Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Manor At St Luke Village,the during CMS and state inspections, most recent first.
Repetitive Menu Selections and Limited Variety: Residents reported that the menu lacked variety and repeatedly featured chicken, pork, and beef items, with resident concerns raised in council and food committee meetings but not addressed. Review of the RD-signed 4-week menu showed multiple consecutive entree patterns, and the DDM and NHA confirmed that similar foods were served for consecutive meals.
Failure to resolve resident council food grievances: Residents repeatedly raised concerns about menu variety, snack choices, food temperature, and labeled snacks during council meetings, but the facility did not respond with documented resolution efforts. Five alert and oriented residents reported that their concerns remained unresolved, and the RD and NHA could not provide evidence that the complaints were being addressed.
Improper Placement of Personal Refrigerator: A resident’s personal refrigerator was observed placed on top of a bedside cabinet that did not fully support the unit’s base. Part of the refrigerator extended beyond the cabinet edge, creating an unbalanced surface, and the manufacturer’s instructions required placement on a flat, stable surface that fully supports the appliance. The NHA acknowledged the refrigerator was not appropriately sized for the cabinet.
Failure to verify significant weight changes and nutritional intake: The facility did not timely assess and validate major weight fluctuations for two residents with intact cognition and diagnoses including muscle wasting and muscle weakness. One resident had extreme unexplained weight swings without documented reweighs or investigation, while another resident reported refusing beef meals, had observed 0% meal intake despite higher charted intake, and experienced a notable weight loss after a refused weigh-in without timely follow-up weights.
A resident’s personal refrigerator was found at 48 degrees Fahrenheit, and an unlabeled food container was stored inside without a date or the resident’s name. Facility logs showed staff were using a higher action threshold than the written policy required, and some days had no documented temp checks, while other readings were above the policy limit.
A resident with pulmonary embolism and rhabdomyolysis, who was cognitively intact, was unable to access his deposited funds when he asked for money to buy food. The receptionist said she could not release the cash because she did not have account information, and the BOM confirmed she was not contacted even though the resident had $47.17 available. A nurse aide later gave the resident $10 of her own money and was reimbursed.
The facility failed to develop and implement discharge plans that matched the goals and preferences of two residents. One resident with COPD and PVD was cognitively intact and repeatedly stated he wanted to go home to be with his wife, but staff confirmed discharge planning had not been initiated and the NHA could not provide documented clinical rationale for keeping him in LTC. Another resident with encephalopathy, bipolar disorder, and schizophrenia had discharge discussions documented with the IDT and family, but the care plan did not address discharge to another facility or long-term placement, and the DON confirmed discharge planning information was absent from the care plan.
Failure to arrange optician services for a resident with decreased vision. A cognitively intact resident with DM and ESRD on dialysis had a physician order for an optician consult after reporting worsening vision, but there was no evidence the resident was seen by an optician at the time of survey. The NHA confirmed no appointment had been made beyond a later follow-up, and the resident reported decreased vision for several months and that his glasses needed adjustment.
Unsupervised Resident Elopement Through Unsecured Door: A resident with Alzheimer's disease and severe cognitive impairment, who was identified in the care plan as at risk for elopement, exited the facility without staff observation and was found outside in the parking lot/front area. Staff reported routine rounds had been completed and the resident had been seen in his room and wheelchair earlier, but he later left the building without authorization or necessary supervision. The NHA confirmed the facility did not have a proper locking process in place at the time of the event.
A resident with cerebral infarction, diabetes, and obstructive uropathy had a Foley catheter placed during a prior hospitalization, and notes in the chart documented plans for a voiding trial and possible urology referral. However, there was no evidence the voiding trial was completed or that the catheter was discontinued before survey review. The resident reported the catheter was uncomfortable and burned, and the DON confirmed the facility failed to timely reassess the need for the catheter.
A resident with liver cirrhosis and chronic ascites had a new right tunneled peritoneal catheter placed, but staff did not obtain or document post-procedure care instructions, failed to secure physician orders, and did not update the care plan to address the new device. Documentation and monitoring for the catheter were absent, and facility leadership confirmed these omissions during interviews.
The facility failed to provide clinical rationale for the continued use of PRN psychotropic medications for two residents. One resident with dementia received Lorazepam for 167 days without re-evaluation, and another with cerebral infarction and hemiplegia had Ativan renewed for 90 days without justification. The DON confirmed the absence of necessary documentation.
The facility failed to consistently provide snacks to residents as desired, with seven residents reporting that they are not consistently offered a nourishing evening snack. Despite the facility's policy to provide snacks according to residents' needs and preferences, grievances and meeting minutes indicate that residents have raised concerns about not receiving nighttime snacks. The Nursing Home Administrator was unable to explain the inconsistency in snack provision.
A resident reported inappropriate conduct by a staff member during peri-care, which was not thoroughly investigated by the facility. The facility failed to obtain witness statements, document a nursing evaluation, notify the physician, complete an incident report, secure evidence, or report to the State Survey Agency as required.
