Maple Ridge Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingston, Pennsylvania.
- Location
- 615 Wyoming Avenue, Kingston, Pennsylvania 18704
- CMS Provider Number
- 395345
- Inspections on file
- 23
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Maple Ridge Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Two residents reported prolonged call bell response times, with one experiencing incontinence due to delayed assistance. Despite repeated complaints voiced in Resident Council meetings and written grievances, the facility did not provide documented resolutions or timely responses, and leadership acknowledged the lack of follow-through on grievances.
A resident with vascular dementia and polyosteoarthritis, who was found to be cognitively intact, was not invited to participate in the development or review of her person-centered care plan. There was no documentation of care plan conferences or invitations for the resident to attend, and this was confirmed by both the resident and facility leadership.
A resident with a new diagnosis of PTSD did not have an individualized, person-centered care plan addressing their PTSD symptoms, triggers, or interventions to minimize re-traumatization. The facility was unable to demonstrate provision of culturally competent, trauma-informed care in line with professional standards.
A resident with severe cognitive impairment and a Stage 2 pressure ulcer did not consistently receive planned interventions such as barrier cream application and regular turning/repositioning. Documentation failed to show that wound care recommendations were followed or that wound progression was adequately monitored. As a result, the resident's pressure ulcer worsened to an unstageable wound, with no evidence of updated interventions after the decline.
Maple Ridge Rehabilitation and Healthcare Center failed to conduct comprehensive nutritional assessments and monitor weight changes for two residents, leading to significant health declines. One resident experienced severe weight loss and was hospitalized in a malnourished state, while another resident's weight loss was not identified or addressed in a timely manner. The facility lacked a qualified nutrition professional during a critical period, and care-planned interventions were not consistently implemented.
A resident with chronic pain and osteoarthritis slipped on a wet floor caused by a leaking window, resulting in a right ankle sprain. Despite the resident's prior report of the issue, the facility failed to address the hazard in a timely manner, leading to the incident. The maintenance department had marked the repair as completed, but the issue persisted until after the resident's injury.
The facility did not address concerns raised by residents about vegetarian food options and failed to involve them in discussions about resident fund activities. Residents reported that their dietary preferences were ignored, and there was no documentation of actions taken to resolve these issues. Additionally, residents were not involved in decision-making regarding the resident fund, and the facility lacked evidence of resident input.
The facility failed to implement person-centered care plans for four residents, leading to deficiencies in addressing specific medical needs and fall risks. A resident's care plan did not include monitoring for a pacemaker, while others were found with beds not in the lowest position or call bells out of reach, contrary to their care plans. These issues were confirmed by facility staff.
The facility failed to involve three residents in the development and revision of their care plans, despite their cognitive ability to participate. Residents with conditions such as schizophrenia, cerebral infarction, chronic kidney disease, and atherosclerotic heart disease reported not being invited to care plan meetings. The DON and NHA confirmed the lack of documented evidence of resident participation in care planning over the past six months.
The facility failed to timely identify and address significant weight loss in two residents. One resident, with conditions like GERD and COPD, experienced a 6.39% weight loss without staff intervention or communication. Another resident, with subarachnoid hemorrhage and dysphagia, lost 13.1% of body weight, and a prescribed Healthshake was not provided. The DON confirmed the facility's failure to act on these issues.
A resident with specific dietary preferences, including being a vegetarian who eats fish, was not provided with a nutritionally adequate menu. Despite expressing dissatisfaction and requesting vegetarian options, the facility failed to plan a suitable menu, resulting in significant weight loss. The resident's preferences were not adequately reflected in her care plan, and there was no follow-up on her concerns.
A resident with severe cognitive impairment was physically abused by another resident with a history of aggressive behavior. Despite interventions, the aggressive resident punched and threw juice at the vulnerable resident. The facility's administration confirmed the failure to prevent this abuse, violating their policy against resident abuse.
A facility failed to ensure an accurate MDS assessment for a resident, as the recorded weight in Section K0200 did not match the most recent weight prior to the assessment. The discrepancy was confirmed by the facility's RD.
The facility failed to properly dispose of garbage and refuse, as observed when two large trash dumpsters were left uncovered. The Nursing Home Administrator confirmed that the dumpster lids should be closed, indicating a lapse in waste management protocols.
The facility failed to maintain a clean and homelike environment on multiple floors, with issues such as black substances on vents, sticky floors, and stained equipment. Observations included dirt, debris, and scuff marks on floors and walls, as well as damaged floor tiles. The Nursing Home Administrator confirmed the expectation for cleanliness and sanitation.
