Maple Heights Health & Rehab Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ebensburg, Pennsylvania.
- Location
- 429 Manor Drive, Ebensburg, Pennsylvania 15931
- CMS Provider Number
- 395828
- Inspections on file
- 63
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at Maple Heights Health & Rehab Center, Llc during CMS and state inspections, most recent first.
A cognitively impaired resident with Alzheimer's disease, dependent on staff for all care needs, attempted to self-propel out of a room by grabbing another resident's bed. A nurse aide repeatedly grabbed and pushed the resident's hands off the bed, after which the resident became agitated and grabbed the aide's arm. The aide then struck the resident's left wrist with a fist, causing the resident to verbalize pain and later be found with small, deep purple bruises on both hands. Another aide witnessed the event and reported it, and the allegation of abuse was subsequently substantiated by facility leadership.
A resident admitted after a fall with a traumatic brain bleed consistently expressed a goal of remaining for LTC due to inability to manage stairs, living alone, and needing assistance with daily care, and this goal was documented by the IDT, social services, therapy, and a CRNP. Despite this, the resident later received a NOMNC and was discharged home without documented follow-up to address the change in plan or ensure safety. Therapy services were not timely updated about the shift from LTC to home discharge and did not provide training on home-related tasks or stair negotiation, even though the resident had multiple stairs at home. The case manager did not notify the insurer of the goal change, and the resident was discharged without written medication instructions specifying which medications to take, at what times and dosages, or which to discontinue.
The facility failed to secure water-absorbing beads, a known ingestion hazard, in an activity room on a dementia unit where residents wander, contrary to its own policy requiring supervised items to be locked. A cognitively impaired resident with dementia, dysphagia, and a care plan for wandering was independently mobile and later found in bed with the floor covered in water beads, coughing and spitting beads from the mouth. Around the same time, staff observed the activity room door open and the cabinet containing the beads unlocked. An LPN and RN assessed the resident, noting coughing, mucus, and abnormal lung sounds, and the resident was transferred to the hospital and admitted to the ICU.
Facility administration, including the NHA and DON, failed to carry out their defined responsibilities to organize and direct resources to ensure resident safety and quality care. Surveyors found that water-absorbing beads were not secured on a dementia unit, based on review of job descriptions, observations, and staff interviews. This failure meant the environment was not kept free of accident hazards as required under F689 and related state regulations, placing residents on the dementia unit at risk for serious harm and resulting in an Immediate Jeopardy finding.
A resident reported that meals were often served cold and of poor quality. During observation, food was delivered in Styrofoam containers and measured below the required temperature, with fried chicken at 127.0°F and spinach at 122.9°F. The meal components lacked seasoning and flavor, and the Assistant Dietary Manager confirmed food should be served at correct temperatures and be palatable.
A resident who was cognitively impaired, required staff assistance for eating, and was on a texture modified diet did not have meal intake documented for multiple breakfast meals as required by facility policy. The lack of documentation was confirmed by the administrator and was not in accordance with established procedures.
A resident with multiple medical conditions experienced a fall and was subjected to verbal abuse by an LPN, who told the resident they could remain on the floor using inappropriate language. The incident was witnessed and confirmed by staff and the resident, violating the facility's abuse prevention policy and resident rights.
A resident with multiple medical conditions experienced a fall and was subjected to abusive language by an LPN, as witnessed by staff and reported by the resident. The incident, which met the criteria for mandatory reporting under state law and facility policy, was not reported to the Department of Health or other required agencies, and the DON was unaware of the reporting obligation.
A resident with dementia and cognitive impairment, who required staff assistance, was transported in a wheelchair without the physician-ordered bilateral elevating leg rests. The nurse aide responsible confirmed the leg rests were not applied as required, and the administrator acknowledged this failure to follow the care plan.
A resident with recent hospital admission and a history of substance use was able to leave the facility undetected after being last seen around noon. Staff did not notice the absence until a lunch tray was untouched for over two hours, and the receptionist had seen the resident leave but mistook him for an employee. The facility's elopement protocol was not activated promptly, and the resident was later found several miles away and taken to the hospital.
The facility did not meet required nurse aide and LPN staffing ratios on several shifts, with multiple days where the number of NAs and LPNs scheduled was below regulatory minimums. Additionally, the facility failed to provide the minimum required hours of direct resident care per day on several occasions, as confirmed by the Nursing Home Administrator and facility records.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
A resident with anxiety and behavioral concerns was not monitored according to physician-ordered 15-minute safety checks. Staff failed to visually observe and document the resident's status as required, and an agency nurse aide was unaware of the safety check order due to incomplete shift reporting and lack of computer access.
Soiled linen and a soiled brief were found on the floor in a resident room without staff present. Facility policy requires all used linen to be bagged at the point of care and placed in a soiled linen container. Both an RN and the DON confirmed that the items should not have been left on the floor and should have been handled according to infection control protocols.
Due to inadequate dietary staffing, several residents reported receiving meals on styrofoam plates with plastic silverware on random occasions, including during breakfast, as confirmed by the Assistant Nursing Home Administrator. This practice was directly linked to low kitchen staffing levels.
A resident with quadriplegia and cognitive impairment developed a new open area on the buttock, initially treated for moisture-associated skin damage. When the wound worsened, new orders for Hydrofera blue were not promptly implemented, and the resident continued to receive the previous treatment for two days. Nursing staff confirmed the delay in updating the treatment orders, resulting in the resident receiving incorrect wound care.
Multiple residents' wheelchairs were found with significant accumulations of removable dust, dirt, and grime on their metal supports, wheels, and seat cushions. Staff interviews confirmed that cleaning these wheelchairs was the responsibility of housekeeping, but a reduction in staff made it difficult to maintain cleanliness. Facility leadership acknowledged that the wheelchairs should have been clean.
A resident was observed self-administering multiple medications at bedside without staff supervision, despite lacking a physician's order, evaluation, or care plan for self-administration. Nursing staff and the administrator confirmed that the required assessment and authorization were not completed, and medications should not have been left at the bedside.
A resident with cognitive impairment was placed at risk when a van driver, who appeared drowsy and was later found to have a blood alcohol level of 0.122 percent, began to fall asleep and swerve off the road during transport to a medical appointment. The nurse aide escorting the resident intervened and returned to the facility, where the incident was reported to supervisory staff.
A resident with a history of heart issues and dementia was mistakenly given another resident's medications by an LPN, leading to a significant drop in blood pressure and subsequent ICU admission. The error involved multiple medications not prescribed to the resident, highlighting a failure to follow the facility's medication administration policy.
The facility failed to prevent abuse and neglect among residents, as evidenced by incidents involving three residents. A resident with dementia reported neglect by a nurse aide, which was substantiated. Another resident with severe dementia was involved in multiple altercations with other residents, leading to substantiated abuse findings. A third resident, with cognitive impairment, hit another resident with a wheelchair footrest, also resulting in a substantiated abuse finding.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in recorded treatments and medications. For example, a resident's assessment did not reflect the administration of gabapentin, while another's failed to indicate hemodialysis treatments. Additionally, inaccuracies were found in the documentation of vaccine offerings and the administration of anti-anxiety and anticonvulsant medications.
The facility failed to update care plans for several residents to reflect changes in their care needs, such as code status, infection control precautions, medication changes, and hospice services. Staff interviews confirmed the lack of documentation in the care plans.
A facility failed to provide adequate activities for a resident with hemiplegia and dysphagia following a stroke. Despite a care plan requiring one-to-one in-room activities, there was no documentation of such activities occurring over several weeks. The resident's spouse noted a lack of in-room activities, and the Activities Director confirmed the absence of documented visits.
The facility failed to document the disposal of controlled medications for two residents. One resident's fentanyl patch disposal was not properly documented by two nurses as required, and another resident's Ativan disposition was not documented upon discharge. These actions were confirmed by the facility's nursing leadership.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies such as failure to prevent resident abuse, timely assessments, and proper medication management. Despite plans of correction, the committee was ineffective in addressing these issues.
The facility failed to maintain essential kitchen equipment in safe operating condition, with issues such as a leaking dishwasher and steam kettle, and several other pieces of equipment out of service for extended periods. Despite these problems, alternate cooking equipment was used, and there were no adverse effects on meal service.
The facility failed to maintain the fire alarm system according to NFPA standards, as they could not provide documentation for a required semiannual visual inspection. An interview with the Facility Administrator and Maintenance Director confirmed the absence of this documentation, indicating a lapse in adherence to fire safety maintenance protocols.
Maple Heights Health and Rehab Center failed to maintain the dignity of a resident by not ensuring proper hygiene assistance. A resident, who required help with daily living activities, was observed with visible facial hair that had not been addressed. The facility lacked a policy for facial hair removal preferences, and staff did not document any inquiry into the resident's preferences. The DON confirmed the absence of a specific protocol for such situations.
A resident was not informed of their medical appointments in advance, despite previous concerns and agreements to provide notice. The resident discovered an appointment through their patient portal, and the DON confirmed the lack of documentation and communication with the resident.
A resident filed a grievance about not receiving medication and care, which was not addressed in a timely manner. The grievance was filed on one date but not assigned until much later, with no evidence of a thorough investigation or resolution communicated to the resident until over a month later. The facility failed to document ongoing efforts to resolve the grievance, leading to a deficiency in grievance handling procedures.