A facility failed to create an individualized discharge plan for a resident with Dysarthria following a stroke. Despite the resident's cognitive intactness and expressed desire to discharge, there were no social service notes or documented discharge planning in the care plan. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to administer oxygen therapy according to professional standards for a resident with COPD. The physician's order lacked a specified oxygen flow rate, and the resident was observed receiving oxygen at 2.0 lpm without this detail in the order. The DON confirmed the oversight, highlighting a deficiency in ensuring proper oxygen therapy administration.
The facility failed to implement a comprehensive infection control program, lacking specific provisions for tracking and responding to respiratory infections like COVID-19, Influenza, and RSV. A resident with upper respiratory symptoms was not tested for viral illnesses before being hospitalized and testing positive for RSV. Staff interviews revealed that testing for respiratory illnesses was not routinely conducted, and the infection control data was incomplete, lacking necessary details for effective monitoring.
The facility failed to provide adequate nursing staff, resulting in delayed care and unmet needs for residents. A resident developed a pressure ulcer due to insufficient repositioning, and another did not receive prescribed ambulation assistance. Staffing levels consistently fell below state requirements, impacting the quality of care.
The facility failed to provide timely assistance to residents, as evidenced by grievances and interviews. A resident reported waiting 30 minutes for help, leading to soiling herself, while another stopped using the call bell due to delayed responses. A group interview revealed that residents experienced long waits for care due to insufficient staffing, with some waiting over an hour for assistance. The NHA and DON acknowledged the need for timely responses, confirming the deficiency.
The facility failed to ensure consistent communication and monitoring for two residents requiring dialysis care. The facility did not consistently record post-dialysis weights and failed to monitor fluid intake for residents on fluid restrictions. Interviews with staff confirmed these deficiencies, highlighting a lack of documented evidence that residents' medical statuses were adequately monitored post-treatment.
A resident experienced a room change without receiving the required written notice, following an incident where his roommate inappropriately touched him. The facility did not provide a written explanation to the resident or his representative, violating federal regulations and resident rights.
A facility failed to communicate necessary resident information during transfers to a hospital on two occasions. Essential details such as practitioner contact information, resident representative details, advance directives, and care instructions were not documented or conveyed. The DON confirmed the lack of communication, potentially affecting the resident's safe transition of care.
A facility failed to ensure accurate MDS assessments for a resident. The resident's quarterly MDS assessment incorrectly listed a Multidrug Resistant Organism (MDRO) as an active diagnosis, despite no clinical evidence supporting this. The DON confirmed the error during an interview.
A facility failed to revise a care plan after a resident was alleged to have inappropriately touched his roommate. Despite discussions with the resident, who denied the behavior, the care plan was not updated to address this potential issue. The oversight was confirmed by the DON, highlighting a lapse in monitoring and revising care plans as per protocol.
A resident at risk for pressure injuries developed an unstageable pressure ulcer due to the facility's failure to consistently implement a care plan that included regular turning and repositioning. Despite being dependent on staff for mobility, the resident was not regularly repositioned, leading to the development of a pressure ulcer. The facility's documentation and staff interviews confirmed lapses in care, resulting in a deficiency citation.
A resident with reduced mobility and muscle weakness did not receive the prescribed Restorative Nursing Program (RNP) for ambulation, as confirmed by clinical records and staff interviews. Despite a physician's order and recommendations for ambulation with a wheeled walker, the facility failed to implement the RNP, as noted in the Documentation Survey Report for April and May.
A resident with dementia exhibited multiple behavioral symptoms, including aggression and wandering, but the facility failed to develop an individualized care plan to address these issues. The care plan lacked specific interventions for managing combative behaviors, and there was no evidence of an interdisciplinary approach or staff competency in providing appropriate dementia care.
A resident with GERD, diabetes, and heart failure experienced inappropriate touching by a roommate, leading to discomfort and a room change. Despite the incident, there was no documentation or follow-up on therapeutic social services to address the resident's mental and psychosocial needs, as confirmed by interviews with the Director of Social Services and the DON.
A facility failed to provide timely written notices of facility-initiated transfers to a resident and her representative. The resident was transferred to a hospital on two occasions without documented evidence of a notice of transfer or discharge letter. This deficiency was confirmed by the Nursing Home Administrator and DON.
Repetitive Menu Selections and Limited Variety
Penalty
Summary
The facility failed to ensure planned menus were sufficiently reviewed and updated to provide adequate variety and prevent repetitive meal selections in accordance with resident preferences. During a Resident Council meeting, residents reported a lack of variety on the menu and stated that chicken and pork were served repeatedly. Resident 34 said residents had made suggestions during resident group meetings about foods they enjoyed and wanted more often, but the facility had not acted on those concerns. Resident 53 stated he was frustrated because the facility continuously served chicken and pork, and Resident 5 reported the menu frequently contained repetitive items, especially chicken, and did not reflect the foods she was accustomed to. Resident 88 also stated the dietary department served too much chicken and that she wished there were more options. A review of the Fall/Winter 2025-2026 menu, signed by the Registered Dietitian, showed multiple repetitive entree patterns across the 4-week cycle, including consecutive servings of chicken, beef, and pork on several days. The menu included chicken alfredo followed by chicken tenders, beef and bean chili followed by lasagna with meat sauce and Salisbury steak, BBQ pork platter followed by BBQ pork on a bun, and later a series of chicken entrees including rotisserie chicken, BBQ chicken thigh, maple Dijon chicken breast, fried chicken, and marinated chicken breast. The Dietary District Manager stated the regional corporate office provided the 4-week seasonal menu and that the facility's Registered Dietitian reviewed it, and the Nursing Home Administrator confirmed that similar foods were served for consecutive meals.
