Manor At St Luke Village,the
Inspection history, citations, penalties and survey trends for this long-term care facility in Hazleton, Pennsylvania.
- Location
- 1711 East Broad Street, Hazleton, Pennsylvania 18201
- CMS Provider Number
- 395636
- Inspections on file
- 29
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Manor At St Luke Village,the during CMS and state inspections, most recent first.
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.
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.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