The facility failed to provide written notice to responsible parties for three residents transferred to the hospital. A resident was found on the floor with confusion and tremors, another experienced lethargy and disorientation, and a third had a fall with bleeding. In each case, there was no documented evidence of written notice explaining the transfer reasons.
The facility failed to complete comprehensive admission MDS assessments within the required 14-day timeframe for five residents. The assessments were completed between 15 to 20 days after admission, as confirmed by clinical records and staff interviews. The Nursing Home Administrator acknowledged the delay, indicating non-compliance with regulatory requirements.
A facility failed to develop a baseline care plan for a resident's hemodialysis needs within 48 hours of admission, as required by policy. The resident, who required hemodialysis three times a week, had specific physician orders for monitoring their AV fistula site, but no baseline care plan was documented. This deficiency was confirmed by an LPN Assessment Coordinator.
A facility failed to develop a comprehensive care plan for a resident with a seizure disorder who was receiving anticonvulsant medications. The care plan lacked documentation addressing the resident's specific needs related to the medications and condition, as confirmed by the DON.
A facility failed to implement appropriate wound care orders for a resident with a non-healing surgical wound. Despite recommendations from a wound consult report to use VASHE wound cleanser and medi-honey, these treatments were not administered as per the Treatment Administration Record. The Director of Nursing noted that the Wound Nurse Practitioner issued orders that did not match the consultant's recommendations, and nursing staff did not verify the orders against the consultant's notes.
A facility failed to provide a discharge summary, including post-discharge medications and a plan of care, for a resident. The deficiency was confirmed through clinical record reviews and staff interviews, revealing a lack of documentation for the required discharge instructions.
The facility failed to follow physician's orders for two residents, leading to deficiencies in care. One resident received a fentanyl patch every 48 hours instead of the prescribed 72 hours. Another resident continued to receive clopidogrel (Plavix) up to the day of a scheduled procedure, despite instructions to stop five days prior. These issues were confirmed by the DON.
The facility failed to use required leg rests for two residents during transport, as specified in their care plans and physician's orders. Both residents, who were cognitively impaired and at risk for falls, were transported without the necessary leg rests by staff members. The Director of Nursing confirmed that the leg rests should have been used.
The facility failed to ensure that a physician and a CRNP documented progress notes for two residents. One resident's physician visit was not documented until a month later, and another resident's initial admission visit and suture removal were not documented. The DON and an LPN confirmed the lack of documentation.
A facility failed to label opened inhalers with the date they were opened, as required by policy and manufacturer's instructions. This was observed in a medication cart, affecting several residents' medications, including fluticasone propion-salmeterol and umeclidinium-vilanterol inhalers. An LPN confirmed the oversight during an interview.
The facility failed to ensure timely completion of laboratory services for two residents. One resident was catheterized twice due to a missed lab pickup, leading to delayed urinalysis results and antibiotic orders. Another resident's urine sample was not picked up, resulting in unnecessary prophylactic treatment for a UTI, despite later results showing no infection. The DON confirmed staff were unaware of the missed lab pickups.
The facility failed to obtain necessary lab tests for a resident with hypothyroidism and did not secure a physician's order for catheterization to collect a urine specimen for another resident with ESRD. The absence of TSH tests for specific months and the lack of a physician's order for an invasive procedure were confirmed by the DON and an LPN, respectively.
A nurse aide failed to follow Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and quadriplegia, as required by facility policy and CDC guidelines. The aide did not wear a gown while emptying the catheter drainage bag, despite signage indicating the need for gown and glove use during high-contact care activities. This oversight was confirmed by the LPN/Infection Control Preventionist.
The facility failed to maintain adequate sprinkler system coverage, as observed in the Therapy Break Room where sprinklers were missing from the ceiling and the space outside the room. This deficiency was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to ensure its multi-disciplinary infection control committee met quarterly with required members, including laboratory personnel and a community member, as per state law. An interview with the Infection Preventionist confirmed the lack of documented evidence of their participation.
The facility lacked a policy for the use of foot rests on wheelchairs during transportation. Observations showed that two residents were transported without foot rests, and staff admitted to not applying them. The DON confirmed the absence of such a policy.
The facility failed to meet the required NA-to-resident staffing ratios over a 21-day period in January 2025. The facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents overnight. The deficiency was identified through a review of nursing schedules and confirmed by the Nursing Home Administrator, with no additional higher-level staff available to compensate for the shortfall.
The facility failed to meet the required LPN-to-resident staffing ratios, with deficiencies noted during day, evening, and overnight shifts over a review period. For example, on one day, the facility required 6.28 LPNs for 157 residents during the day shift but only had 6.19 LPNs available. The Nursing Home Administrator confirmed the staffing shortfall, and no additional higher-level staff were available to compensate.
Physical Abuse of Cognitively Impaired Resident by Nurse Aide
Penalty
Summary
The facility failed to protect a resident from abuse when a nurse aide physically struck the resident during an interaction in the resident's room. Facility policy dated September 23, 2025, stated that abuse, neglect, mistreatment, exploitation, and misappropriation of resident property would not be tolerated. Resident 2 had an admission MDS dated December 7, 2025, indicating cognitive impairment, dependence on staff for all care needs, and a diagnosis of Alzheimer's disease. On December 15, 2025, at approximately 6:11 p.m., during supper, the resident attempted to self-propel out of the room and grabbed another resident's bed to assist with movement. According to a nurse's note and an event report, Nurse Aide 2 responded by grabbing the resident's hands to make him let go of the bed and pushing him away, which caused the resident to become agitated and again grab the bed. A witness statement and interview with Nurse Aide 1, who observed the incident, revealed that after the resident again grabbed the bed, Nurse Aide 2 forcefully removed the resident's hands, leading the resident to grab the aide's arm and tell him to stop. Nurse Aide 2 then removed the resident's hands from his arm and struck the resident's left wrist with his fist, after which the resident said, "ouch that hurt" and held his arm. Nurse Aide 2 then pushed the resident out of the room into the lounge. A subsequent skin check documented small, deep purple bruises on both of the resident's hands, though the resident was able to move both hands without signs or symptoms of pain or swelling. The regional director of clinical services later confirmed that the allegation of abuse by Nurse Aide 2 toward this resident was investigated and substantiated.
Failure to Align Discharge Planning With Resident Goals and Provide Complete Discharge Instructions
Penalty
Summary
The facility failed to develop and implement a discharge planning process that aligned with a resident's stated goal of remaining for LTC and failed to provide complete discharge instructions, including medication times and dosages. The resident was admitted after a fall at home resulting in a traumatic brain bleed and was assessed as cognitively intact but needing assistance with daily care. A comprehensive MDS and care plan documented that his goal was LTC placement. Social services notes, a CRNP note, and an interdisciplinary team meeting all recorded that the resident did not want to return to his prior living arrangement due to inability to manage stairs, living alone, and being unable to care for himself, and that he was willing to apply for state insurance to stay for LTC. Subsequently, social services documented that the resident was issued a NOMNC and would discharge home, but there was no evidence in the clinical record that the facility followed up with the resident or family regarding this change in plan to ensure his safety upon discharge. Therapy assessments and goals remained focused on LTC, and the Rehab Program Manager confirmed that therapy was not notified of the change in goal until shortly before discharge and had not worked with the resident on home-related tasks such as housework, cooking, laundry, or stair training, despite knowing he had 12 stairs at home. The case manager did not inform the insurer that the resident’s goal had changed from LTC to going home, and the Nursing Home Administrator acknowledged that the resident was discharged without written instructions listing his medications, including times, dosages, and which medications to discontinue.
Unsecured Water Beads on Dementia Unit Lead to Resident Ingestion and ICU Transfer
Penalty
Summary
The deficiency involved the facility’s failure to keep water-absorbing beads, an identified choking and obstruction hazard, securely stored on a dementia unit where residents wander. Facility policy required that items needing close supervision be stored in locked cabinets or other secure areas, with cabinets locked when not in active use. Manufacturer instructions and a U.S. Consumer Product Safety Division warning specified that water beads can expand significantly when ingested and pose a serious medical emergency, including life-threatening intestinal blockages or choking. Despite these known hazards and policies, the water beads used for activities were kept in a cabinet in the north lounge activity/dining room on the dementia unit and were not secured. Resident 1, who had dementia, cognitive impairment, dysphagia, and a care plan indicating wandering behavior and the need for a secure environment, was independently mobile on the unit. On the night of the incident, a nurse aide observed the resident in bed at approximately 2:15 a.m. with nothing unusual noted. During 5:00 a.m. rounds, two nurse aides entered the resident’s room and found the resident in bed with the floor covered in water beads. The resident was coughing and spitting water beads out of his mouth. One aide went to get the LPN, and neither aide reported seeing the resident access any items. At about the same time, one of the nurse aides noticed that the north lounge activity room door was open, the light was on, and the cabinet where the water beads were kept was open. When the LPN arrived to assess the resident, she observed the resident coughing up water beads and mucus, with stable vital signs but bilateral rattling lung sounds, and notified the RN. The RN’s assessment documented that the resident was awake, alert with confusion, spitting up water beads, with even, unlabored respirations, cough, and diminished lung sounds with congestion. The DON later confirmed that the water beads had been unsecured in the north lounge activity/dining room on the dementia unit and that it was unknown how many beads the resident had ingested. The resident was transferred to the hospital and admitted to the intensive care unit.