Failure to Resolve Resident Council Food Grievances
Penalty
Summary
The facility failed to honor residents’ rights to organize and participate in resident/family groups by not putting forth sufficient efforts to promptly resolve repeated complaints and grievances raised during resident group meetings. The facility’s Resident and Family Grievances policy stated that grievances voiced in resident or family council meetings should be recorded, forwarded as needed, and addressed with prompt efforts toward resolution, including acknowledgment and active work toward resolving the concern. Review of food committee meeting minutes showed repeated resident concerns about dietary services, including requests for more soups with meat, pierogies, Polish foods, cooking demonstrations, more meal variety at dinner, snack choices, and concerns that snacks arrived labeled with resident information. Residents also reported that fish and pork were not generally liked, that there were no snack options, and that they wanted additional foods such as stewed tomatoes and crab cakes. During a resident group interview, five alert and oriented residents who normally attended council meetings stated that when they raised food concerns at meetings, the facility did not respond and their concerns remained unresolved. Individual residents described ongoing issues with snacks, food temperature, and menu variety. One resident said she did not always receive a snack, another said she was given the same snack each night without a choice, and others reported that fresh fruit was served hot, eggs were cold, coffee was not hot, and the menu was repetitive with too much pork and chicken. The Registered Dietician confirmed monthly meetings with resident groups but could not provide documented evidence that the facility was resolving or addressing the complaints. The Nursing Home Administrator also could not provide documented evidence that resident complaints and grievances related to food and dietary services were being addressed, responded to, or resolved.
Improper Placement of Personal Refrigerator
Penalty
Summary
The facility failed to ensure a safe and orderly environment related to the placement of a personal refrigerator for Resident 23. During an observation in the resident’s room, the personal refrigerator was found sitting on top of a bedside cabinet that did not fully support the appliance’s base. A portion of the refrigerator extended beyond the edge of the cabinet, creating an unbalanced surface, and the unit was positioned three feet off the ground. The refrigerator manufacturer’s instructions required the appliance to be placed firmly on a flat, stable surface that fully supports its size and weight to prevent tipping, shifting, or falling. The Nursing Home Administrator later acknowledged that the refrigerator was not appropriately sized to be placed on the bedside cabinet.
Failure to Verify Significant Weight Changes and Nutritional Intake
Penalty
Summary
The facility failed to timely evaluate nutritional requirements and maintain acceptable nutritional status for two residents with significant weight changes. The facility policy on Weight Monitoring stated that weights were to be used as an indicator of nutritional status, that significant weight changes included 5% in one month, 7.5% in three months, or 10% in six months, and that residents with identified weight loss were to be monitored weekly. The report found that the facility did not consistently verify extreme weight fluctuations, did not document reweighs to confirm accuracy, and did not show that nutritional parameters were reassessed when significant changes occurred. Resident 5 was admitted with diagnoses including muscle wasting and had intact cognition with a BIMS score of 15. The resident reported being transferred with a mechanical lift and being weighed by lift or wheelchair, and denied activities that would explain large weight changes. The weight record showed multiple major fluctuations, including a drop from 280.5 lbs. to 234.5 lbs. and later an increase from 234.5 lbs. to 299.8 lbs. The record lacked evidence that these extreme changes were questioned, validated, or investigated, and there was no documented evidence that reweighs were obtained to verify the accuracy of the weights. Resident 29 was admitted with muscle weakness and had intact cognition with a BIMS score of 14. The resident reported not eating because of dissatisfaction with meals containing beef and stated that weight loss was occurring. The weight record showed a decline from 137 lbs. on admission to 123.5 lbs., a 9.85% loss. After a refused weigh-in, the record lacked evidence that additional timely attempts were made to obtain a reweight before the later documented weight loss. During observation, the resident consumed 0% of lunch, but meal completion documentation for that period recorded intake between 26% and 50%. The dietician confirmed beef meals were served on multiple occasions and could not provide evidence of the alternative meals offered or whether meal completion for those alternatives was documented.