The facility failed to implement policies to protect residents from being disenrolled from Medicare health plans without informed consent. Seven residents were disenrolled without proper documentation of their understanding or consent, despite discussions about potential benefits. The facility lacked procedures for assisting residents with Medicare plan changes, leading to non-compliance with CMS guidelines.
Failure to Resolve Resident Grievances and Delayed Call Bell Response
Penalty
Summary
The facility failed to adequately address and resolve resident complaints and grievances, as evidenced by a review of facility policy, Resident Council meeting minutes, written grievances, and interviews with residents and staff. The facility's Grievance Policy requires that all grievances be considered and responded to in writing, with the Nursing Home Administrator (NHA) responsible for overseeing the process. Despite this, concerns about delayed call bell responses were repeatedly raised during Resident Council meetings and in written grievances. Specifically, one resident reported having to wait a long time for staff to respond to her call bell, and although the facility conducted call bell audits, the resident refused to sign the grievance as resolved, stating the issue persisted. The grievance was nonetheless marked as completed and resolved by the NHA. Interviews with two cognitively intact residents revealed ongoing issues with staff response times to call bells, with both reporting waits exceeding 30 minutes, particularly during the second and third shifts. One resident described experiencing a bowel incontinence episode due to delayed assistance. The NHA and Director of Nursing (DON) acknowledged that there was no documented evidence of completed resolutions for grievances raised during Resident Council meetings or for verbal complaints. These findings indicate that the facility did not follow its own grievance policy and failed to ensure prompt and effective resolution of resident complaints.
Resident Not Invited to Participate in Care Planning
Penalty
Summary
The facility failed to ensure that a resident was invited to participate in the development and implementation of her person-centered care plan. Clinical record review showed that the resident, who was admitted with vascular dementia and polyosteoarthritis, was cognitively intact as evidenced by a BIMS score of 15. Despite this, there was no documentation that the resident had been invited to participate in care planning or attend any care plan meetings. During an interview, the resident confirmed she had not been invited to participate in the care planning process or attend any care plan meetings. Further review of the clinical record revealed that no care plan conference had been conducted for the resident since November of the previous year, and there was no documentation of any invitation to participate in the care plan process. The DON and NHA confirmed the absence of such documentation.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to provide trauma-informed care for a resident who had been newly diagnosed with Post-Traumatic Stress Disorder (PTSD). A review of the resident's clinical record showed that the care plan in effect did not identify the resident's PTSD symptoms, triggers, or include resident-specific interventions to minimize triggers or prevent re-traumatization. The deficiency was confirmed through staff interview, which revealed the facility could not demonstrate that culturally competent, trauma-informed care was provided in accordance with professional standards of practice or that the resident's experiences and preferences were considered to eliminate or mitigate triggers related to PTSD.
Failure to Implement Pressure Ulcer Interventions Resulting in Wound Deterioration
Penalty
Summary
The facility failed to consistently implement planned interventions and provide necessary treatment and services to prevent the worsening of a pressure ulcer for a resident with significant cognitive impairment and multiple care needs. The resident was admitted with a Stage 2 pressure ulcer and was identified as being at moderate risk for pressure injuries, requiring total staff assistance for activities of daily living, including turning and repositioning. The care plan included specific interventions such as application of a protective barrier cream after incontinence episodes, regular turning and repositioning, weekly skin inspections, wound evaluations, and use of pressure-reducing devices. Despite these planned interventions and recommendations from the wound care consultant, documentation revealed that the recommended barrier cream was not ordered or applied as directed, and there was no consistent evidence that staff turned and repositioned the resident according to the care plan. Additionally, wound measurements and thorough evaluations were not consistently documented, making it difficult to assess the wound's progression or the effectiveness of interventions. The resident's pressure ulcer worsened from a Stage 2 to an unstageable wound, with a significant increase in size and the presence of slough, indicating a decline in skin integrity. Interviews with facility leadership confirmed the lack of evidence for implementation of the wound care consultant's recommendations, absence of a consistent turning and repositioning schedule, and insufficient evaluation of the wound's status. There was also no documentation of updated or intensified interventions in response to the worsening wound, contrary to facility policy and best practice guidelines for pressure ulcer management.
