Maybrook Hills Rehabilitation And Healthcare Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Altoona, Pennsylvania.
- Location
- 301 Valley View Boulevard, Altoona, Pennsylvania 16602
- CMS Provider Number
- 395514
- Inspections on file
- 36
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Maybrook Hills Rehabilitation And Healthcare Cente during CMS and state inspections, most recent first.
Comprehensive MDS assessments and Care Area Assessment processes were not completed within the required time frames for multiple residents, with assessments being finalized several days late. The RNAC confirmed that these delays occurred, as identified through review of clinical records and staff interviews.
Quarterly MDS assessments were not completed within the required time frames for multiple residents. Review of clinical records and staff interviews confirmed that several MDS assessments were either delayed or missing, in violation of regulatory requirements for timely resident assessment documentation.
The facility did not transmit MDS assessments to the CMS QIES ASAP System within the required 14-day period for three residents. Quarterly MDS assessments for these residents were submitted late, with delays ranging from several weeks to over six months, as confirmed by the RNAC.
Surveyors found that several residents' MDS assessments were inaccurately coded, failing to reflect the administration of medications such as antidepressants, insulin, anticonvulsants, diuretics, opioids, and antibiotics, despite physician orders and documentation in the MARs. The errors were confirmed by the RN Assessment Coordinator after review of clinical records and staff interviews.
Three residents did not receive medications according to physician orders, including failure to administer constipation treatments as prescribed, not assessing vital signs before giving antihypertensive medication, and administering blood pressure medication despite parameters to hold. The DON confirmed these lapses in medication administration.
A resident with a history of UTIs and sepsis, who was receiving daily amoxicillin and Methenamine Hippurate for UTI prevention, did not have a comprehensive care plan addressing their specific needs related to ongoing antibiotic use. The absence of this care plan was confirmed by the DON.
An opened multidose vial of Aplisol solution used for TB skin testing was found undated in a medication storage refrigerator on one unit. Facility policy and manufacturer instructions require opened vials to be dated and discarded after 30 days. An LPN and the DON both confirmed the vial was not dated as required.
A resident with unstageable pressure ulcers did not have Enhanced Barrier Precautions (EBP) implemented as required by infection control guidelines. There was no signage or PPE available in the resident's room, and EBP was not ordered or care planned until several days after the wounds were identified. Staff confirmed that EBP was missed for this resident, resulting in a deficiency for not following infection prevention protocols.
A resident with multiple fractures and cognitive intactness received PRN pain medications outside of physician-ordered parameters. Oxycodone was administered for mild pain and Tylenol for moderate pain, contrary to the specified pain level guidelines. The DON confirmed the medications were not given as ordered.
A resident with an indwelling catheter was not provided care in accordance with Enhanced Barrier Precautions, as an LPN failed to use gloves or a gown during medication administration, including handling spilled pills and applying medicated patches. The LPN was unaware of the resident's EBP status and did not follow facility policy prohibiting direct contact with medications, as confirmed by the DON.
The facility failed to follow proper infection control practices for handling soiled linen for two residents. A nurse aide was observed carrying soiled laundry with bare hands, and two other aides threw soiled items on the floor during care. The facility's policy requires gloves and proper disposal of soiled items, which was confirmed by the Nursing Home Administrator.
The facility failed to complete comprehensive admission and annual MDS assessments within the required time frame for four residents. The assessments were completed 15, 18, 21, and 19 days after admission, exceeding the 14-day requirement. This delay was confirmed through staff interviews.
The facility failed to complete quarterly MDS assessments within the required timeframe for four residents. The assessments were completed beyond the 14-day requirement after the ARD, as confirmed by the Nursing Home Administrator.
The facility failed to accurately complete MDS assessments for several residents, omitting critical information such as the administration of antibiotics, use of medical devices, and provision of hospice care. These inaccuracies were confirmed by the Nursing Home Administrator.