Personal Refrigerator Food Storage Not Monitored to Policy Standards
Penalty
Summary
The facility failed to ensure that food stored in a resident’s personal refrigerator was monitored and maintained at safe temperatures and that food items were properly labeled and dated. The facility policy for Safe Food Handling for Foods from Visitors stated that food intended for later consumption should be labeled with the resident’s name and current date, and that refrigerators storing food should be checked daily and kept at 41 degrees Fahrenheit or less. However, an observation of the resident’s room revealed a personal refrigerator with an internal temperature of approximately 48 degrees Fahrenheit and an unlabeled container of food that was not dated. A later observation with the nursing home administrator confirmed the refrigerator temperature remained at 48 degrees Fahrenheit and the food container still lacked a date and the resident’s name. Review of the refrigerator temperature logs showed staff were only instructed to take action when temperatures exceeded 46 degrees Fahrenheit, which did not match facility policy. The logs also showed no evidence that the refrigerator was monitored on two of the documented days, and on several other days the temperature was recorded at 42 degrees Fahrenheit, above the policy standard.
Resident Funds Not Properly Accessed or Accounted For
Penalty
Summary
The facility failed to safeguard, manage, and accurately account for a resident's personal funds deposited with the facility. Facility policy stated that when a resident authorizes the facility to hold personal funds, the facility must act as fiduciary and safeguard, manage, and account for those funds. The resident trust fund form also stated that requests for less than $50 for residents whose care is funded by Medicaid would be honored the same day. Resident 53 was admitted with diagnoses including pulmonary embolism and rhabdomyolysis, and a quarterly MDS dated October 15, 2025, showed he was cognitively intact with a BIMS score of 15. During an interview on January 5, 2026, Resident 53 stated he was angry and frustrated because he tried to get his money from the receptionist the day before but was told she could not give it to him because she did not have his account information. He said he wanted to buy a hoagie and confirmed that later that evening a nurse aide gave him $10 of her own money until the issue was resolved. The receptionist later confirmed she did not give the resident his funds because she did not have access to his account information, which had not been working since August 2025, and said she had to contact the BOM before allowing withdrawals. The BOM confirmed that on January 4, 2026, Resident 53 had $47.17 available, that the receptionist was supposed to contact her to verify account balances, and that she was not contacted. The BOM also provided a receipt showing the nurse aide was reimbursed for the $10.
Discharge Plans Did Not Reflect Resident Goals or Preferences
Penalty
Summary
The facility failed to develop and implement discharge plans that accurately reflected the discharge goals and preferences of two residents. The facility policy required discharge planning to focus on the resident’s goals and outcomes, to determine expected discharge goals upon admission and during care plan reviews, and to document when discharge to the community was considered unsafe or unrealistic. The policy also required timely documentation of discharge needs and the discharge plan in the clinical record. Resident 40 was admitted with COPD and peripheral vascular disease and was cognitively intact with a BIMS score of 15 on a quarterly MDS. Although one MDS indicated active discharge planning to return to the community was not occurring and the care plan stated the resident wished to remain in LTC, multiple progress notes documented that the resident wanted to go home and be with his wife, felt depressed and anxious about being in the nursing home, and stated his wife was home alone and he wanted to help her. During interview, the resident stated his preference and goal was discharge home and that staff had told him he was not safe to be discharged. Staff confirmed discharge planning had not been initiated, the care plan did not match the resident’s wishes, and the NHA could not provide documented evidence of the clinical rationale preventing discharge to the community. Resident 3 was admitted with encephalopathy, bipolar disorder, and schizophrenia, and an admission MDS showed a BIMS score of 14. The admission MDS Section Q indicated the resident’s overall discharge plan was to discharge to another facility and/or institution. A Social Services progress note documented a care plan meeting with the interdisciplinary team and the resident’s brother, during which the brother stated the discharge plan was for long-term care. However, the comprehensive care plan did not identify or address a discharge plan, including transfer to another facility or remaining in the facility for long-term placement, despite the documented discharge discussions and decisions. The DON confirmed that discharge planning information was absent from the care plan prior to the survey.
Failure to Arrange Optician Services for Resident With Decreased Vision
Penalty
Summary
The facility failed to ensure that Resident 6 received proper treatment and assistive devices to maintain vision and that a professional specializing in vision assistive devices was arranged as needed. Resident 6 was admitted with diagnoses including diabetes and end stage renal disease and was dependent on dialysis. A Quarterly MDS dated December 29, 2025, identified the resident as cognitively intact with a BIMS score of 13. The resident’s last visual acuity evaluation was on July 3, 2025, with follow-up noted in six to nine months. A nursing progress note dated November 17, 2025, documented a new optician consult related to decreased vision since the resident’s last dialysis visit, and a physician order the same day directed an optician consultation for that reason. However, at the time of the survey on January 7, 2026, there was no evidence the resident had been seen by an optician. During interview, the NHA stated the resident was due to be seen at a follow-up appointment on February 25, 2026, and confirmed no appointment had been made other than that follow-up despite the physician’s order. The resident later stated he had been experiencing decreased vision for several months and felt his glasses needed adjustment.