Failure to Conduct Nutritional Assessments and Monitor Weight Loss
Penalty
Summary
Maple Ridge Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding nutrition and hydration status maintenance. The facility failed to conduct a comprehensive nutritional assessment and monitor resident weights consistently and accurately, which led to a failure in identifying changes in nutritional status and implementing appropriate interventions for two residents. Resident CR1, admitted with dysphagia and other conditions, experienced significant weight loss shortly after admission. Despite a policy requiring a nutritional assessment within 72 hours, no such assessment was completed, and no interventions were initiated to address the resident's poor intake or weight loss. The resident was later transferred to the hospital in a severely malnourished and dehydrated state. Resident A1, who had a history of Barrett's esophagus and cancer, also experienced significant weight loss over a 30-day period. Although the resident's care plan included periodic weight monitoring and nutritional interventions, the facility failed to identify the weight loss in a timely manner and did not implement additional nutritional strategies. Observations revealed that the resident was not consistently provided with finger foods, an intervention included in the care plan to support the resident's independence and nutritional intake. Interviews with facility staff, including the RD and DON, confirmed the deficiencies in nutritional assessments and interventions. The facility lacked a qualified nutrition professional during a critical period, and the care-planned accommodations for Resident A1 were not consistently implemented. These failures contributed to the residents' deteriorating nutritional status and were not addressed in a timely manner, leading to significant health declines.
Plan Of Correction
Please note that the filing of this Plan of Correction does not constitute any admission to the alleged violations set for in the statement of deficiencies. This Plan of Correction is being filed as evidence of the facility's continued compliance with all applicable laws. 1. Resident CR1 was discharged from facility on 3/25/25. Resident Al therapy screen for eval placed 4/16/25. Resident Al reassessed by RD on 4/16/25, and a revised nutrition plan will be implemented if necessary. 2. A facility-wide audit will be completed on residents with nutritional risks over the past 14 days to determine if Initial Nutritional Assessment was completed within 72 hours and interventions are in place for those at risk. Will review residents over last 2 weeks who trigger for significant weight loss to ensure that proper interventions have been implemented. 3. Education on and review of facility policy provided to RD on timely completion of Initial Nutrition Assessment. Education provided to Nursing staff/RD to ensure that interventions put in place for residents who trigger at risk for weight or have significant weight loss. 4. DON/Designee will audit 10 random resident charts weekly x 4 weeks, then q 2 weeks x 2 months for timely completion of Initial Nutrition Assessment, RD interventions are in place for those at risk, and nutrition care plans are updated. Results of audits will be reviewed at monthly QAPI meeting.
Failure to Address Leaking Window Leads to Resident Injury
Penalty
Summary
The facility failed to provide an environment free from accident hazards, resulting in an incident involving a resident who slipped on a wet floor caused by a leaking window. The resident, who was cognitively intact and able to ambulate independently with a walker, reported twisting her ankle during the incident. The resident had previously informed her social worker about the leaking window, and a maintenance repair ticket was created. However, the facility did not address the issue until after the resident's slip, leading to a minor injury. The investigation revealed that the maintenance department had marked the repair order as completed, despite the window still leaking. The facility's Regional Maintenance Director confirmed that a quote for repairs was obtained only after the incident, with plans to address the issue during upcoming renovations. The Nursing Home Administrator acknowledged the facility's failure to respond promptly to the resident's concerns, which resulted in the accident and subsequent injury.
Failure to Address Resident Concerns and Involve in Fund Activities
Penalty
Summary
The facility failed to consider and act upon the views and recommendations raised during resident group meetings, as evidenced by the lack of response to concerns expressed by residents regarding vegetarian food options. During a resident council meeting, residents raised concerns about the availability of vegetarian hotdogs and bacon, but these concerns were not documented in the facility's grievance log, nor was there any evidence of a response in subsequent meeting minutes. Resident 22 specifically noted that her dietary preferences were not addressed, and the Nursing Home Administrator could not provide documentation of any actions taken to resolve these issues. Additionally, the facility did not involve residents in discussions or decision-making regarding resident fund activities. The resident council meeting minutes included a Treasurer's Report section, but there was no documented evidence of discussions about monetary activities or resident input. Residents interviewed were unaware of the purpose of the Treasurer's Report and did not recall any discussions about the resident fund. The Activities Director maintained financial records but could not provide evidence of resident involvement in fund activities. The Nursing Home Administrator acknowledged the facility's responsibility to consider resident views but could not provide documentation of such considerations.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement person-centered care plans for four residents, leading to deficiencies in addressing their specific medical needs and fall risks. Resident 8's care plan did not include the presence of a pacemaker or how to monitor it, despite the resident's diagnosis of heart failure and having a pacemaker. This oversight was confirmed by the Director of Nursing during the survey. Resident 7, diagnosed with chronic kidney disease, had a care plan indicating a risk for falls due to generalized weakness and poor balance. However, during an observation, it was found that the resident's bed was not in the lowest position as required by the care plan. Similarly, Resident 66, who had a history of falls and was at high risk for falling, was found without the call bell within reach, contrary to the care plan's interventions. This was confirmed by a Nurse Aide during an observation. Resident 64, diagnosed with osteoarthritis and at high risk for falls, had a care plan that included a bed clip alarm and keeping the bed in the lowest position. However, during an observation, it was noted that the bed alarm was not connected, and the bed was not in the lowest position. These deficiencies were acknowledged by the facility's Director of Nursing and Nursing Home Administrator, who confirmed the responsibility to ensure the implementation of person-centered care plans to mitigate fall risks.