The facility failed to administer medications as ordered for two residents. One resident did not receive Lasix and Potassium despite weight increases and was given Midodrine when blood pressure was too high. Another resident missed doses of Insulin Aspart, Renvela, and Insulin Glargine due to being at dialysis, with no administration upon return. These issues were confirmed by the Assistant DON.
The facility failed to administer enteral feedings according to physician's orders for two residents. One resident did not receive Jevity 1.5 when her meal intake was below 50%, and received it when her intake was above 50%. Another resident did not receive a 240 ml bolus of Isosource 1.5 when her intake was below 50%, and received it when her intake was above 50%. Additionally, staff did not check residuals before administering tube feedings, as required by policy.
The facility failed to follow infection control practices, including not cleaning a blood pressure cuff between residents and not using Enhanced Barrier Precautions (EBP) for residents with indwelling devices. Observations revealed staff handling soiled linen without gloves and providing care without appropriate PPE, as confirmed by staff interviews.
The facility failed to allow residents to dine in the main dining room due to a broken air conditioner, affecting their right to make choices about significant aspects of their lives. Despite residents' expressed desires, the dining room remained closed without alternative measures, as confirmed by staff and residents.
The facility failed to provide timely and accurate notices regarding the end of Medicare coverage for two residents. One resident did not receive a timely SNF Beneficiary Protection Notification Review form or ABN, and the ABN lacked details on coverage and costs. Another resident received an incomplete ABN notice. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to provide written notices to residents and their representatives regarding hospital transfers for six residents, including those with conditions like sepsis, cancer, and acute kidney injury. This deficiency was confirmed through record reviews and staff interviews, revealing a lack of compliance with notification requirements.
The facility failed to complete timely significant change MDS assessments for two residents admitted to hospice care. One resident with an end-stage illness and another with COPD did not have their assessments completed within the required time frame, as confirmed by the Nursing Home Administrator.
A facility failed to develop a care plan for a resident with cognitive impairment who required a CPAP machine for sleep apnea. Despite physician's orders and documented use of the CPAP, no care plan was in place to address this need, as confirmed by the Assistant DON.
The facility failed to update care plans for two residents, leading to discrepancies in documented care needs. One resident's care plan inaccurately reflected anticoagulant therapy, while another's tube feeding regimen was not updated to match physician's orders. These issues were confirmed through staff interviews and record reviews.
A resident with a history of falls and cognitive impairment experienced two falls without new interventions being implemented to prevent future incidents. Despite the resident's need for extensive assistance and the presence of a bed alarm during one fall, the facility did not document any new preventive measures, as confirmed by staff interviews.
A facility failed to provide trauma-informed care for a resident with PTSD, as evidenced by the absence of documented triggers and preventive measures in the care plan. The resident, who was moderately cognitively impaired and diagnosed with depression and PTSD, did not have a trauma-informed care assessment completed, as confirmed by the Assistant Director of Nursing.
The facility failed to conduct annual performance evaluations for three nurse aides as required. Personnel files showed that evaluations were not completed according to hire dates, and the Nursing Home Administrator confirmed the absence of these evaluations, indicating non-compliance with staff performance review protocols.
The facility failed to secure and label medications properly. A controlled medication was found unsecured and unlabeled in a medication cart, and another resident's medication was administered incorrectly due to outdated labeling. The facility's policies on medication security and labeling were not followed.
The facility failed to maintain sanitary conditions in the kitchen as dietary workers did not comply with the policy requiring beard and hair nets. Several workers were observed without proper beard and hair coverings during food preparation, which was confirmed by the Dietary Manager and Nursing Home Administrator.
A facility failed to document daily weights for a resident undergoing hemodialysis, as required by their care plan and physician's order. Despite obtaining the weights, staff did not have a designated area in the clinical record to chart them, leading to incomplete documentation.
A facility failed to obtain necessary hospice documentation for a resident with dementia receiving hospice care. Despite a care plan indicating hospice services, there was no evidence of obtaining the current hospice recertification of terminal illness or plan of care for the specified certification period, as confirmed by the Nursing Home Administrator.
The facility's QAPI committee failed to address repeated deficiencies in comprehensive assessments, care plans, medication management, food service, and medical records, despite having plans of correction involving audits and committee reviews.