Removal Plan
- Removed the water beads from the facility.
- Identified residents that have the potential to be affected.
- Completed a house review of rooms and lounges for any foreign objects and any other items that would pose a similar issue.
- Provided education to nursing and activities staff on removing items that would pose a potential risk for residents to ingest.
- Locked and secured all activity cabinets.
- Educated newly hired staff on removing items that would pose a potential risk for residents to ingest.
- Will monitor and maintain ongoing compliance.
- Director of Nursing or designee will complete observation audits to ensure items that have potential to be ingested are removed and activity cabinets are locked.
Failure of Administration to Control Environmental Hazard on Dementia Unit
Penalty
Summary
The deficiency involves the facility administration, specifically the Nursing Home Administrator (NHA) and Director of Nursing (DON), failing to effectively use facility resources to promote resident safety and maintain residents’ highest practicable physical well-being. Review of the NHA’s job description, dated September 23, 2025, showed that the NHA is responsible for leading, directing, and managing overall operations in accordance with applicable federal, state, and local regulations, and for organizing and directing resources to ensure quality care for each resident at all times. The DON’s job description, also dated September 23, 2025, indicated responsibility for organizing, developing, managing, and directing the Nursing Service Department in compliance with regulatory standards, and working directly with the Administrator and Medical Director to ensure the highest degree of quality care, including following all health, sanitary, and infection control policies and established nursing standards of practice. Based on review of employee job descriptions, observations, and staff interviews, surveyors determined that the NHA and DON did not fulfill these essential duties because they failed to ensure that water-absorbing beads were secured. This failure occurred on the dementia unit and resulted in the residents’ environment not being kept free of accident hazards, as required under 42 CFR 483.25(d)(1)(2) (F689 – Free of Accident Hazards/Supervision/Devices). The unsecured water-absorbing beads placed residents on the dementia unit at risk for serious harm and created an Immediate Jeopardy situation. The deficiency was also cited under 28 Pa. Code 201.14(a) Responsibility of Licensee, 28 Pa. Code 201.18(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to serve food that was both palatable and at appetizing temperatures, as required by its own policy. The policy specified that hot foods should be at least 135 degrees Fahrenheit when plated and remain palatable at the point of delivery, with the use of appropriate hot/cold holding equipment and prompt transportation to maintain temperature. However, observations during a lunch meal service revealed that food was served in Styrofoam containers, and a test tray delivered to the third floor showed the fried chicken at 127.0 degrees F and the spinach at 122.9 degrees F, both below the required temperature. Additionally, the fried chicken had a hard border, and the mashed potatoes, seasoned spinach, and cornbread were noted to lack seasoning and flavor. A resident interviewed reported that the quality and quantity of food served was poor, and that hot foods were often served cold. The recipes used for the meal in question were minimal in seasoning, with the seasoned spinach only containing salt, the mashed potatoes containing minced garlic, margarine, and salt, and the cornbread being made from a mix with water added. The Assistant Dietary Manager confirmed that food should be served at correct temperatures and be palatable, but the observations and resident feedback indicated that this standard was not met.
Failure to Document Meal Intake for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident who was cognitively impaired, dependent on staff for personal care, and had a diagnosis of dysphagia. According to facility policy, staff are required to document the provision of Activities of Daily Living (ADL) care, including actual meal consumption, each shift. However, a review of the resident's records showed that meal intakes were not documented for several breakfast meals in August and September 2025. The care plan specified that the resident required a texture modified diet and staff assistance at meals, but there was no evidence that meal intakes were recorded on the specified dates. The Nursing Home Administrator confirmed the lack of documentation for these meals, which was not in accordance with the facility's policy.
Failure to Protect Resident from Verbal Abuse by LPN
Penalty
Summary
A facility failed to protect a resident from verbal abuse by a staff member. According to the facility's abuse policy, all forms of abuse, neglect, and mistreatment are prohibited, and all allegations must be investigated. A cognitively intact resident with a history of falls, diabetes, atrial fibrillation, and seizures experienced a witnessed fall in the bathroom. Documentation and witness statements revealed that after the fall, an LPN told the resident that they could "stay on the f******g floor" and made similar statements, which were corroborated by both the resident and a nurse aide. The resident expressed that they did not want the LPN to care for them anymore. Interviews with the resident and facility staff confirmed the incident and the use of inappropriate language by the LPN following the resident's fall. The interim administrator substantiated that the LPN made the abusive statement. The facility's failure to ensure the resident was free from verbal abuse constituted a violation of resident rights and facility policy.
Failure to Report Alleged Abuse to State Agencies
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the required state agencies, including the Department of Health, Ombudsman, Protective Services, the resident's representative, and law enforcement, as mandated by state law and facility policy. The incident involved a resident who was cognitively intact and required staff assistance for daily care, with medical conditions including diabetes, atrial fibrillation, and seizures. After a witnessed fall in the bathroom, the resident and a nurse aide reported that an LPN told the resident to stay on the floor, using profane language, and the resident expressed that he did not want the LPN to care for him anymore. Despite the facility's policy requiring immediate reporting of all abuse allegations and the state law mandating such reports, the Director of Nursing was unaware of the reporting requirement, and the incident was not reported to any of the appropriate authorities. The deficiency was confirmed through review of facility policies, state law, clinical records, and staff and resident interviews.
Failure to Use Required Wheelchair Leg Rests During Resident Transport
Penalty
Summary
A deficiency was identified when a resident with cognitive impairment and a diagnosis of dementia, who required staff assistance for personal care, was transported in a wheelchair without the physician-ordered bilateral elevating leg rests. The resident's care plan specified the use of these leg rests for transport and when outside. During an observation, a nurse aide transported the resident from a common area to the resident's bedroom for lunch without applying the leg rests. The nurse aide confirmed that the leg rests were not used as required, and the nursing home administrator also acknowledged that the leg rests should have been applied according to the physician's order but were not.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Delayed Response
Penalty
Summary
Maple Heights Health and Rehab was found noncompliant with federal and state regulations after a complaint survey revealed that the facility failed to maintain an environment free of accident hazards for one resident. The facility's elopement policy required staff to conduct a head count and announce a code green if a resident was missing, with subsequent notifications to administration, the DON, and the attending physician, and to contact emergency responders if the resident was not found in a reasonable time. Despite these procedures, a resident with a recent history of hospital admission, housing instability, and substance use was able to leave the facility undetected. On the day of the incident, the resident was last seen by a nurse aide around noon. At 2:30 p.m., staff noticed the resident's lunch tray was untouched and that he had not been seen for over two hours. A search was initiated, and it was discovered that the receptionist had seen the resident leave the building at 12:30 p.m., mistaking him for an employee. The code green protocol was not activated until after this discovery, and the local police were notified. The resident was eventually found several miles away and taken to the hospital for evaluation. Interviews with staff revealed delays in recognizing the resident's absence and in activating the facility's elopement protocol. The administrator stated that the resident left against medical advice and did not consider it an elopement. However, the sequence of events and staff interviews indicated that the required supervision and timely response to a missing resident were not provided, resulting in the resident's unsupervised departure from the facility.
Plan Of Correction
Preparation and submission of this Plan of Correction is required by state and federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding. Resident R2 no longer resides in the facility. To identify residents who have the potential to be affected, a review of resident elopement risk evaluations done in the last quarter will be conducted to ensure those at risk for elopement have appropriate interventions. To prevent recurrence, nursing staff was educated on the elopement policy and licensed nurses were educated on the Against Medical Advice discharge policy at the time of the event by the Director of Nursing/designee. To monitor and maintain compliance, the Director of Nursing/designee will audit 5 residents at risk of exit seeking to ensure interventions are in place weekly x 4 weeks and monthly x 2 months. Results of the audits will be forwarded to the center Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Meet Minimum Staffing Ratios and Direct Care Hours
Penalty
Summary
The facility failed to meet required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of nursing schedules, staffing information, and staff interviews. Specifically, there were eight days where the day shift did not meet the minimum of one NA per 10 residents, four days where the evening shift did not meet the minimum of one NA per 11 residents, and nine days where the night shift did not meet the minimum of one NA per 15 residents. On these days, the number of NAs scheduled was consistently below the required ratios based on the facility census, and no additional higher-level staff were available to compensate for the shortfall. The Nursing Home Administrator confirmed that all staffing hours were provided as documented and acknowledged the failure to meet the required ratios on the specified days. Additionally, the facility did not meet the minimum required Licensed Practical Nurse (LPN) staffing ratios for the night shift on two days. The census data indicated that the number of LPNs scheduled was below the required minimum of one LPN per 40 residents for the night shift, and again, no excess higher-level staff were available to make up for the deficiency. The Nursing Home Administrator confirmed the shortfall in LPN staffing for the identified days. The facility also failed to provide the minimum required hours of direct resident care per day for nine days within the review period. The nursing time schedules showed that the facility provided less than the required 3.20 hours of direct care per resident on these days, with the lowest being 2.84 hours. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged that the facility did not meet the required daily direct care hours on the specified days.
