Masonic Village At Elizabethtown
Inspection history, citations, penalties and survey trends for this long-term care facility in Elizabethtown, Pennsylvania.
- Location
- One Masonic Drive, Elizabethtown, Pennsylvania 17022
- CMS Provider Number
- 395560
- Inspections on file
- 20
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Masonic Village At Elizabethtown during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and fragile skin was found to have a sizable bruise on the right axilla and upper arm, with the resident unable to explain its cause. Facility policy required complete incident documentation, including detailed circumstances and staff statements, but only one staff statement was obtained, documenting that a nursing assistant had reported the bruise to another employee. No additional statements were collected from staff who had provided care before the bruise was identified, and no further investigation was conducted because licensed staff and the DON believed the bruise location was consistent with contact from a bed enabler.
A resident with severe cognitive impairment and multiple medical conditions fell from a whirlpool chair and sustained injuries after a nurse aide failed to properly secure the chair's safety belt and locking bars. The resident required maximal assistance for bathing and transfers, and the aide had previously received training on whirlpool safety. Facility staff confirmed that the safety mechanisms were not engaged at the time of the incident, leading to the substantiated finding of neglect.
The facility failed to maintain the fire resistance rating of exit stairtower enclosures, affecting two smoke compartments. Observations revealed that doors to the Clinics South Stairtower and West Stairtower did not positively latch within their frames, compromising the fire resistance rating. These issues were confirmed by the Assistant Director of Facilities and Grounds.
The facility did not conduct functional testing of smoke detectors in three of 43 smoke compartments within the past year. Specific rooms affected include 2981, 2998, 3918, 4917, 4965, and 4966. The Assistant Director of Facilities and Grounds confirmed the oversight.
The facility did not maintain the automatic sprinkler system as required, with an electrical cable zip-tied to the sprinkler piping in the 4th floor IT Mechanical Room, affecting one smoke compartment.
The facility failed to maintain unobstructed access to a portable fire extinguisher on the Washington 3rd floor, as it was blocked by a wheelchair and a chair. This was confirmed by the Assistant Director of Facilities and Grounds, highlighting a deficiency in maintaining clear access to fire safety equipment.
The facility failed to ensure that the Washington 3rd floor Supply Room door, next to a resident room, positively latched within the door frame. This deficiency was observed and confirmed by the Assistant Director of Facilities and Grounds, affecting one of the 43 smoke compartments in the facility.
The facility failed to ensure the unobstructed closing of smoke barrier doors, as observed on the Roosevelt 2nd floor near a resident room, where a patient lift obstructed the door. This deficiency was confirmed by the Assistant Director of Facilities and Grounds, affecting two of 43 smoke compartments.
A deficiency was identified when a broken electrical outlet was observed in the corridor on the Roosevelt 3rd floor, between a resident room and the Laundromat. The Assistant Director of Facilities and Grounds confirmed the compromised condition of the receptacle.
The facility failed to maintain the fire resistance of linen chute enclosure doors, affecting two smoke compartments. Observations revealed that the linen chute doors on the 4th and 2nd floors of the Roosevelt building did not positively latch within their frames. This deficiency was confirmed by the Assistant Director of Facilities and Grounds.
The facility failed to monitor the use of surge suppressors and extension cords, leading to deficiencies in three smoke compartments. High-draw appliances were improperly plugged into a surge suppressor in a conference room, and daisy-chained surge suppressors were found at a care base. Additionally, an extension cord was supplying power to a surge suppressor in a provider's room, all confirmed by the Assistant Director of Facilities and Grounds.
The facility failed to maintain accurate MDS assessments for two residents. One resident's MDS inaccurately reported falls with major injury, while another's MDS incorrectly indicated significant weight changes. These inaccuracies were confirmed by the DON, highlighting deficiencies in clinical record maintenance.
A resident with anxiety and emotional distress expressed a desire to die on multiple occasions, yet did not receive a behavioral health evaluation until over a month after it was ordered. The delay in providing necessary mental health services was confirmed by the DON, highlighting a deficiency in timely care.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. Facility policy on Occurrence Prevention, Documentation, and Reporting, last reviewed July 21, 2026, required that all sections of the incident report be completed to the best of staff’s ability, including details surrounding the incident and statements from staff or individuals involved in the resident’s care or the situation prior to or during the incident, as well as those involved in the incident response. The resident’s quarterly MDS dated September 16, 2025, showed a BIMS score of 9, indicating moderate cognitive impairment. On October 6, 2025, progress notes documented a bruise to the right front axilla measuring 3.56 cm by 4.34 cm, and an additional note the same day documented that an LPN observed a dark bruise to the resident’s right upper arm, with the resident unsure how the bruise occurred. Review of facility documentation showed that only one staff statement was obtained, from Employee E4, indicating that a nursing assistant from the outgoing shift had reported the bruise to Employee E4. No other statements were obtained from staff who had provided care prior to identification of the bruise. The documentation also noted that the resident was independent with self-propelling a wheelchair, able to move upper and lower extremities independently, and had thin, fragile skin that increased the risk for skin injury. In an interview on January 23, 2025, licensed staff (Employee E3) and the Director of Nursing confirmed that no additional staff statements were collected and that no further investigation was conducted because the bruise’s location was considered consistent with contact from a bed enabler.