A resident with heart failure did not receive prescribed Torsemide due to a transcription error by a nurse, leading to fluid overload and severe swelling. The error occurred when the nurse failed to update the medical record with the physician's order.
A resident with heart failure did not receive prescribed Torsemide due to a nurse's failure to transcribe a physician's order into the medical record. This oversight led to the resident missing doses from late May to early June, confirmed by the DON.
A facility failed to administer oxygen therapy as ordered by a physician for a resident. The resident, who was cognitively intact and required oxygen for hypoxia, was observed receiving oxygen at a flow rate of five lpm instead of the prescribed two lpm. This discrepancy was confirmed by an LPN during an interview.
A cognitively impaired resident reported verbal abuse by a family member, but the facility failed to report the allegation to the Department of Health. Despite the resident's distress and fear, the Director of Nursing did not report the incident, citing lack of direct witness accounts and the resident's cognitive impairment.
The facility did not develop comprehensive care plans for two residents. One resident with a skin tear on the left shin did not have an updated care plan reflecting wound clinic recommendations. Another resident with End Stage Renal Disease requiring dialysis lacked a care plan for managing the dialysis catheter and process. The DON confirmed the absence of these care plans.
A facility failed to obtain necessary physician's orders for a resident with ESRD requiring dialysis. The resident received dialysis treatments without documented orders, and there were no orders for the care and monitoring of the dialysis catheter or emergency equipment at the bedside. This was confirmed by the DON.
The facility failed to accurately complete MDS assessments for two residents, resulting in incorrect documentation of hypoglycemic medication administration and omission of oxygen therapy, non-invasive mechanical ventilation, and dialysis. Physician's orders and treatment records confirmed these treatments, but the MDS assessments did not reflect them, as confirmed by the RNAC.
The facility failed to adhere to wound care recommendations for a resident, continuing an outdated treatment alongside a new one. Additionally, staff did not notify a physician about another resident's elevated blood sugar levels as required. These deficiencies were confirmed by the DON.
The facility failed to maintain complete and accurate clinical records for two residents. One resident experienced an unwitnessed fall, and although assessed, the documentation was not included in the clinical record. Another resident frequently rang the call bell, but this behavior was not documented, leading to the use of a non-working call bell. The DON confirmed these documentation lapses.
Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments and Care Area Assessment (CAA) processes within the required time frames for 11 out of 65 residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments and CAA completion dates must be no later than 13 days after admission, and comprehensive MDS assessments must be completed at least every 92 days. Review of clinical records, the CMS MDS validation report, and staff interviews confirmed that multiple MDS assessments were completed several days past the required deadlines for the identified residents. Specific examples include assessments being completed between 1 and 15 days late for various residents. The Registered Nurse Assessment Coordinator (RNAC) confirmed during an interview that these comprehensive MDS assessments were not completed within the mandated time frames. This deficiency was identified through review of clinical documentation and staff interviews, as well as validation against regulatory requirements.