Plan Of Correction
There is no evidence that any resident was adversely affected. Current residents have the potential to be affected. The facility will schedule, monitor, and manage the nursing assistant staff ratios to meet the requirements. To prevent recurrence, the Nursing Home Administrator will review the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings will be held to review the scheduled staffing ratios and hours per patient day for the upcoming day(s) to ensure the facility plans to meet the requirements. To maintain and monitor compliance, the Nursing Home Administrator/designee will conduct audits of the nursing assistant staffing ratios to determine minimums were met weekly x4 and monthly x2. Results of the audits will be forwarded to the center Quality Assurance Performance Improvement committee for review and recommendations. There is no evidence that any resident was adversely affected. Current residents have the potential to be affected. The facility will schedule, monitor, and manage the hours per patient day to meet the requirements. To prevent recurrence, the Nursing Home Administrator will review the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings will be held to review the scheduled staffing ratios and hours per patient day for the upcoming day(s) to ensure the facility plans to meet the requirements. To maintain and monitor compliance, the Nursing Home Administrator/designee will conduct audits of the hours per patient day to determine minimums were met weekly x4 and monthly x2. Results of the audits will be forwarded to the center Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Complete Physician-Ordered 15-Minute Safety Checks
Penalty
Summary
The facility failed to ensure that physician-ordered 15-minute safety checks were completed for a resident with a diagnosis of anxiety and a history of behavioral issues, including inappropriate interactions with female residents. According to facility policy, staff are required to visually observe residents on 15-minute checks and document their status using an observation tool. The resident in question had a physician's order and nursing documentation indicating the need for 15-minute safety checks due to ongoing behavioral concerns. On the day of observation, the resident was seen resting in his room for a period of 44 minutes without any staff conducting the required safety checks. An agency nurse aide, who entered the room during this time, was unaware of the safety check requirement and reported that this information was not provided during shift report. The aide also noted she was unable to access the computer system to review orders. The Director of Nursing confirmed that staff should have been conducting and documenting the 15-minute checks as per policy and physician orders.
Improper Handling of Soiled Linen
Penalty
Summary
Surveyors observed soiled linen and a soiled brief lying on the floor inside a resident room, with no staff present in the room or hallway at the time. According to the facility's environmental services policy for laundry, all used linen is to be handled as potentially contaminated, bagged at the point of care, and placed in a soiled linen container in the soiled utility room or laundry chute. Interviews with a registered nurse and the Director of Nursing confirmed that the soiled linen and brief should not have been left on the floor and should have been properly bagged and transported according to policy. This failure to follow established infection control practices for handling linen constituted a deficiency under the cited regulation.
Insufficient Dietary Staffing Led to Use of Disposable Meal Service Items
Penalty
Summary
The facility failed to provide sufficient dietary staff to perform essential kitchen duties, resulting in residents being served meals on styrofoam plates with plastic silverware on random days without explanation. Multiple residents reported receiving their meals in this manner, with one resident stating it occurred about half the time and specifically noting it happened during breakfast on the day of the interview. The Assistant Nursing Home Administrator confirmed that plastic silverware was provided for breakfast due to low staffing in the kitchen. These findings indicate that inadequate staffing in the dietary department led to the use of disposable meal service items for residents.
Failure to Timely Update Pressure Ulcer Treatment Orders
Penalty
Summary
A resident with quadriplegia, traumatic brain injury, and cognitive impairment was identified as having a new open area on the right lower buttock, initially assessed as moisture-associated skin damage. The care plan included cleansing the wound, applying medihoney, and covering with an adhesive foam dressing. Despite a wound healing consult noting the area was worsening, there was no documented evidence that the new treatment order to use Hydrofera blue was initiated promptly. The Treatment Administration Record showed that the wound treatment was not updated in a timely manner, and the resident continued to receive the previous treatment for two days after the new order was given. Interviews with the Director of Nursing and a Registered Nurse confirmed that the orders for the resident's worsening wound were not updated as required, resulting in the resident receiving the incorrect treatment. This failure to provide timely and appropriate pressure ulcer care was identified during a review of clinical records and staff interviews, constituting a deficiency under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Maintain Clean and Homelike Environment Due to Unclean Wheelchairs
Penalty
Summary
The facility failed to provide a clean and homelike environment for five residents, as evidenced by observations of their wheelchairs, which were found to have moderate to large accumulations of removable, dried-on debris, dust, dirt, and grime on various parts including the metal supports, wheels, and seat cushions. These conditions were directly observed by surveyors during their review, with each of the five residents' wheelchairs exhibiting visible, removable contaminants that had not been addressed. Interviews with staff, including LPNs, nurse aides, and housekeepers, confirmed that the wheelchairs should have been clean and that it was the responsibility of housekeeping to maintain their cleanliness. Staff indicated that a reduction in housekeeping personnel had made it difficult to keep up with cleaning tasks, and the nursing home administrator acknowledged that the wheelchairs should not have had dust, dirt, or debris present.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to determine if a resident was safe to self-administer medications, as required by facility policy and regulatory standards. The policy stated that residents wishing to self-administer medications must have a physician's order and an evaluation to determine their capability. Review of the resident's clinical record showed no physician's order for self-administration, no documented evaluation of the resident's ability to self-administer medications, and no care plan addressing this issue. During an observation, the resident was found taking medications at her bedside without staff supervision. The medications included several tablets of varying shapes and colors. Interviews with nursing staff and the Nursing Home Administrator confirmed that the resident had not been evaluated for self-administration and did not have the necessary physician's order, and that medications should not have been left at the bedside.
Resident Placed at Risk During Transport by Impaired Van Driver
Penalty
Summary
A deficiency occurred when a resident, who was cognitively impaired and had communication limitations, was being transported to an orthopedic appointment. The nurse aide escorting the resident reported that the van driver arrived late, appeared drowsy, and drove the van at an unusually slow speed. During the trip, the driver began to fall asleep and swerved off the road, prompting the nurse aide to fabricate a story about the appointment being canceled in order to return safely to the facility. Upon return, the nurse aide immediately reported the incident to supervisory staff. A reasonable suspicion report documented that the van driver exhibited signs of intoxication, including sleepiness, bloodshot and droopy eyes, slurred speech, and difficulty standing. A subsequent blood alcohol test confirmed the driver had a blood alcohol level of 0.122 percent while responsible for transporting the resident. This incident demonstrated a failure to maintain an environment free of accident hazards and to provide adequate supervision to prevent accidents during resident transportation.
Medication Error Leads to ICU Admission
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who received another resident's medications. This error occurred when an LPN confused the resident with another and administered a series of medications not prescribed to them. The medications included aspirin, tamsulosin, vitamin-b, depakote, buspar, Plavix, Cymbalta, folic acid, docusate, gabapentin, lisinopril, memantine, ingrezza, Seroquel, and lopressor. The facility's policy for medication administration required that medications be administered according to physician orders, which was not followed in this instance. The resident involved had a medical history that included non-ischemic myocardial injury, dementia, encephalopathy, atrial fibrillation, and heart failure. Following the administration of the incorrect medications, the resident's blood pressure dropped significantly, and their pulse rate decreased, prompting the physician to order an evaluation at the emergency department. The resident was subsequently admitted to the intensive care unit for low blood pressure and required vasopressors. Interviews with the hospital's medical doctor and the nursing home administrator confirmed that the resident's condition was a direct result of receiving the wrong medications.