Unsupervised Resident Elopement Through Unsecured Door
Penalty
Summary
The facility failed to ensure adequate supervision and environmental safety for a resident identified as being at risk for elopement. Resident 89 had diagnoses including Alzheimer's disease and major depressive disorder, and the quarterly MDS showed severe cognitive impairment with a BIMS score of 07. The resident's care plan identified him as at risk for elopement due to impaired safety awareness, with a goal that he would not leave the facility unattended, although a later elopement risk assessment identified him as low risk. On the evening of the incident, nursing staff reported routine rounds and observed the resident in his room and later in his wheelchair, with no distress or stated intent to leave the facility. A nurse aide stated she assisted the resident and then left the room, and an LPN reported the resident had been present in his room before the incident. Another LPN stated the resident was known to occasionally go to the front area of the building during evening hours. The resident was later found outside the building in the parking lot/front area after having exited without being observed by staff. A nursing progress note documented that the resident had exited the facility without observation and was located outside, then returned without incident. Witness statements indicated the front door had been locked earlier in the evening, but the NHA later confirmed the facility did not have a proper locking process in place at the time of the elopement. The resident stated he had gone outside to get fresh air, and the event was documented as an unsupervised exit from the facility.
Failure to Timely Reassess Need for Foley Catheter
Penalty
Summary
The facility failed to evaluate the clinical necessity of an indwelling urinary catheter for one resident who was sampled. The resident was admitted with diagnoses including cerebral infarction and diabetes, was cognitively intact with a BIMS score of 14, and had a Foley catheter ordered for obstructive uropathy. A nurse practitioner note documented that the catheter had been inserted during a prior hospitalization and that a voiding trial was planned, with urology referral if the trial failed. A later note again referenced a planned voiding trial and removal of the Foley catheter, with straight catheterization if the resident could not urinate within eight hours and retention of the Foley if residual urine was greater than 300 ml. At the time of survey, there was no evidence that a voiding trial had been completed or that the Foley catheter had been discontinued. The resident told the surveyor the catheter was new, had been inserted before admission, and was uncomfortable and burning. The DON stated nursing staff were responsible for reading physician or physician extender notes regarding resident clinical information and recommendations. After surveyor inquiry, an order was entered for Foley removal and a voiding trial, and a nursing note later documented the resident was incontinent with a moderate amount of urine. The DON later confirmed the facility failed to timely reassess the need for catheter placement.
Failure to Monitor and Care Plan for New Peritoneal Catheter
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for a resident with liver cirrhosis and chronic ascites who had both a left-side thoraco-abdominal drain and a newly placed right tunneled peritoneal catheter. Upon the resident's admission and subsequent readmission, the facility did not obtain or document post-procedure care instructions for the right tunneled peritoneal catheter, as the family had taken the instructions and staff did not contact the interventional radiology department to acquire them. There were no physician orders or care plan entries specific to the care, monitoring, or drainage frequency for the new catheter, and the baseline care plan only referenced abdominal drains in general without distinguishing between the two sites. Clinical documentation, including assessments, progress notes, medication administration records, and treatment administration records, lacked any reference to the right tunneled peritoneal catheter, its care, or monitoring. The readmission assessment noted the presence of a right lower quadrant drain site covered by a surgical dressing, but did not include follow-up appointment details or specific care instructions. Additionally, a change in condition assessment inaccurately described the resident's recent hospitalization as a drain repair rather than the placement of the new catheter, and a skin evaluation prior to discharge did not acknowledge the presence of the right tunneled peritoneal catheter. Interviews with facility leadership confirmed that there was no evidence of continued monitoring, no appropriate physician orders, and no implementation of a care plan for the right tunneled peritoneal catheter. The resident was later sent to the hospital for worsening jaundice and was admitted for sepsis and a mucus plug in the bronchi. The facility's actions and omissions were not in accordance with their own policies or professional standards of nursing practice, as required by state regulations.
Lack of Clinical Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary use of psychoactive drugs by not providing clinical rationale for the continued use of PRN psychotropic medications for two residents. Resident 75, diagnosed with dementia, had a physician's order for Lorazepam 0.5 mg every eight hours as needed for anxiety, which was continued for 167 days without documented clinical rationale or re-evaluation beyond the 14-day limit. The medication was administered 25 times in March 2025, yet there was no physician documentation justifying its continued use. Similarly, Resident 77, with diagnoses including cerebral infarction and hemiplegia, had a PRN order for Ativan 0.5 mg every eight hours for anxiety, which was renewed for 90 days without documented clinical rationale or re-evaluation beyond the 14-day limit. The Ativan was administered 21 times in March 2025. The Director of Nursing confirmed the absence of necessary physician documentation to justify the continuation of these PRN psychotropic medications beyond the 14-day period, as required by regulations.