Failure to Secure Safety Mechanisms During Bathing Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when a nurse aide failed to properly secure the safety mechanisms of a whirlpool chair, resulting in a resident falling forward from the chair and sustaining multiple injuries. The resident, who had severe cognitive impairment and required maximal assistance for bathing and transfers, was found face down and wet in the empty whirlpool tub by nursing staff. The safety features of the chair, including a seatbelt and locking safety bars, were not properly engaged at the time of the incident, as confirmed by a re-enactment conducted by licensed staff. The nurse aide involved was unable to provide a clear account of the events leading up to the fall and only stated that the incident happened quickly. The resident involved had significant medical conditions, including Alzheimer's disease, dementia with psychotic disturbances, anxiety, psychosis, chronic atrial fibrillation, and chronic heart failure. The resident's clinical record indicated a need for substantial or maximal assistance with bathing and transfers, and a BIMS score reflecting severe cognitive impairment and inability to direct care. After the fall, the resident was assessed and found to have a hematoma to the forehead, abrasions to the left knee and fifth toe, and bruises to both calves, but did not report pain or discomfort and did not require pain medication. Facility documentation and staff interviews confirmed that the nurse aide had received training on whirlpool safety and had demonstrated the required technique prior to the incident. However, the investigation determined that the aide failed to follow established procedures and the resident's care plan, resulting in the resident's fall and injuries. The facility substantiated the occurrence of neglect based on these findings.
Failure to Maintain Fire Resistance Rating of Stairtower Enclosures
Penalty
Summary
The facility failed to maintain the fire resistance rating of exit stairtower enclosures, affecting two of 43 smoke compartments. On December 16, 2024, an observation revealed that the door to the Clinics South Stairtower on the 4th floor of the Roosevelt Building did not positively latch within the door frame. This issue was confirmed through an interview with the Assistant Director of Facilities and Grounds. Similarly, on December 17, 2024, it was observed that the door to the West Stairtower on the 2nd floor of the Clinics also failed to positively latch. This was again confirmed by the Assistant Director of Facilities and Grounds, indicating a compromised fire resistance rating of the stairtower.
Plan Of Correction
1. The door to the 4th floor door to the Clinics and Clinic's 2nd floor was repaired on 12/18/2024 to ensure positive latching within the door frame. 2. Maintenance staff will be educated that stair tower doors will be maintained to ensure positive latching within the door frame. General education to staff to report doors not latching for appropriate work orders. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that stair tower doors will positively latch within the door frame. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Failure to Test Smoke Detectors
Penalty
Summary
The facility failed to conduct functional testing of smoke detectors within the previous twelve months, affecting three out of 43 smoke compartments. This deficiency was identified during a document review and interview conducted on December 16, 2024. The specific rooms where smoke detectors were not functionally inspected include rooms 2981, 2998, 3918, 4917, 4965, and 4966. The Assistant Director of Facilities and Grounds confirmed during the interview that the smoke detectors in these rooms had not been tested within the required timeframe.
Plan Of Correction
1. The smoke detectors were functionally inspected in the previous twelve months, in the following rooms on 07/03/2024 and placed in the Life Safety book: a) 2981; b) 2998; c) 3918; d) 4917; e) 4965; f) 4966; 2. Maintenance staff will be educated that smoke detectors will be functionally inspected every twelve months. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building to ensure that smoke detectors are functionally inspected every twelve months as well as the Life Safety book is reviewed semi-annually. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Improper Maintenance of Sprinkler System
Penalty
Summary
The facility failed to maintain the automatic sprinkler protection system in accordance with NFPA 25 standards. During an observation on December 17, 2024, at 10:47 AM, it was discovered that an electrical cable was improperly zip-tied to the sprinkler piping within the Clinics 4th floor IT Mechanical Room. This deficiency affected one of the 43 smoke compartments within the facility, indicating a lapse in maintaining the sprinkler system free from extraneous weight.