Failure to Prevent Abuse and Neglect Among Residents
Penalty
Summary
The facility failed to ensure that residents were free from abuse or neglect, as evidenced by incidents involving three residents. Resident 58, who has dementia and is dependent on staff for toileting needs, reported that a nurse aide pulled her call bell out and left her without assistance. This allegation was substantiated, and the nurse aide was terminated. The Director of Nursing confirmed the substantiation of the abuse/neglect allegation. Resident 130, who is cognitively impaired and has severe dementia with anxiety, was involved in multiple resident-to-resident altercations. In one incident, Resident 130 flipped a supper tray on another resident, leading to a physical altercation. In another incident, Resident 130 was kicked by another resident while wandering the hall. These incidents were investigated, and the resident-to-resident abuse was substantiated. Resident 130 was subsequently admitted to a Behavioral Health Unit for further evaluation. Resident 134, who is cognitively impaired and has a history of physical behavioral symptoms, was involved in an altercation where he hit another resident with a footrest from his wheelchair. The incident was a result of a misunderstanding due to Resident 134's mental state. The facility's investigation confirmed the occurrence of resident-to-resident abuse. These incidents highlight the facility's failure to prevent abuse and neglect among residents, as evidenced by the substantiated cases of abuse and neglect.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, as determined through a review of clinical records and staff interviews. The inaccuracies were found in various sections of the MDS assessments, which are crucial for reflecting the residents' medical and treatment statuses. For instance, Resident 12's assessment inaccurately indicated that the influenza vaccine was not offered, despite documentation showing the resident refused it. Similarly, Resident 17's assessment failed to record the administration of gabapentin, an anticonvulsant medication, which was given as per the physician's orders. Further discrepancies were noted in the assessments of other residents. Resident 18's MDS assessment did not reflect the administration of bumetanide, a diuretic medication, despite records showing it was administered daily. Resident 25, who required hemodialysis, had an assessment that did not indicate the receipt of dialysis treatments, contrary to nursing notes. Additionally, Resident 41's assessment failed to record the administration of diazepam, an anti-anxiety medication, which was given daily as ordered. The inaccuracies extended to Resident 93, whose assessment incorrectly stated that vaccines were not offered, despite declination forms indicating refusal. Resident 122's assessment did not reflect the administration of Tramadol and Topiramate, despite records showing these medications were given. Interviews with the Licensed Practical Nurse Assessment Coordinator confirmed these coding errors, highlighting a failure in accurately documenting the residents' treatment and medication administration in the MDS assessments.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #12 will have a corrected Minimum Data Set (MDS). Resident #17 will have a corrected MDS. Resident #18 will have a corrected MDS. Resident #25 will have a corrected MDS. Resident #41 will have a corrected MDS. Resident #93 will have a corrected MDS. Resident #122 will have a corrected MDS. To identify other residents with the potential to be affected, the MDS nurse/designee will audit the most recent MDS assessment of residents to ensure they are coded correctly. Modifications will be made as necessary. To prevent a future occurrence, the Nursing Home administrator/designee provided education to the MDS nurses on proper coding of the MDS items. To monitor and maintain ongoing compliance, the MDS team/designee will complete an audit weekly x4 then monthly x2 to ensure MDS assessments are being properly coded. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Care Plan Updates Not Reflecting Changes in Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for seven residents. For Resident 2, the care plan was not updated to reflect a change in code status from full code to Do Not Resuscitate (DNR), despite a physician's order indicating the change. The Director of Nursing confirmed that the care plan should have been updated to reflect this change. Resident 25's care plan was not revised to include Enhanced Barrier Precautions (EBP), contact, and droplet precautions, even though there was signage indicating these precautions were in place. Similarly, Resident 79's care plan was not updated to include EBP, despite signage indicating the precautions. Interviews with staff confirmed the lack of documentation in the care plans for these precautions. Other deficiencies included Resident 41's care plan not being updated to reflect the discontinuation of an antibiotic, Resident 64's care plan not reflecting a change in out-of-bed orders to an evolution chair, Resident 106's care plan not being updated to reflect hospice services, and Resident 130's care plan not reflecting the discontinuation of a diuretic. These omissions were confirmed through interviews with the Director of Nursing and other staff members.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #2 careplan changes were completed and are accurate. Resident #25 careplan changes were completed and are accurate. Resident #41 careplan changes were completed and are accurate. Resident #64 careplan changes were completed and are accurate. Resident #79 careplan changes were completed and are accurate. Resident #106 careplan changes were completed and are accurate. Resident #130 careplan changes were completed and are accurate. To identify other residents with the potential to be affected, the Director of Nursing/designee will review care plans to ensure any changes to code status, Enhanced Barrier Precautions, antibiotics, out of bed orders, hospice care and residents on diuretic medication within the last two weeks were reviewed/revised correctly on the care plan. To prevent a future occurrence, the Director of Nursing/designee provided education to the interdisciplinary team on the comprehensive care planning policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure any changes to orders are reflected on the care plan. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to provide adequate, ongoing activities designed to meet the needs of a resident, identified as Resident 9, as required by §483.24(c)(1). The facility's life enrichment programming policy mandates an ongoing resident-centered program based on comprehensive assessments and care plans, which should cater to the interests and abilities of each resident. However, for Resident 9, who has hemiplegia and dysphagia following a stroke, there was no documented evidence of participation or refusal of activities during several weeks across November 2024 to January 2025. Interviews revealed that Resident 9's spouse indicated the resident does not like to get out of bed and is not provided with in-room activities, leaving television as the only option. The Activities Director confirmed that Resident 9 was scheduled for weekly one-to-one bedside/in-room visits and activities, but there was no documentation to support that these activities occurred during the specified weeks. This lack of documentation and activity provision indicates a failure to meet the resident's needs as outlined in their care plan.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #9 activity preferences and care plan were updated. To identify other residents with the potential to be affected, the Life Enrichment Director/designee will complete 100% audit of all residents to identify those at risk and in need of a 1:1 visit. To prevent a future occurrence, Life Enrichment Director will create a separate calendar listing the residents who trigger for a 1:1 visit based on the observation completed. Life Enrichment Director/designee will educate Life Enrichment Staff on how this process designed will work moving forward within the department and facility. To monitor and maintain ongoing compliance, Life Enrichment Director/designee will monitor the monthly activity logs for residents with Care plans for 1 to 1 visit weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Document Controlled Medication Disposal
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents. For one resident, the facility's policy required that two licensed nurses witness and document the disposal of fentanyl patches. However, there was no documented evidence that two staff members signed off on the destruction of the old fentanyl patches on multiple occasions. The Director of Nursing confirmed the lack of documentation for the destruction of the patches. For another resident, who was discharged to another nursing facility, there was no documented evidence of the disposition of Ativan, a controlled drug, upon discharge. The Assistant Nursing Home Administrator confirmed the absence of documentation regarding the medication's disposition. These deficiencies indicate a failure to adhere to the facility's procedures for managing controlled substances, as required by regulations.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility could not go back and fix Resident #44 destruction log. The facility could not go back and fix the accountability log for Resident #149 narcotic at time of discharge. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit Fentanyl destruction logs for the last 30 days to ensure two signatures are present and review residents discharged over the last 2 weeks to ensure accountability of narcotics if resident was to be discharged with them. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on the proper destruction of medications and medication disposition of discharged residents. To monitor and maintain ongoing compliance, the Director of Nursing/designee will audit Fentanyl destruction logs and accountability of narcotics on discharge weekly x4 and then monthly x2 to ensure two signatures are present and residents are discharged with narcotics if ordered by Medical Director (MD). Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Repeated Deficiencies in QAPI Implementation
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in multiple surveys. These deficiencies included a failure to prevent resident abuse and neglect, timely completion of comprehensive assessments, and inaccuracies in Minimum Data Set (MDS) assessments. Additionally, the facility struggled with developing comprehensive care plans and providing professional nursing services. The survey results also highlighted issues with ensuring a safe environment free of accident hazards, as well as failures in accountability for controlled medications and proper storage and labeling of medications. The facility was cited for not ensuring that physicians and certified registered nurse practitioners wrote, signed, and dated progress notes with each visit. Furthermore, the facility's infection control practices were found to be deficient. Despite the facility's plans of correction, which included completing audits and reporting results to the QAPI committee, the committee was ineffective in addressing and correcting these deficiencies. The repeated nature of these issues across multiple surveys indicates a systemic problem in the facility's ability to implement and sustain effective quality assurance measures.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility is unable to fix the Quality Assurance audits at the time of the survey. There were no other issues identified at the time of the survey. To prevent a future occurrence, the Nursing Home Administrator will educate department heads on the Quality Assurance and Process Improvement Policy. To monitor and maintain ongoing compliance, the Nursing Home Administrator/designee will complete an audit weekly x4 then monthly x2 to ensure that audits are being completed, reviewed and have process improvement plans put into place if necessary. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Facility Fails to Maintain Safe Operating Condition of Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed during a survey. The dishwashing machine was not registering a temperature during the first rinse cycle and was leaking water onto the floor. Additionally, a steam kettle was leaking water, which was being caught by a plastic bucket placed underneath it. These issues were observed during a kitchen inspection. Interviews with the Dietary Manager and the Nursing Home Administrator revealed that several pieces of kitchen equipment had been malfunctioning for extended periods. The dishwasher had been leaking and not functioning to full capacity since September 2024. The steam kettle required a new seal since June 2024, and an upright cooler had been out of service since May 2024. The garbage disposal was not in use due to a loud noise, and one oven was unusable since March 2024 because of a broken door pin. The second oven had a broken on/off switch but was still in use. One pressure cooker had been out of service since August 2024, and the second pressure cooker was irreparable since September 2024. Despite these issues, alternate cooking equipment was used, and there were no adverse effects on meal service.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. No residents had any adverse reactions. To prevent a future occurrence, the Administrator/designee will work with Maintenance staff on the processing repair orders to assure kitchen equipment repairs are fixed timely. Work orders have been initiated for the equipment listed in deficiency. To monitor and maintain ongoing compliance, the Maintenance Director/designee will complete an audit weekly x4 and then monthly x2 to ensure kitchen equipment parts have been ordered, then internally fixed or vendor has fixed the equipment. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Document Semiannual Fire Alarm Inspection
Penalty
Summary
The facility failed to maintain the fire alarm system as required by NFPA 101, NFPA 70, and NFPA 72 standards. During a documentation review on January 30, 2025, it was discovered that the facility could not provide documentation for a semiannual visual inspection of the fire alarm system. This lack of documentation indicates that the required inspection was not conducted or recorded, which is a violation of the fire safety standards that mandate regular testing and maintenance of fire alarm systems. An interview with the Facility Administrator and Maintenance Director on the same day confirmed the absence of documentation for the semiannual inspection of the fire alarm system and devices. This deficiency highlights a lapse in the facility's adherence to the approved program for fire alarm system maintenance, as the records of system acceptance, maintenance, and testing were not readily available as required.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Vendor was contacted when survey ended to schedule the semi annual visual inspection of the fire alarm system. 2. To prevent recurrence, Maintenance manager/designee will preschedule twice a year for the visual inspection to be completed. Administrator will be notified of those inspection dates and monitor them for completion. 3. To maintain and monitor compliance, Administrator or designee will review inspection dates and have them reported to monthly safety committee meeting, then turned into Monthly QAPI meeting.