Failure to Include Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and revised with the participation of the residents and their representatives for three residents. Resident 15, who was admitted with schizophrenia and cerebral infarction, was found to be cognitively intact with a BIMS score of 15. However, she reported not being invited to participate in recent care plan meetings and expressed interest in discussing her discharge options and goals. Similarly, Resident 31, with chronic kidney disease and chronic respiratory failure, and a BIMS score of 14, also indicated not being invited to participate in care plan meetings. Resident 49, diagnosed with atherosclerotic heart disease and a BIMS score of 15, reported not being included in care plan meetings and expressed a desire to attend. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure residents are given the opportunity to participate in the development and revision of their care plans. Despite the interdisciplinary team meeting quarterly to discuss and revise each resident's plan of care, there was no documented evidence that Residents 15, 31, and 49 were offered the opportunity to participate in their care plan meetings over the past six months. The DON and NHA acknowledged the necessity of including residents in the care planning process to the greatest extent possible.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to timely identify and assess a significant weight loss in Resident 22, who was admitted with conditions including GERD, COPD, and cerebral atherosclerosis. Despite being cognitively intact and aware of her weight loss, the resident reported that staff had not discussed her weight loss or dietary preferences with her. The facility's policy required monitoring and intervention for weight changes, but there was no documented evidence of a nutritional assessment or notification to the resident or physician about the weight loss. The resident's weight dropped below her ideal body weight range, yet no reassessment or care plan revision was conducted. Additionally, the facility did not implement a planned nutrition intervention for Resident 142, who experienced a significant weight loss of 13.1% over a short period. The resident, diagnosed with subarachnoid hemorrhage, diabetes, and dysphagia, was ordered a Healthshake with meals to address the weight loss. However, during a survey, it was observed that the Healthshake was not provided as ordered, and the resident's meal ticket did not reflect this intervention. The registered dietitian confirmed the oversight, indicating a failure to follow the physician's order. The Director of Nursing confirmed the facility's failure to timely identify and address the weight loss issues for both residents. The lack of timely intervention and communication with the residents and their physicians contributed to the deficiencies noted in the survey. The facility did not act upon the significant weight changes, nor did it develop and implement necessary nutritional support measures to maintain the residents' nutritional status.