Failure to Complete Quarterly MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frames for 15 out of 65 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly MDS assessment must have an assessment reference date (ARD) no more than 92 days after the ARD of the most recent assessment, and the assessment must be completed within 14 calendar days after the ARD. Review of clinical records revealed that for multiple residents, either the quarterly or comprehensive MDS assessments were not completed within these mandated time frames. Specific examples included assessments with ARDs that were not followed by timely completion, as well as instances where no prior assessment was completed within the required 92-day period. Interviews with the Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS assessments for the identified residents were not completed as required. The deficiency was identified through review of the RAI Manual, clinical records, and staff interviews, and it was determined that the facility did not comply with the regulatory requirements for timely completion of resident assessments as outlined in 28 Pa. Code 211.5(f) regarding clinical records.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for three residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, comprehensive MDS assessments must be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments must be submitted within 14 days of the MDS Completion Date. Review of the MDS validation report from iQIES revealed that three residents had quarterly MDS assessments that were submitted late. Specifically, one resident's quarterly MDS assessment was completed but not submitted until over six months later, another resident's assessment was submitted more than three weeks after completion, and a third resident's assessment was submitted nearly a month late. An interview with the Registered Nurse Assessment Coordinator (RNAC) confirmed that these MDS assessments were not completed and transmitted within the required timeframes.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for six residents, as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, the assessments did not accurately reflect the medications administered to the residents during the seven-day assessment periods. For example, residents who received antidepressants, insulin, anticonvulsants, diuretics, opioids, and antibiotics according to physician orders and Medication Administration Records (MARs) were not properly coded in the corresponding MDS sections. These discrepancies were identified through a review of clinical records, MARs, and staff interviews. The affected residents had documented orders and received medications such as Venlafaxine, Escitalopram, Keppra, Insulin Glargine, Mirtazapine, Lasix, Gabapentin, Tramadol, and Bacitracin-Polymixin B ointment. However, their MDS assessments failed to indicate the administration of these medications in the relevant sections. The Registered Nurse Assessment Coordinator confirmed that the assessments for these residents were coded incorrectly, resulting in inaccurate documentation of their care needs and treatments.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for medication administration for three residents. One resident, who was cognitively impaired and required extensive assistance, had physician's orders for Senna and Bisacodyl to be administered as needed for constipation if no bowel movement occurred within a specified number of days. Review of records showed that the resident went up to seven days without a bowel movement, and staff did not administer the prescribed medications until the sixth day, contrary to the physician's orders. The Director of Nursing confirmed that the medications were not given as ordered. Another resident, also cognitively impaired and diagnosed with hypertension, had an order for Propranolol with instructions to hold the medication if the heart rate was below 60 or systolic blood pressure was below 100. Staff failed to assess and document the resident's heart rate and blood pressure prior to administration. A third resident, who was cognitively intact and had renal insufficiency requiring dialysis, had an order for Midodrine to be held if systolic blood pressure exceeded 130. Despite this, the medication was administered multiple times when the resident's systolic blood pressure was above the threshold. The Director of Nursing confirmed that the medication should have been held on those occasions.
Failure to Develop Individualized Care Plan for Antibiotic Use
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident who was cognitively intact but required substantial assistance with daily care tasks. Clinical records showed that the resident had physician's orders for daily amoxicillin and Methenamine Hippurate for the prevention of urinary tract infections (UTIs), due to a history of UTIs with sepsis. Despite these ongoing medication orders, there was no documented evidence that a care plan was created to address the resident's specific care and treatment needs related to the use of these antibiotic medications. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that a care plan should have been developed for the resident's antibiotic use.
Undated Opened Aplisol Vial Found in Medication Refrigerator
Penalty
Summary
Surveyors found that the facility failed to date an opened multidose vial of Aplisol solution, used for tuberculosis skin testing, in one of two medication storage area refrigerators on Unit D2. The facility's medication storage policy requires all medications to be stored according to the manufacturer's recommendations, which for Aplisol specify that vials in use for more than 30 days should be discarded. During an observation, an opened and undated vial of Aplisol was found in the refrigerator. An LPN confirmed at the time of observation that the vial was not dated when opened and acknowledged it should have been. The DON also confirmed that the vial should have been dated upon opening.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC regarding Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers. According to the facility's policy and updated federal guidance, residents with chronic wounds, such as pressure ulcers, require EBP, which includes the use of gowns and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). Review of clinical records showed that a resident had unstageable pressure ulcers on the left heel and foot, with physician orders for daily wound care. However, there was no evidence that EBP was ordered or care planned for this resident until several days after the wounds were documented. Observations revealed that there was no signage or notification indicating EBP in the resident's room, nor was any personal protective equipment (PPE) available in or around the room during the survey. Staff interviews confirmed that the requirement for EBP was missed for this resident, despite the presence of pressure ulcers. The deficiency was cited under state regulations for failure to implement appropriate infection prevention and control measures.