Plan Of Correction
1. The electrical cable zip-tied to the sprinkler piping within Clinic's 4th floor IT Mechanical Room was corrected on 12/19/2024. 2. Maintenance staff will be educated that the automatic sprinkler protection system will be free of extraneous weight. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that the automatic sprinkler protection system will be free of extraneous weight. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Obstructed Access to Fire Extinguisher
Penalty
Summary
The facility failed to maintain unobstructed access to portable fire extinguishers, as required by NFPA 101 and NFPA 10 standards. During an observation on December 17, 2024, at 10:33 AM, it was noted that the portable fire extinguisher on the Washington 3rd floor, located next to the East Mini Care Base, was obstructed by a wheelchair and a chair. This obstruction was confirmed in an interview with the Assistant Director of Facilities and Grounds at the same time, indicating a lapse in ensuring clear access to essential fire safety equipment within one of the 43 smoke compartments in the facility.
Plan Of Correction
1. The Washington 3rd floor portable fire extinguisher, located next to the East Mini Care Base, obstructed by a wheelchair and a chair was corrected on 12/17/2024. 2. Staff will be educated in maintaining unobstructed portable fire extinguishers. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that portable fire extinguishers are unobstructed. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain the corridor doors to positively latch, which is a requirement for ensuring the safety and security of the smoke compartments. During an observation on December 17, 2024, at 9:49 AM, it was noted that the door to the Washington 3rd floor Supply Room, located next to Resident Room 3911, did not positively latch within the door frame. This deficiency affects one of the 43 smoke compartments within the facility. The Assistant Director of Facilities and Grounds confirmed during an interview at the same time and date that the corridor door did not latch properly. This failure to maintain the door's positive latching mechanism is a violation of the regulations that require doors protecting corridor openings to resist the passage of smoke and to have positive latching hardware, especially in areas that are not fully sprinklered.
Plan Of Correction
1. The Washington 3rd Supply Room door, next to Resident Room 3911, was corrected on 12/18/2024 to ensure that it positively latched within the door frame. 2. Maintenance staff will be educated that corridor doors protecting corridor openings in other than required enclosures of vertical openings, exits, hazardous areas will be maintained to ensure positive latching within the door frame. General staff education to initiate work orders when doors are not latching appropriately. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that corridor doors protecting corridor openings in other than required enclosures of vertical openings, exits, hazardous areas will be maintained to ensure positive latching within the door frame. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Obstructed Smoke Barrier Door Due to Patient Lift
Penalty
Summary
The facility failed to maintain the unobstructed closing of smoke barrier doors, which is a requirement for ensuring fire safety within the building. During an observation, it was noted that the smoke barrier door on the Roosevelt 2nd floor, near Resident Room 2648, was obstructed by a patient lift, preventing it from closing properly. This deficiency was confirmed through an interview with the Assistant Director of Facilities and Grounds, who acknowledged the obstruction of the smoke barrier door. This issue affected two out of 43 smoke compartments within the facility.
Plan Of Correction
1. The Roosevelt 2nd floor smoke barrier door, by Resident Room 2648, obstructed from closing by a patient lift was corrected on 12/16/2024. 2. Staff will be educated in maintaining the unobstructed closing of smoke barrier doors. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that smoke barrier doors are unobstructed. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Electrical Receptacle Integrity Deficiency
Penalty
Summary
The facility failed to maintain the physical integrity of an electrical receptacle, which was identified as a deficiency during a survey. On December 16, 2024, at 1:06 PM, an observation revealed that an electrical outlet located in the corridor on the Roosevelt 3rd floor, between Resident Room 3801 and the Laundromat, was physically broken. This finding was confirmed through an interview with the Assistant Director of Facilities and Grounds, who acknowledged the compromised condition of the electrical receptacle.
Plan Of Correction
1. The Roosevelt 3rd floor outlet, located within the corridor, between Resident Room 3801 and the Laundry, was replaced on 12/18/2024. 2. Maintenance staff will be educated in maintaining the physical integrity of electrical receptacles. Staff education will include initiating work orders when receptacles are physically broken. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure the physical integrity of electrical receptacles. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Linen Chute Doors Fail to Latch Properly
Penalty
Summary
The facility failed to maintain the fire resistance of linen chute enclosure doors, affecting two smoke compartments. During an observation on December 16, 2024, it was noted that the linen chute doors on the 4th and 2nd floors of the Roosevelt building did not positively latch within their frames. This deficiency was confirmed through interviews with the Assistant Director of Facilities and Grounds, who acknowledged the compromised fire resistance rating of the linen chute enclosures.
