village,the | 12.6 mi | ★★★★★ | 16 | 0 |
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