Inconsistent Provision of Snacks to Residents
Penalty
Summary
The facility failed to consistently provide snacks as desired by residents, as evidenced by a review of scheduled facility mealtimes, resident committee meeting minutes, grievances filed with the facility, select facility policy, and resident and staff interviews. The facility's policy states that snacks and beverages should be provided as identified in residents' individual plans of care, with bedtime snacks offered to all residents and additional snacks available upon request. However, the time between dinner and breakfast the next day exceeds 14 hours, and grievances and meeting minutes indicate that residents have raised concerns about not receiving nighttime snacks. During a group interview, seven residents reported that they are not consistently offered a nourishing evening snack, with some residents stating that the facility does not have snacks available when requested and that staff do not always distribute them. Despite bringing this issue to staff's attention, residents expressed frustration that nothing has improved over the last few months. The Nursing Home Administrator was unable to explain why residents are not receiving the snacks as desired, confirming that it is the facility's policy to offer and serve nourishing snacks in accordance with residents' needs, preferences, and requests.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough and complete investigation of an allegation of sexual abuse involving a resident, identified as Resident 63. The resident, who was admitted with diagnoses including congestive heart failure and chronic kidney disease, reported discomfort and inappropriate conduct by Employee 1 during peri-care. The resident expressed feeling assaulted when Employee 1's fingers went into her rectum, which meets the facility's definition of sexual abuse. Despite this serious allegation, the facility did not follow its own policy or federal guidelines for investigating such claims. The facility's inaction included failing to obtain written statements from witnesses or other staff, not documenting a comprehensive nursing evaluation, and not notifying the attending physician. Additionally, the facility did not complete an incident report, secure physical evidence, or report the investigation results to the State Survey Agency within the required timeframe. Interviews with the NHA and DON confirmed the lack of evidence for a completed investigation, highlighting a significant deficiency in handling the abuse allegation.
Failure to Develop Individualized Discharge Plan
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 58, who was admitted with diagnoses including Dysarthria following a stroke. The resident was cognitively intact, as indicated by a BIMS score of 15, and expressed a desire to discharge from the facility during a psychiatry consult. However, there were no social service notes or documented evidence in the resident's comprehensive care plan regarding discharge planning. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of a current discharge goal and plan for the resident.
Oxygen Therapy Administration Deficiency
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered in accordance with professional standards of care for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The deficiency was identified when a review of the clinical records revealed that the physician's order for the resident's oxygen therapy did not specify the required oxygen flow rate per liter. The resident was observed receiving oxygen at 2.0 liters per minute via nasal cannula, but the physician's order only indicated that oxygen should be administered as needed for blood oxygen saturation levels below 88%, without specifying the flow rate. During interviews, the Director of Nursing confirmed that the physician's order lacked the necessary details regarding the oxygen flow rate, which is a requirement for administering oxygen therapy according to professional standards. The resident, who was cognitively intact, was unaware of her prescribed oxygen liter flow rate. This oversight in the physician's order and the facility's failure to ensure compliance with professional standards of care led to the deficiency being cited.
Inadequate Infection Control Program and Tracking
Penalty
Summary
The facility failed to develop and implement a comprehensive infection control program, as evidenced by the lack of specific provisions for tracking, analyzing, and responding to respiratory infections such as COVID-19, Influenza, and RSV. The infection control policy, last revised in January 2025, did not include guidelines for consistent monitoring and investigation of infections, nor did it provide for the implementation of isolation precautions for respiratory illnesses. The Infection Preventionist and Director of Nursing confirmed the absence of additional policies to address these issues. The facility's infection control tracking logs were found to be inadequate, lacking evidence of a functional method for monitoring and investigating infections. The logs did not document trends, clusters, or changes in infection rates, and there was no documentation indicating that residents with upper respiratory symptoms were tested for viral illnesses. Specifically, Resident 1, who was admitted with metabolic encephalopathy and diabetes, exhibited symptoms of an upper respiratory infection but was not tested for any respiratory virus before being transferred to the hospital, where they tested positive for RSV. Interviews with facility staff revealed that while COVID-19 testing supplies were available, testing was not routinely conducted for symptomatic residents unless indicated by the facility's COVID-19 assessment form. The facility no longer implemented isolation precautions for COVID-19, and testing for other respiratory illnesses was not part of the routine protocol. The infection control data collected was incomplete, lacking details such as resident room locations, infectious organisms, and treatments provided, and there was no documented analysis of infection trends or follow-up measures to prevent the spread of infections.
Inadequate Staffing Leads to Delayed Care and Pressure Injuries
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate care and delayed responses to residents' requests for assistance. Multiple grievances and resident council meeting minutes highlighted the ongoing staffing shortages, with residents expressing concerns about the lack of timely care. Interviews with residents and their families revealed that residents often waited extended periods for assistance, leading to incidents of incontinence and frustration among residents and their families. Resident 88, who was admitted with conditions including atrial fibrillation and acute kidney failure, was particularly affected by the staffing deficiencies. Her baseline care plan required regular turning and repositioning to prevent pressure injuries, but documentation showed that these interventions were not consistently performed. As a result, Resident 88 developed an unstageable pressure ulcer, which was not present upon admission. The facility's failure to adhere to the care plan and provide adequate staffing contributed to the development of this pressure injury. Additionally, Resident 75, who required ambulation assistance as part of a Restorative Nursing Program, did not receive the prescribed care. Despite physician orders and therapy recommendations, the resident was only walked once in 29 days, indicating a lack of implementation of the care plan. The facility's staffing levels consistently fell below the state minimum requirements, further exacerbating the inability to provide necessary care to residents.