Failure to Follow Physician Orders for PRN Pain Medication
Penalty
Summary
The facility failed to ensure that physician's orders for as needed (prn) pain medications were followed for one resident. According to the clinical record review, the resident was cognitively intact, required supervision with daily care, and had diagnoses including right arm fracture, osteoporosis, and a pathological lumbar spine fracture. Physician's orders specified that acetaminophen (Tylenol) was to be administered for mild pain (pain level 1-3) and oxycodone for moderate to severe pain (pain level 4-10). However, the Medication Administration Record showed that oxycodone was given for a pain level of 3, and Tylenol was given for a pain level of 5, both of which were outside the prescribed parameters. The DON confirmed that the medications were not administered according to the physician's orders.
Failure to Follow Enhanced Barrier Precautions and Medication Administration Protocols
Penalty
Summary
The facility failed to follow established infection control guidelines and its own policies regarding Enhanced Barrier Precautions (EBP) and medication administration for a resident with an indwelling urinary catheter. Observations revealed that a Licensed Practical Nurse (LPN) did not wear gloves or a gown while administering medications, applying and removing medicated patches, and providing insulin injections to the resident, despite the resident being on EBP due to the presence of an indwelling catheter. The LPN also handled spilled medications with bare hands, including picking up pills from the medication cart and administering them to the resident, contrary to facility policy that prohibits touching tablets or capsules with fingers. The resident involved was cognitively impaired, required assistance with care, and had an indwelling catheter, as well as orders for insulin and topical/transdermal medications. The LPN stated she was unaware that the resident was on EBP and confirmed she did not use gloves during medication administration or when handling spilled medications. The Director of Nursing confirmed that the resident was on EBP and that appropriate PPE should have been used during care. These actions were not in compliance with CDC and CMS infection control guidelines, as well as facility policy.
Infection Control Deficiency in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices concerning the handling of soiled linen for two residents. Observations revealed that a nurse aide exited the room of a resident carrying soiled laundry with bare hands, contrary to the facility's infection control policy that mandates the use of gloves. The nurse aide confirmed the requirement to wear gloves when handling soiled laundry. Additionally, during a bed bath for another resident, two nurse aides were observed throwing soiled gowns, briefs, and bed linens on the floor instead of placing them in bags for proper disposal. The aides acknowledged that the soiled items should not be thrown on the floor and should be bagged and taken to the dirty linen bins. The facility's infection control policy, dated May 8, 2024, specifies that staff should handle soiled linen using standard precautions, such as wearing gloves. The Nursing Home Administrator confirmed that gloves should be worn when carrying soiled laundry out of resident rooms and that soiled items should not be placed on the floor. The deficiency was identified during a review of facility policies, clinical records, observations, and staff interviews, highlighting a failure to follow established infection control protocols.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission and annual Minimum Data Set (MDS) assessments within the required time frame for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 32, 128, 204, and 225 were completed 15, 18, 21, and 19 days after admission, respectively. This delay in completing the assessments was confirmed through interviews with the Nursing Home Administrator and the Assistant Director of Nursing. The deficiency was identified during a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. The manual specifies that the Assessment Reference Date (ARD) must be set within 366 days after the ARD of the previous comprehensive assessment, and the assessment should be completed no later than the ARD plus 14 calendar days. The facility's failure to adhere to these guidelines resulted in the late completion of the MDS assessments for the mentioned residents, as confirmed by the facility's staff.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 calendar days after the ARD. However, the facility did not adhere to these guidelines for Residents 33, 147, 157, and 159. For Resident 33 and Resident 147, the quarterly MDS assessments were completed 15 days after the ARD, exceeding the 14-day requirement. Resident 157's assessment was completed 19 days after the ARD, and Resident 159's assessment was completed 17 days after the ARD. These delays were confirmed during an interview with the Nursing Home Administrator, indicating a failure to complete the assessments on time as required by the regulations.