Plan Of Correction
1. (Observation 1) -- The Roosevelt 4th floor Linen Chute door that failed to positively latch was corrected on 12/18/2024. (Observation 2) -- The Roosevelt 2nd floor Linen Chute door that failed to positively latch was corrected on 12/18/2024. 2. Maintenance staff will be educated in maintaining the fire resistance rating for Linen Chute doors. Staff has been educated to initiate a work order when a linen chute door is not latching appropriately. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure the fire resistance rating for Linen Chute doors. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Improper Use of Surge Suppressors and Extension Cords
Penalty
Summary
The facility failed to properly monitor the use of surge suppressors and extension cords, leading to deficiencies in three of the 43 smoke compartments. On December 16, 2024, a surge suppressor was observed supplying electrical power to two refrigerators and a coffee machine in the Roosevelt 2nd floor West Conference Room. This setup was confirmed by the Assistant Director of Facilities and Grounds, indicating that high-draw appliances were improperly plugged into a surge suppressor. Further observations on December 17, 2024, revealed additional issues. A surge suppressor was found supplying power to another surge suppressor at the Washington 3 Care Base, confirmed by the Assistant Director of Facilities and Grounds as a daisy-chained setup. Additionally, an extension cord was supplying power to a surge suppressor in the Clinics 3rd floor LGH Providers Room, which was also confirmed by the Assistant Director. These findings indicate a failure to adhere to proper electrical safety standards as outlined by NFPA guidelines.
Plan Of Correction
1. (Observation 1) The surge suppressor supplying electrical power to two refrigerators and a coffee machine, within the Roosevelt 2nd floor West Conference Room, was corrected on 12/26/2024. Staff will be educated on not having high draw appliances plugged in to surge suppressors. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that high draw appliances are not plugged in to surge suppressors. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment. (Observation 2) The surge suppressor supplying power to another surge suppressor, at the Washington Care Base was corrected on 12/16/2024. Staff will be educated on not using a surge suppressor to supply electrical power to another surge suppressor. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that a surge suppressor is not used to supply electrical power to another surge suppressor. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment. (Observation 3) The extension cord supplying electrical power to a surge suppressor, within the Clinic's 3rd floor office was corrected on 12/17/2024. Staff will be educated on not using extension cords to supply electrical power to a surge suppressor. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that an extension cord is not used to supply electrical power to a surge suppressor. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to maintain accurate assessments for two residents, leading to deficiencies in their clinical records. For Resident 97, the Quarterly Minimum Data Set (MDS) inaccurately indicated that the resident had experienced two falls with major injury since admission or the prior assessment. However, a review of the clinical record revealed no evidence of such falls. This discrepancy was confirmed by the Director of Nursing, who acknowledged the inaccurate coding of the MDS. Similarly, Resident 108's Quarterly MDS inaccurately reported both significant weight loss and gain. Upon reviewing the clinical record and weight summaries, no evidence of significant weight loss was found. The Director of Nursing confirmed the inaccuracy in the MDS coding for Resident 108 as well. These inaccuracies in the MDS assessments were identified as deficiencies under the relevant Pennsylvania Code sections for clinical records and nursing services.
Plan Of Correction
1. R97 had no evidence of falls with major injury - her MDS was corrected during the survey. R108's MDS has been corrected. 2. November's QM Report was reviewed for residents who had been coded as having had weight loss and falls with major injury. 3. The RNAC and Nutritional Service teams have been re-educated on accurate MDS. 4. Weekly audits will be conducted by the RNAC manager and Nutritional Service manager / designee to confirm accurate MDS in weight loss and falls with major injury for (4) weeks. These audits will be reviewed, trended, and determined for the need for future audits deemed by the QAPI team.
Delay in Behavioral Health Services for Resident
Penalty
Summary
The facility failed to provide timely behavioral health services to a resident with a history of anxiety and emotional distress. The resident, who was admitted with diagnoses including anxiety, expressed feelings of wanting to die on multiple occasions, as documented in nurse's notes on August 14 and October 4, 2024. Despite these expressions of distress, the resident did not receive a behavioral health evaluation until November 27, 2024, which was over a month after the physician ordered a psychology evaluation on October 18, 2024. The delay in obtaining the psychology evaluation was confirmed by the Director of Nursing on December 5, 2024. The resident's condition, characterized by statements of not wanting to live and difficulty getting out of bed, was acknowledged by the physician, who noted the resident's preference for conversation over medication. However, the lack of timely intervention from behavioral health services represents a deficiency in the facility's obligation to provide necessary care and services to address the resident's mental health needs.
Plan Of Correction
1. R97 has been seen by the psychologist. 2. A comprehensive review has been conducted for any upcoming psychology appointments with appropriate appointment dates. 3. The clinic staff has been re-educated on scheduling Behavioral Health appointments in an appropriate time frame. 4. Weekly audits will be conducted by the director of ancillary services to confirm appropriate time frames with Behavioral Health appointments for (4) weeks. These audits will be reviewed, trended, and determined for the need for future audits deemed by the QAPI team.
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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