Failure to Provide Adequate Vegetarian Menu for Resident
Penalty
Summary
The facility failed to ensure a pre-planned nutritionally adequate menu for a resident, identified as Resident 22, who was admitted with diagnoses including gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), and cerebral atherosclerosis. The resident was cognitively intact and had specific dietary preferences, being a vegetarian who also consumed fish and seafood. Despite these preferences being noted in the resident's nutritional risk assessment, they were not adequately reflected in the resident's profile or plan of care. The facility's diet manual included a vegetarian diet, but there was no planned menu for such a diet at the time of the survey. Resident 22 expressed dissatisfaction with the food choices available, specifically requesting vegetarian options like veggie hot dogs and veggie bacon during a Resident Council Meeting. However, there was no follow-up or resolution to these concerns in subsequent meetings. The resident also reported significant weight loss over a short period, which was confirmed by the Nursing Home Administrator. The facility did not engage with the resident regarding her weight loss or dietary preferences, leading to a failure in meeting her nutritional needs and preferences.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, which is a violation of their policy prohibiting such acts. The incident involved Resident 39, who is severely cognitively impaired with a BIMS score of 2, indicating severe cognitive impairment. Resident 39 was subjected to physical abuse by Resident CR4, who is cognitively intact with a BIMS score of 14. Resident CR4 has a history of behaviors related to dementia, including agitation and aggression, which were documented in his care plan. On April 19, 2024, Resident CR4 was observed yelling at Resident 39 in the dining room. Despite staff attempts to redirect Resident CR4, he continued to be aggressive. Witnesses reported that Resident CR4 punched and kicked Resident 39 and attempted to throw coffee on him. A progress note confirmed that Resident CR4 punched Resident 39 in the face and threw a glass of orange juice at him, stating aggressive intentions. Resident CR4 was subsequently sent to a community hospital due to his combative behavior. The facility's Nursing Home Administrator and Director of Nursing confirmed the incident and acknowledged the failure to prevent the abuse. The facility's policy clearly states that residents should be free from abuse by anyone, including other residents. Despite interventions in place for Resident CR4's aggressive behaviors, the facility did not effectively prevent the physical abuse of Resident 39, highlighting a deficiency in ensuring resident safety.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set Assessment (MDS) accurately reflected the status of a resident. Specifically, the admission MDS assessment for Resident 142 incorrectly recorded the resident's weight in Section K0200. The assessment indicated a weight of 116 pounds, whereas the resident's weight record showed a weight of 115.6 pounds on the date of admission and 108.6 pounds on the most recent date prior to the MDS assessment. This discrepancy was confirmed during an interview with the facility's registered dietitian, who acknowledged that the MDS should have been coded to reflect the most recent weight prior to the assessment date.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on July 18, 2024. During observations at 8 AM and again at 12 PM, it was noted that the facility's two large trash dumpsters, which contained bags of garbage and trash, were not covered. The lids to both garbage dumpsters were observed to be open during each observation. In an interview conducted on the same day at approximately 2:30 PM, the Nursing Home Administrator confirmed that the dumpster lids should be closed, indicating a failure to adhere to proper waste management protocols.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for residents on the second, third, and fourth floors, as observed during a survey. On the second floor, a black substance was found on the air vent above the nurses' station, and the community television and dining area had a sticky floor with dried liquid stains and food crumbs in the refrigerator. The counter was littered with liquid stains, food, and paper debris, and the microwave contained dried food and liquid stains. The garbage can lacked a lid and was filled with trash. The second-floor hallway had dirt, debris, and black scuff marks, and resident rooms, except for one, had floors coated with a thick brown residue and black scuff marks. On the third floor, liquid stains, black scuff marks, and gouges were observed on the hallway walls, and damaged floor tiles were found under the bed legs in a resident room. A thick brown substance accumulated along the baseboard of the dining/activity room. On the fourth floor, a wheelchair and broda chair were stained with dried substances, and the floor baseboard had a thick black substance. Damaged floor tiles were also observed under the bed legs in a resident room, and the hallway floor had dirt, debris, and black scuff marks. The resident rooms on this floor had floors covered with a thick brown residue and black scuff marks. The Nursing Home Administrator confirmed that the environment and equipment were expected to be clean and sanitary.
Failure to Ensure Informed Consent for Medicare Disenrollment
Penalty
Summary
The facility failed to develop and implement policies and procedures to protect residents from being disenrolled from their Medicare health plans without their informed consent. This deficiency was identified through a review of clinical records, CMS guidance, facility documentation, and staff interviews. The facility disenrolled seven residents from their Medicare Advantage plans without ensuring that the residents or their representatives fully understood the implications of such changes. The residents affected included those with various medical conditions such as diabetes, bipolar disorder, cognitive communication deficits, and dementia. The review revealed that the facility's Business Office Manager (BOM) had discussions with residents about transitioning to traditional Medicare, citing potential benefits such as increased therapy time and reduced need for authorizations. However, there was no evidence that the residents were provided with written and verbal explanations of the risks associated with disenrollment, nor was there documentation of the residents' cognitive ability to understand these changes. In some cases, the residents were noted to be cognitively intact, while others had moderate cognitive impairments, raising concerns about their capacity to make informed decisions. Interviews with the Nursing Home Administrator and BOM confirmed that the facility lacked policies and procedures for assisting residents with Medicare plan changes. This oversight led to the facility initiating changes in Medicare health plans without proper documentation of the residents' requests or consent. The deficiency was cited as past non-compliance, indicating that the facility had not adhered to CMS guidelines and resident rights regarding Medicare health plan enrollment and disenrollment.
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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