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for eight residents, as required by the Resident Assessment Instrument (RAI) User's Manual. The deficiencies were identified through a review of clinical records and staff interviews. For several residents, the MDS assessments did not accurately reflect the administration of medications or the use of medical devices. For instance, one resident was administered an antibiotic for a urinary tract infection, but the MDS assessment did not indicate this. Similarly, another resident was using a wander/elopement alarm, but the MDS assessment failed to record its use. In other cases, the facility did not accurately document the use of respiratory support devices and dialysis treatments. One resident was using a BIPAP device and receiving dialysis, but these were not recorded in the MDS assessment. Another resident was using a CPAP device for sleep apnea, yet this was not reflected in the assessment. Additionally, the use of antipsychotic medication for a resident with schizophrenia was not documented, despite being administered daily during the assessment period. The facility also failed to document hospice care and oxygen use for residents who were receiving these services. One resident was admitted to hospice care for chronic obstructive pulmonary disease, but the MDS assessment did not indicate hospice care was being provided. Another resident was receiving oxygen therapy, yet this was not recorded in the assessment. These inaccuracies were confirmed by the Nursing Home Administrator during an interview, highlighting a significant lapse in the facility's assessment processes.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for two residents. Resident 2, who had a diagnosis of heart failure, was prescribed an as-needed diuretic, Lasix, and Potassium to be administered if there was a significant weight increase. Despite documented weight increases, there was no evidence that these medications were given. Additionally, Resident 2 was prescribed Midodrine for hypotension, which was to be withheld if the systolic blood pressure exceeded 130 mmHg. However, the medication was administered on multiple occasions when the resident's blood pressure was above this threshold. Resident 143, who was cognitively intact and had diagnoses of diabetes and renal failure, was supposed to receive Insulin Aspart, Renvela, and Insulin Glargine. These medications were not administered on specific dates because the resident was at dialysis, and there was no documentation that they were given upon the resident's return. Interviews with the Assistant Director of Nursing confirmed these lapses in medication administration for both residents.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
The facility failed to administer enteral feedings in accordance with physician's orders for two residents, leading to deficiencies in their care. Resident 20, who was usually understood and had a feeding tube, was supposed to receive Jevity 1.5 if she consumed less than 50% of her meal. However, the Medication Administration Record (MAR) showed that the resident did not receive the prescribed 237 ml of Jevity 1.5 on several occasions when her meal intake was below 50%, and conversely, she received it when her intake was above 50%. This inconsistency was confirmed by the Assistant Director of Nursing. Similarly, Resident 56, who was cognitively impaired and dependent on staff for eating, had orders to receive a 240 ml bolus of Isosource 1.5 if she consumed less than 50% of her meal. The MAR revealed that the resident did not receive the bolus on multiple occasions when her intake was below 50%, and she received it when her intake was above 50%. Additionally, there was no documentation of staff checking residuals before administering the tube feeding, as required by the facility's policy. This was also confirmed by the Assistant Director of Nursing.
Infection Control Deficiencies in Equipment Cleaning and PPE Use
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by multiple observations and staff interviews. During a medication administration, a Licensed Practical Nurse (LPN) used a blood pressure cuff on two residents without cleaning it between uses, which was confirmed by both the LPN and the Assistant Director of Nursing. This action violated the facility's infection control policy, which mandates cleaning of medical equipment between residents to prevent cross-contamination. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or chronic wounds, as required by updated CMS guidelines. For instance, a resident with a urinary catheter did not have appropriate signage or personal protective equipment (PPE) available outside their room. Interviews with the LPN Manager and Infection Preventionist confirmed the oversight. Similarly, another resident with a feeding tube and tracheostomy did not receive care with the necessary PPE, as observed when a nurse aide provided incontinence care without gloves or a gown. Further deficiencies were noted in the handling of soiled linen and the administration of enteral feedings. A nurse aide was observed carrying soiled linen with bare hands, contrary to the facility's policy requiring gloves. Moreover, an LPN administered a bolus feeding to a resident with a feeding tube while only wearing gloves, omitting the required gown. These actions were confirmed through interviews with the involved staff and the Nursing Home Administrator, highlighting a pattern of non-compliance with infection control protocols.