Staffing Shortages Lead to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This deficiency was identified through a review of grievances, resident group meeting minutes, and interviews with residents, families, and staff. Specific instances included a grievance from a resident who was not offered a shower due to staff shortages, and multiple residents reported long wait times for assistance, particularly on weekends. Resident 88 reported waiting 30 minutes for staff to respond to her call bell, resulting in soiling herself, and her family member expressed concerns about inadequate staffing leading to her being left in bed for extended periods, potentially contributing to a pressure injury. During interviews, Resident 298 mentioned experiencing pain and stopping the use of the call bell due to delayed responses. A group interview with alert and oriented residents revealed a consensus that the facility lacked sufficient staff to meet residents' needs promptly, leading to long waits for care. Residents 23, 30, and 64 shared experiences of waiting over an hour for assistance, with Resident 30 noting that she and her husband, both dependent on staff, faced significant delays. The Nursing Home Administrator and Director of Nursing acknowledged the need for timely responses to residents' requests for assistance, confirming the deficiency in providing dignified care.
Deficiencies in Dialysis Care and Monitoring
Penalty
Summary
The facility failed to ensure consistent communication and monitoring for two residents requiring dialysis care. The facility's policy on Coordination of Hemodialysis Services mandates communication between the facility and the dialysis center, including the use of a Dialysis Communication form to document pre and post-dialysis weights and other relevant information. However, for Residents 76 and 54, the facility did not consistently record post-dialysis weights, which are crucial for monitoring potential complications after dialysis treatments. Resident 76, diagnosed with End Stage Renal Disease (ESRD), was prescribed hemodialysis three times a week and a fluid restriction of 1,000 cc per day. The facility's records showed a lack of consistent monitoring of the resident's fluid intake from meals and medications, and the plan of care did not specify the fluid amounts provided at meals and snacks. Similarly, Resident 54, also diagnosed with ESRD and dementia, was prescribed dialysis and a fluid restriction of 1,500 cc per day. The facility failed to accurately record and monitor the fluid intake for this resident as well. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, confirmed the deficiencies in documenting fluid intakes and post-dialysis weights. The facility did not follow up with the dialysis center to ensure that post-dialysis weights were collected and recorded, leading to a lack of documented evidence that the residents' medical statuses were adequately monitored post-treatment.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident or their representative before making a room change, as required by federal regulatory guidance under S483.10(e)(6). This deficiency was identified during a review of the clinical record and interviews with the resident and staff. The resident, who was admitted with diagnoses including gastro-esophageal reflux disease, diabetes, and heart failure, experienced an incident where his roommate inappropriately touched him, making him feel uncomfortable. Although the resident did not initially report the incident, a staff member informed him that his room would be changed because the police were going to arrest his roommate. The room change occurred without providing the resident or his representative with a written explanation of the reasons for the move. Interviews with the Director of Social Services and the Nursing Home Administrator confirmed the lack of documentation and written notice regarding the room change. The facility did not comply with the requirement to inform the resident and/or their representative in writing about the room change, which is a violation of resident rights as outlined in 28 Pa Code 201.29 (a).
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for one resident. Specifically, the clinical record review revealed that a resident was transferred to the hospital on two separate occasions, December 13, 2023, and March 15, 2024, without documented evidence of communication of essential information. This information included the contact details of the practitioner responsible for the resident's care, resident representative contact information, advance directive information, special instructions or precautions for ongoing care, and comprehensive care plan goals. During an interview, the Director of Nursing confirmed the absence of evidence that the necessary information was communicated to the receiving health care institution or provider for the resident's transfers. This lack of communication could potentially impact the safe and effective transition of care for the resident, as the receiving facility was not provided with critical information needed for the resident's ongoing care.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident. Specifically, a review of a resident's quarterly MDS assessment indicated that the resident had a Multidrug Resistant Organism (MDRO) listed under active diagnoses. However, upon reviewing the clinical records, there was no evidence to support that the resident had an acute or colonized MDRO. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the MDS entry was an error.
Failure to Revise Care Plan for Alleged Inappropriate Behavior
Penalty
Summary
The facility failed to revise a comprehensive care plan in response to an allegation of inappropriate behavior by a resident. Resident 13, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and diabetes, was involved in an incident where his roommate, Resident 49, alleged that Resident 13 touched him inappropriately while he was sleeping. Despite the social service staff and the Nursing Home Administrator discussing the incident with Resident 13, who denied the behavior and expressed feeling safe, there was no documented evidence that the care plan was reviewed or revised to address this potential behavior. The care plan for Resident 13 focused on mood problems related to depression and other personal issues, with interventions such as medication administration, activity programs, and behavioral health consults. However, it lacked any updates or revisions concerning the allegation of inappropriate touching, as noted in the Social Service Progress note. This oversight was confirmed during an interview with the Director of Nursing, indicating a failure to address and monitor the potential behavior as required by the facility's protocols.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure sore development for a resident, identified as Resident 88. The resident was admitted with conditions including atrial fibrillation and acute kidney failure, and was assessed to be at risk for pressure injuries. Despite a care plan that included turning the resident every two hours, providing incontinence care, and applying preventative skin care, documentation revealed that these interventions were not consistently implemented. The resident was found to have an unstageable pressure ulcer on the coccyx, which was not present upon admission, indicating a lapse in the care plan execution. The resident's clinical records and interviews with the resident and family members highlighted that the resident was not regularly turned or repositioned as required. The resident was dependent on staff for mobility and was often left in bed until late in the morning. The Braden Scale assessments were inconsistent with the resident's actual condition, as the resident was found to be incontinent of urine multiple times and walked only occasionally. The lack of timely response to the resident's call bell and insufficient staff to provide necessary care were also noted. The wound's progression was documented, showing initial improvement followed by fluctuations in size, indicating ongoing issues with wound management. Interviews with the Director of Nursing and Nursing Home Administrator confirmed the facility's responsibility to prevent pressure injuries, yet they could not provide evidence of adherence to the care plan. The deficiency was cited under specific state codes, highlighting failures in medical records, resident care policies, and nursing services.