Failure to Maintain Resident Dignity in Hygiene Assistance
Penalty
Summary
Maple Heights Health and Rehab Center was found to be non-compliant with certain resident rights requirements as per 42 CFR Part 483, Subpart B, and the 28 PA Code. The deficiency involved a failure to maintain the dignity of a resident, identified as Resident 84, in the provision of hygiene assistance. The resident, who was capable of understanding and communicating, had a care plan indicating a need for assistance with activities of daily living, including morning and evening care. The facility's bath schedule specified that the resident was to receive showers on certain evenings, but on one occasion, the resident refused a shower and accepted a bed bath instead. Observations made on two separate days revealed that Resident 84 had visible facial hair, which had not been addressed by the staff. There was no documented evidence that the staff had asked the resident about her preference regarding facial hair removal, nor was there a policy in place for such preferences. An interview with the Director of Nursing confirmed that the staff did not have a specific protocol for addressing facial hair removal for female residents, and it was left to the discretion of the staff based on the resident's response at the time of their shower.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This Plan Of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #84 had facial hair removed at the time of the survey. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit female residents to see if they have a preference on facial hair removal and will add it to their shower day order and plan of care. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff on the resident right policy/in-service as well as the importance of following female resident's preference on facial hair removal. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of 10 random female residents to ensure there is no facial hair present weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Inform Resident of Medical Appointments
Penalty
Summary
The facility failed to honor a resident's right to be informed and participate in their treatment decisions, as required by regulations. Specifically, the facility did not notify a resident of their medical appointments in advance, despite the resident's expressed desire to be informed. The resident, who was capable of understanding and communicating, had previously raised concerns about not being informed of appointments, and it was agreed that they would receive at least a week's notice. However, the resident was sent to a procedure without prior notification, as confirmed by interviews and clinical records. The deficiency was further evidenced by the lack of documentation in the resident's clinical record indicating that they were informed of appointments on two specific dates. The Director of Nursing confirmed the absence of such documentation and acknowledged that the resident's sister was notified instead, as she had requested to be informed. This oversight in communication and documentation led to the resident discovering an upcoming appointment through their patient portal rather than being informed by the facility staff.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This Plan Of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Facility could not go back and notify Resident #79 of a previous appointment. Facility clarified Resident #79 preference of notification at the time of the survey. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit appointments for the previous month to see if notifications were made and documented. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff/transportation on the resident right to make informed choices and participate in his/her treatment. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of 10 appointments (if applicable) to ensure notifications are completed and documented weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Resolve Resident Grievance Timely
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances for a resident, identified as Resident 18, who was cognitively intact and required assistance from staff for care. The resident filed a grievance on December 25, 2024, regarding not receiving her gas pill and not being washed up for the day. Despite asking for assistance from a nurse aide and an LPN at 1:00 p.m., the resident was not attended to until 3:00 p.m. by two unknown nurse aides. The grievance was not assigned until January 7, 2025, and there was no documented evidence of a thorough investigation, including interviews or written statements from the staff involved. The grievance form indicated that nursing was to review medication changes with the resident, but there was no documentation of whether the grievance was confirmed or not. Additionally, there was no evidence of ongoing efforts to resolve the resident's concerns until January 28, 2025, when the Nursing Home Administrator met with the resident to discuss changes to her care. The resident was not informed of the grievance resolution until January 29, 2025, over a month after the grievance was filed. An interview with the Nursing Home Administrator confirmed the lack of documented evidence of ongoing efforts to resolve the grievance and the delay in informing the resident of the resolution. This failure to address the grievance in a timely manner and to keep the resident informed of the resolution process is a deficiency in the facility's grievance handling procedures.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #18 grievance was resolved and reviewed with the resident at the time of the survey. To identify other residents with the potential to be affected, the Social Service Department/designee will audit grievances for the month of January to ensure they were addressed and to resolve per policy. To prevent a future occurrence, the Director of Nursing/designee will educate department heads on the grievance policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of current grievances to ensure they are addressed and resolved timely weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice to the responsible parties of three residents regarding their transfers to the hospital, which is a requirement under §483.15(c)(3)-(6)(8). Resident 12, who was cognitively intact, was found on the floor with confusion, tremors, and hyperventilation, leading to a hospital transfer. However, there was no documented evidence that a written notice was provided to the resident's responsible party explaining the reason for the transfer. Resident 32 experienced a change in condition, including lethargy and disorientation, prompting a transfer to the emergency department for further evaluation. On a separate occasion, the resident requested to go to the emergency department due to shortness of breath. In both instances, there was no documented evidence that a written notice was provided to the responsible party regarding the reasons for the hospital transfers. Resident 84 was found on the floor with a laceration and bleeding, necessitating a hospital transfer for evaluation. Again, there was no documented evidence that a written notice was provided to the responsible party regarding the reason for the transfer. Interviews with facility staff confirmed the lack of documentation for the required written notices for all three residents.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This Plan Of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility could not go back and notify Resident #12, Resident #32, or Resident #84 of their immediate transfer/discharge from the facility in written notification. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit residents who had an immediate transfer/discharge within the last two weeks to see if the written notification to responsible parties was completed. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff/social service department on the immediate transfer/discharge paperwork to ensure that families and responsible parties moving forward are notified in writing of the transfer from the facility. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of weekly hospital transfers to ensure written notifications to responsible parties were completed weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required 14-day timeframe for five residents. According to the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following a resident's admission. However, the assessments for Residents 141, 143, 147, 152, and 165 were completed between 15 to 20 days after their respective admission dates, exceeding the mandated timeframe. The deficiency was confirmed through a review of the RAI User's Manual, clinical records, and staff interviews. The Nursing Home Administrator acknowledged that the admission MDS assessments for the mentioned residents were not completed within the required timeframes. This oversight indicates a failure in adhering to the regulatory requirements for timely assessments, which are crucial for evaluating and addressing the residents' needs and care plans.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #141 will have a timely Minimum Data Set (MDS) assessment completed. Resident #143 will have a timely MDS assessment completed. Resident #147 was discharged from the facility on 12/25/24. Resident #152 will have a timely MDS assessment completed. Resident #165 will have a timely MDS assessment completed. To identify other residents with the potential to be affected, the MDS nurse/designee will audit current residents and new admissions for the last 30 days to ensure assessments are not overdue. To prevent a future occurrence, the Nursing Home administrator/designee provided education to the MDS nurses on completion of MDS assessments in accordance with the assessment reference date. To monitor and maintain ongoing compliance, the MDS team/designee will complete an audit weekly x4 then monthly x2 to ensure MDS assessments are in accordance with the assessment reference date. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Develop Baseline Care Plan for Hemodialysis
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed for a resident's immediate care needs, specifically related to hemodialysis. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission, including necessary healthcare information to provide effective and person-centered care. However, for one resident, who was a new admission from the hospital and required hemodialysis three times a week, there was no documented evidence of a baseline care plan addressing their hemodialysis care and treatment needs. The resident had specific physician orders related to their hemodialysis treatment, including checking the AV fistula site daily for bleeding and monitoring for a bruit and thrill. Despite these orders, the facility did not develop a baseline care plan to address these critical care needs. This deficiency was confirmed during an interview with the LPN Assessment Coordinator, who acknowledged that a baseline care plan was not developed for the resident's hemodialysis care needs.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #94 care plan was reviewed at the time of the survey by the interdisciplinary team and will be revised/updated as needed. To identify other residents with the potential to be affected, the Minimum Data Set (MDS) nurse/designee will audit new admissions over the last 30 days to ensure that a baseline care plan was generated within 48 hours of admission, and reflected instructions needed to provide effective care to the resident based on physician orders and resident preferences/goals. To prevent a future occurrence, the Director of Nursing/designee provided education to the MDS nurses on the baseline care plan policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure baseline care plans are generated within 48 hours of admission and include information regarding resident's immediate care needs. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Develop Comprehensive Care Plan for Resident with Seizure Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident 44, who was cognitively impaired and had a seizure disorder. The resident was receiving anticonvulsant medications, specifically valproic acid and levetiracetam, as per physician's orders. However, the resident's care plan did not include any documented evidence addressing the care needs related to the anticonvulsant medications or the seizure disorder. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have included the use of anticonvulsant medications and the seizure disorder. The facility's policy required that comprehensive care plans be developed and updated regularly to meet the resident's medical, nursing, and psychosocial needs, but this was not adhered to in the case of Resident 44.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #44 will have an anticonvulsant/seizure disorder care plan created. To identify other residents with the potential to be affected, the Director of Nursing/designee will review other residents on anticonvulsants and with a seizure disorder to ensure they have appropriate care plans in place. To prevent a future occurrence, the Director of Nursing/designee provided education to the interdisciplinary team on the comprehensive care planning policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure comprehensive care plans are in place. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to clarify and implement appropriate treatment orders for a resident with a non-healing surgical wound. According to the Pennsylvania Code, registered nurses are required to collect and analyze data to determine nursing care needs and carry out actions that promote well-being. However, the facility did not adhere to these standards. A quarterly Minimum Data Set assessment indicated that the resident was alert, oriented, and required assistance with care. A wound consult report recommended specific treatments, including the use of VASHE wound cleanser and medi-honey applied to alginate, but these were not followed as per the Treatment Administration Record. Further wound consult reports recommended soaking the wound in VASHE and applying medihoney with a biofilm dressing, but these instructions were also not followed. An interview with the Director of Nursing revealed that the Wound Nurse Practitioner wrote orders that did not align with the wound consultant's recommendations, and nursing staff failed to review the consultant's notes to ensure consistency with the orders. This discrepancy led to the facility's failure to meet professional standards of quality in providing care for the resident.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #2 careplan changes were completed and are accurate. Resident #25 careplan changes were completed and are accurate. Resident #41 careplan changes were completed and are accurate. Resident #64 careplan changes were completed and are accurate. Resident #79 careplan changes were completed and are accurate. Resident #106 careplan changes were completed and are accurate. Resident #130 careplan changes were completed and are accurate. To identify other residents with the potential to be affected, the Director of Nursing/designee will review care plans to ensure any changes to code status, Enhanced Barrier Precautions, antibiotics, out of bed orders, hospice care and residents on diuretic medication within the last two weeks were reviewed/revised correctly on the care plan. To prevent a future occurrence, the Director of Nursing/designee provided education to the interdisciplinary team on the comprehensive care planning policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure any changes to orders are reflected on the care plan. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations. Resident #69 handwritten order for wound care was to cleanse the wound; order entered into the computer that was followed was to cleanse the wound. Clarification for the order was obtained at the time of the survey to "cleanse the wound". To identify other residents with the potential to be affected, the Director of Nursing/designee will review wound consult notes and handwritten orders for the last 2 weeks to ensure they match and get any clarification if needed. To prevent a future occurrence, the Director of Nursing/designee provided education to the licensed staff on ensuring progress notes from the wound Certified Registered Nurse Practitioner (CRNP), match the handwritten order and get clarification if needed. Education was also provided to the wound CRNP to ensure that his orders in his notes match his handwritten orders. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 on wound care orders and wound care progress notes to ensure accuracy and consistency. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Provide Discharge Summary and Plan
Penalty
Summary
The facility failed to ensure that a discharge summary, including post-discharge medications and a post-discharge plan of care, was completed for a resident. This deficiency was identified during a review of clinical records and staff interviews. Specifically, for one of the three discharged residents reviewed, there was no documented evidence that the resident received discharge instructions that included post-discharge medications or a post-discharge plan of care. The deficiency was highlighted by a nursing note indicating that the resident was picked up by a transport company to be discharged to another facility. However, as of the day before the discharge, there was no documentation of the required discharge instructions. An interview with the Assistant Nursing Home Administrator confirmed the absence of this documentation, which is a violation of the regulatory requirements for discharge summaries.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Facility is unable to create the discharge summary for Resident #149. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit the last month of discharged residents to ensure the discharge summary was completed and make corrections if applicable/able. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff on how to properly complete a discharge summary. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of discharged residents to ensure the discharge summary was completed weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in their care. For one resident, who was cognitively impaired and receiving opioid pain management, the facility did not follow the prescribed schedule for applying a fentanyl patch. The physician's order specified that the patch should be applied every 72 hours, but records showed it was applied every 48 hours, contrary to the order. This discrepancy was confirmed by the Director of Nursing during an interview. Another resident, who was scheduled for a suprapubic catheter exchange, was supposed to discontinue the use of clopidogrel (Plavix) five days prior to the procedure as per the interventional radiology consultation. However, the medication was administered up to the day of the procedure, which was not in accordance with the medical recommendation. This oversight was also confirmed by the Director of Nursing, indicating a failure to follow the necessary pre-procedure instructions.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #44 and Resident #79 did not suffer any adverse reactions. Resident #44 medication order is accurate. Resident #79 does not have any procedures scheduled at this time that require a medication to be on hold. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit residents who were to have procedures completed in the last two weeks to ensure medications that were to be held were and any medications that were put on hold had dates extended if needed. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on how to properly place medications on hold and follow consult recommendations to place medications on hold. To monitor and maintain ongoing compliance, an audit of scheduled procedures and order holds will be completed weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Use Assistance Devices for Resident Transport
Penalty
Summary
The facility failed to ensure that two residents received the necessary assistance devices to prevent accidents, as required by their care plans and physician's orders. Resident 64, who was cognitively impaired and required assistance for personal care needs, was observed being transported without the required bilateral leg rests on her chair. This was contrary to the physician's orders and care plan, which specified that leg rests should be used for transport and outside. Nurse Aide 8 admitted to not applying the leg rests before transporting the resident. Similarly, Resident 120, also cognitively impaired and requiring assistance, was transported without the necessary leg rests. The resident's care plan and physician's orders indicated that standard leg rests should be used for transport and outside. Licensed Practical Nurse 9 transported the resident without leg rests, acknowledging that this was done because the resident was being disruptive. The Director of Nursing confirmed that the leg rests should have been used as ordered for both residents.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #64 and Resident #120 did not have any adverse reactions from being transported without leg rests. Resident #64 and Resident #120 will have, moving forward, leg rests on when being transported by staff. There were no other identified issues at the time of the survey. To prevent a future occurrence, the Director of Nursing/designee provided education to staff on the seating and positioning policy. The education included using wheelchair legs for transporting. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure staff transporting residents are utilizing leg rests. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Document Physician and CRNP Progress Notes
Penalty
Summary
The facility failed to ensure that the physician and the Certified Registered Nurse Practitioner (CRNP) wrote, signed, and dated progress notes with each visit for two residents. For one resident, a nursing note indicated that the resident was seen by the physician at the bedside, and new verbal orders were received. However, there was no documented evidence of a progress note from the physician for this visit until a month later when it was faxed to the facility. The Director of Nursing confirmed the absence of the progress note in the resident's clinical record until it was received by fax. For another resident, who was a new admission from the hospital, there was no documented evidence of a progress note for the initial admission visit by the physician. The Director of Nursing confirmed the lack of documentation and mentioned that the physician recalled seeing the resident. Additionally, hospital discharge instructions indicated that the resident was to have sutures removed, but there was no documented evidence that the CRNP completed a progress note regarding the suture removal. The LPN/Infection Control Preventionist confirmed the absence of documentation and noted that the CRNP was behind in updating progress notes.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility is not able to obtain previous physician note for Resident #84. At the time of the survey, the facility obtained the note for Resident #84 from the Certified Registered Nurse Practitioner. At the time of the survey, the facility obtained the note for Resident #79 from the physician. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit a 2 week look back of physician and certified Registered Nurse Practitioner visits to ensure notes are present. To prevent a future occurrence, the Director of Nursing/designee provided education to the physician and Certified Registered Nurse Practitioner on writing a note for each resident that they visit. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to verify a note is present for each resident that they visit. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to comply with the labeling requirements for multi-dose medication containers, as observed in one of the four medication carts inspected. Specifically, the First-Floor Southeast medication cart contained several inhalers that were opened but not labeled with the date they were opened, contrary to the facility's policy and manufacturer's instructions. The medications involved included fluticasone propion-salmeterol inhalers for Residents 32 and 135, umeclidinium-vilanterol inhaler for Resident 48, and fluticasone-umeclidinium-vilanterol inhaler for Resident 95. These medications have specific expiration guidelines once opened, which were not adhered to, as the opened dates were not recorded. During an interview, LPN 10 confirmed the oversight, acknowledging that the inhalers for the residents mentioned were indeed opened and not dated as required. The facility's policy, dated December 30, 2024, mandates that staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened. This deficiency was identified based on a review of facility policies, manufacturer's instructions, clinical records, and direct observations.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #32, Resident #135, Resident #48 and Resident #95 undated medications were discarded at the time of the survey. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit med carts to ensure that resident inhalers are dated properly. To prevent a future occurrence, the Director of Nursing/designee provided education to licensed nursing staff on the storage and expiration dating of medications and biologicals policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure that multi-dose vials are being dated properly. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely completion of prescribed laboratory services for two residents. For one resident, a urinalysis and culture and sensitivity were ordered on two separate occasions, but the lab did not pick up the specimen on the first occasion. The resident was straight catheterized twice due to the initial failure to collect the specimen. The preliminary results of the urinalysis were eventually reviewed, and new orders for an antibiotic were received. For another resident, a urinalysis was ordered due to recent falls and agitation. Although the sample was obtained and the lab was notified, the specimen was not picked up and was found in the refrigerator the following day. The resident was prophylactically treated for a urinary tract infection, but subsequent urinalysis results indicated that the resident did not have an infection. The Director of Nursing confirmed that the hospital lab is responsible for picking up lab specimens and that staff were unaware when labs were not picked up timely.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #58 did not have any adverse reactions. Resident #120 did not have any adverse reactions. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit residents from the last 2 weeks who had an order for a Urine Analysis (UA) to ensure it was obtained timely. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on how to properly place an order for a UA and ensure it is picked up from the lab timely. Lab now has a routine schedule of being at the facility on Monday, Wednesday, Thursday, and Friday, and if it is a STAT then we call them. To monitor and maintain ongoing compliance, the Director of nursing/designee will review orders placed for a UA daily in clinical morning meeting weekly x4 and then monthly x2 to ensure urines are obtained and collected timely. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Obtain Lab Tests and Orders for Invasive Procedure
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for one resident and did not secure a physician's order for an invasive procedure to collect a specimen for another resident. For Resident 18, who was cognitively intact and diagnosed with hypothyroidism, the facility did not obtain the required Thyroid Stimulating Hormone (TSH) tests for September and December 2024, as per the physician's orders. This was confirmed by the Director of Nursing during an interview, where it was acknowledged that there was no evidence of the TSH tests being conducted for the specified months. For Resident 84, who had End-Stage Renal Disease and was dependent on hemodialysis, the facility failed to obtain a physician's order for catheterization to collect a urine specimen. Although there was an order to obtain a urine specimen and contact the hospital's laboratory, the progress note indicated that a straight catheterization was attempted without a physician's order. This was confirmed by the Licensed Practical Nurse/Infection Control Preventionist, who acknowledged the absence of a physician's order for the catheterization procedure.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #84 did not suffer any adverse effects from the urine being obtained via straight cath. Resident #18 did not suffer any adverse effects from the lab not being obtained and had a Thyroid stimulating hormone (TSH) drawn on 1/3/25 which was within normal limits. To identify other residents with the potential to be affected, the Director of Nursing/designee will review labs for the prior 2 weeks to ensure labs were obtained as ordered and review any that were not with the medical director to see if they need reordered. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on how to properly place laboratory orders and verify labs were obtained. Education will include obtaining doctors orders for invasive procedures. To monitor and maintain ongoing compliance, laboratory orders will be reviewed weekly x4 and then monthly x2 to ensure labs are obtained when ordered. The check to ensure labs are obtained as ordered is that they are triggered to the Medication Administration Record (MAR) for sign off. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) for a resident identified as Resident 79. The deficiency was observed when a nurse aide did not follow the Enhanced Barrier Precautions (EBP) while providing care to the resident. Specifically, the nurse aide was observed emptying the resident's indwelling catheter drainage bag without wearing a gown, which is a requirement under the EBP for high-contact care activities. Resident 79 had an indwelling catheter and a diagnosis of quadriplegia, which placed them at high risk for acquiring or spreading multidrug-resistant organisms (MDROs). The facility's policy, in line with CDC guidelines, required the use of gown and gloves during high-contact care activities for residents with indwelling medical devices. Despite signage on the resident's door indicating the need for EBP, the nurse aide only wore gloves and failed to don a gown while performing the task. The Licensed Practical Nurse/Infection Control Preventionist confirmed that the nurse aide should have been wearing both a gown and gloves while emptying the catheter drainage bag and assisting the resident to reposition in bed. This oversight in following the established infection control protocols contributed to the facility's failure to prevent the potential spread of infections, as required by the infection prevention and control program.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #79 did not have any adverse reactions. There were no other issues identified at the time of the survey. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff on the proper use of personal protective equipment and when to use it. To monitor and maintain ongoing compliance, the director of nursing/designee will complete an audit weekly x4 and then monthly x2 to ensure staff is wearing the proper personal protective equipment. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Deficiency in Sprinkler System Coverage
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system, which resulted in a deficiency affecting one of 23 smoke compartments. During an observation on January 30, 2025, at 11:20 a.m., it was noted that while there were sprinklers installed under the low bulkhead in the Therapy Break Room, there were no sprinklers on the ceiling above or in the space outside of the room. This lack of sprinkler coverage was confirmed during an interview with the Facility Administrator and Maintenance Director on the same day at 12:30 p.m.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Vendor was contacted when survey ended to schedule the service for installing the sprinklers in the designated areas in the Therapy Break Room. 2. To prevent recurrence, completion of the sprinkler installation will correct stated issue. 3. To maintain and monitor compliance, Administrator or designee will review sprinklers once completed and have them reported to monthly safety committee meeting, then turned into Monthly QAPI meeting.
Infection Control Committee Deficiency
Penalty
Summary
The facility failed to ensure compliance with Pennsylvania state law regarding the operation of a multi-disciplinary infection control committee. According to the Act 52 Infection Control Plan, the facility is required to have a multi-disciplinary committee that meets at least quarterly, including representatives from various departments such as medical staff, nursing, laboratory personnel, and a community member. However, as of January 30, 2025, the facility could not provide documented evidence that the committee included the required laboratory personnel or a community member in its meetings. An interview with the Infection Preventionist confirmed the absence of documented evidence showing the participation of laboratory personnel or a community member in the committee meetings, either in person or via phone. This deficiency indicates a failure to adhere to the infection control plan's requirements, potentially impacting the health and safety of residents and healthcare workers by not having a fully representative committee to address infection control issues.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility cannot go back and correct previously held infection control meetings. There were no other issues at the time of the survey. To prevent a future occurrence, the Regional Director of Clinical Services educated the Infection Control Nurse and Director of Nursing on Act 52. To monitor and maintain ongoing compliance, the facility will have a community member present at infection control meetings quarterly. A lab member will attend a quarterly meeting. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Lack of Policy for Wheelchair Foot Rests
Penalty
Summary
The facility failed to ensure a written policy was in place for the use of foot rests on wheelchairs during transportation. Observations revealed that Resident 64 was transported by a nurse aide from her bedroom to the small activity room without foot rests on her wheelchair. The nurse aide admitted to not applying the leg rests prior to transportation. Similarly, Resident 120 was moved by an LPN from the activity room to the area in front of the nurses' station without leg rests on her wheelchair. The LPN acknowledged not using the leg rests, stating the resident was being disruptive. An interview with the Director of Nursing confirmed the absence of a policy regarding the use of foot rests on wheelchairs for transportation.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility will not be creating a policy pertaining to leg rests. There were no other issues at the time of the survey. To prevent a future occurrence, the Director of Nursing/designee provided education to staff on the seating and positioning policy. The education included the use of wheelchair leg rest for transport. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure staff transporting residents are utilizing leg rests. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Staffing Deficiency in Nursing Services
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios across multiple shifts over a period of 21 days in January 2025. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the overnight shift. This deficiency was identified through a review of nursing schedules, staffing information, and staff interviews. On several specific days, the facility's census data indicated a need for a certain number of NAs based on the number of residents, but the actual number of NAs scheduled fell short. For instance, on January 6, 2025, with a census of 156 residents, 15.60 NAs were required for the day shift, but only 12.59 NAs were available. Similar shortfalls were noted on other days, such as January 7, 10, 11, and 12, 2025, where the number of NAs scheduled was consistently below the required number based on the resident census. The deficiency was further compounded by the lack of additional higher-level staff to compensate for the shortfall in NA staffing. The Nursing Home Administrator confirmed during an interview on January 30, 2025, that the facility did not meet the required staffing ratios on the days in question. This failure to adhere to staffing regulations indicates a systemic issue in maintaining adequate staffing levels to meet the needs of the residents during the specified period.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility cannot retroactively correct past staffing issues. To prevent a future occurrence, the scheduler will be reeducated on staffing nurse aides to include expectations of Hours Per Patient Day and ratios by the director of nursing/designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources and scheduler to review ratio compliance for upcoming schedules. During staffing meetings, discussion will be held on efforts to fill open slots to meet ratio by contacting external agencies for staff and asking in-house staff to cover additional shifts. To monitor and maintain ongoing compliance, the Director of Nursing/designee will monitor nurse aide hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios as mandated by regulations effective July 1, 2023. The regulation requires a minimum of one LPN per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. However, the facility did not comply with these staffing requirements on multiple occasions during the review period from January 5 through January 29, 2025. Specifically, the facility was deficient in providing the required number of LPNs during the day shift for four out of 14 days, during the evening shift for 10 out of 21 days, and during the overnight shift for 13 out of 21 days. For instance, on January 8, 2025, the facility had a census of 157 residents, necessitating 6.28 LPNs during the day shift, but only 6.19 LPNs were available. Similarly, on January 6, 2025, the facility required 3.90 LPNs for the overnight shift with a census of 156 residents, but only 2.03 LPNs were present. The deficiency was confirmed through a review of nursing schedules, staffing information, and staff interviews. The Nursing Home Administrator acknowledged the failure to meet the required staffing ratios during an interview on January 30, 2025. No additional higher-level staff were available to compensate for the staffing shortfall, further exacerbating the deficiency.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility cannot retroactively correct past staffing issues. To prevent a future occurrence, the scheduler will be reeducated on staffing licensed practical nurses to include expectations of Hours Per Patient Day and ratios by the director of nursing/designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources and scheduler to review ratio compliance for upcoming schedules. During staffing meetings, discussion will be held on efforts to fill open slots to meet ratio by contacting external agencies for staff and asking in-house staff to cover additional shifts. To monitor and maintain ongoing compliance, the Director of Nursing/designee will monitor licensed practical nurse hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. Results of audits will be forwarded to the facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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