Failure to Implement Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to provide restorative nursing services as planned to maintain the mobility and functional abilities of Resident 75. The resident, who was admitted with diagnoses including reduced mobility, muscle wasting, muscle weakness, and unsteadiness on feet, had a physician's order dated March 22, 2024, for Restorative Nursing Program (RNP) ambulation. However, during an interview on May 28, 2024, Resident 75 reported that staff were not walking her as ordered, and she had only been walked once in the past 29 days despite informing the staff about this issue. A review of the resident's clinical records, including a Physical Therapy Discharge Summary and a Rehab Services Restorative Nursing/Functional Maintenance Referral form, indicated that the resident was to receive ambulation with a wheeled walker for up to 300 feet with contact guard assist. Despite these recommendations and a physician's order for physical therapy dated May 23, 2024, the facility's Documentation Survey Report for April and May 2024 revealed that the RNP for ambulation was not implemented. Interviews with the Director of Therapy Services and the Director of Nursing confirmed the lack of documented evidence that the prescribed RNP program was provided to Resident 75.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia, who exhibited multiple behavioral symptoms. The resident, who was admitted with diagnoses including dementia, overactive bladder, and myasthenia gravis, was noted to be severely cognitively impaired. The resident displayed various behavioral symptoms such as physical aggression towards others, verbal aggression, and other disruptive behaviors like wandering, disrobing in public, and urinating on the floor. These behaviors were documented to have a significant negative impact on the resident and potentially on other residents. Despite the resident's documented behaviors and the negative impact, the facility's care plan did not adequately address these issues. The care plan included interventions such as administering medications, anticipating needs, and providing positive interactions, but it failed to address the resident's combative behaviors, such as smacking and hitting staff. Additionally, the care plan did not include specific interventions for managing these physically combative behaviors, nor was there evidence of an interdisciplinary approach to the resident's dementia care. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the facility had not updated the resident's care plan to address the known dementia-related behaviors. There was no evidence that the facility had developed an interdisciplinary approach or ensured that staff had the necessary competencies to provide appropriate services. Furthermore, there was no indication that the facility attempted to provide meaningful activities to promote the resident's engagement and enhance their mental health and well-being.
Failure to Provide Therapeutic Social Services for Resident's Well-being
Penalty
Summary
The facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of a resident, identified as Resident 89. The resident, who was admitted with diagnoses including gastro-esophageal reflux disease (GERD), diabetes, and heart failure, experienced an incident where his roommate inappropriately touched him, making him feel uncomfortable and uneasy. Although the resident did not initially report the incident, a staff member informed him that his room would be changed due to the roommate's impending arrest. The resident's room was subsequently changed, but there was no documentation of the incident or the reasons for the room change in the clinical records. Interviews with the Director of Social Services and the Director of Nursing revealed a lack of documentation regarding the incident and the provision of therapeutic social services to Resident 89. The Director of Social Services acknowledged that Resident 89 had expressed discomfort about his roommate's behavior, but there was no documented follow-up or evidence of counseling services provided to address the resident's mental and psychosocial needs. This lack of documentation and follow-up indicates a failure to meet the regulatory requirements for medically-related social services.
Failure to Provide Transfer Notices
Penalty
Summary
The facility failed to provide timely written notices of facility-initiated transfers to a resident and the resident's representative. Specifically, Resident 21 was transferred to a community hospital on two occasions, December 11, 2023, and March 15, 2024, without documented evidence of a notice of transfer or discharge letter being provided to the resident or her representative. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the lack of documentation for the required notices for both transfer events.
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What surveyors actually found near you
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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 Hazleton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion At St Luke Village, The | 0.2 mi | ★★★★★ | 8 | 0 |
| Mountain City Nursing & Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Forest Hills Rehabilitation & Healthcare Center | 7.2 mi | ★★★★★ | 11 | 0 |
| Kadima Rehabilitation & Nursing At Luzerne | 7.5 mi | ★★★★★ | 0 | 0 |
| Greenwood Center For Nursing And Rehab | 8.2 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.