Failure to Facilitate Resident Dining Choices Due to Broken Air Conditioner
Penalty
Summary
The facility failed to ensure that residents could make choices about significant aspects of their lives, such as dining in the main dining room. This deficiency affected nine residents who expressed their desire to eat in the main dining room but were unable to do so due to a broken air conditioner. The facility decided to close the dining room, citing high temperatures and the need to wait for a part to fix the air conditioner. Interviews with residents and staff confirmed that the dining room remained closed, and no alternative measures were taken to allow residents to dine there. The Nursing Home Administrator and Maintenance Director confirmed that the air conditioning units were not functioning, and a vendor was consulted to assess the situation. However, the facility did not monitor the temperatures in the dining room and opted to close it as a precaution. The decision to close the dining room was made without attempting other interventions to maintain its operation, thus limiting the residents' ability to exercise their right to choose where to dine.
Failure to Provide Timely and Accurate Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required notice to residents or their representatives regarding the end of Medicare coverage and potential liability for services not covered. Specifically, for Resident 201, the facility did not issue a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form or an Advance Beneficiary Notice (ABN) in a timely manner. The resident's Medicare A services began on March 1, 2024, and ended on April 22, 2024, but the verbal notification to the resident's responsible party was only given on May 1, 2024, which was not 48 hours in advance as required. Additionally, the ABN notice provided did not specify the items and services covered or not covered under Medicaid or by the facility's per diem rate, nor did it include the cost of those items and services. For Resident 228, the facility also failed to provide a complete ABN notice. The resident began Medicare A services on February 7, 2024, and the last covered day was April 1, 2024. Although the SNF Beneficiary Protection Notification Review form and ABN were signed on March 29, 2024, the ABN notice did not include necessary details about coverage and costs. An interview with the Nursing Home Administrator confirmed these deficiencies, acknowledging that the ABN forms for both residents were not completed accurately and should have been.
Failure to Provide Written Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reasons for hospital transfers, as required by regulations. This deficiency was identified through clinical record reviews and staff interviews, affecting six residents. For Resident 85, who was cognitively intact and dependent on staff for personal care, there was no documented evidence of written notice provided for a hospital transfer due to elevated troponin levels and sepsis. Resident 96, who had cancer and dementia, was transferred multiple times to the hospital for various reasons, including chest pain, sepsis, and septic shock. Despite these significant medical events, there was no documented evidence of written notices provided to the resident or their representative for any of these transfers. Similarly, Resident 157, who was cognitively intact and had osteomyelitis, was transferred to the hospital twice for elevated white blood cell count and other symptoms, but again, no written notices were documented. Other residents, including Resident 171 with cancer and end-stage renal disease, Resident 192 with a suprapubic catheter, and Resident 218 with acute kidney injury, were also transferred to hospitals without documented written notices to them or their representatives. Interviews with the Nursing Home Administrator and the Assistant Director of Nursing confirmed the lack of awareness and compliance with the requirement to provide written notices for hospital transfers.
Failure to Complete Timely MDS Assessments for Hospice Admissions
Penalty
Summary
The facility failed to complete comprehensive significant change Minimum Data Set (MDS) assessments within the required time frame for two residents who experienced significant changes in their conditions. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the Assessment Reference Date (ARD) and the significant change comprehensive MDS assessment must be completed no later than the 14th calendar day after a significant change in the resident's status is determined. However, for Resident 96, who was admitted to hospice care due to an end-stage illness on July 26, 2024, there was no documented evidence of a completed significant change in status MDS assessment within the required time frame. This was confirmed by the Nursing Home Administrator during an interview on August 27, 2024. Similarly, Resident 171, who was admitted to hospice care with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) on January 31, 2024, also lacked documented evidence of a completed significant change in status MDS assessment within the required time frame. This deficiency was confirmed by the Nursing Home Administrator during an interview on August 26, 2024. The failure to complete these assessments as required by the RAI User's Manual and 28 Pa. Code 211.5(f) Clinical Records indicates a lapse in the facility's compliance with mandated assessment protocols.
Failure to Develop Individualized Care Plan for CPAP Use
Penalty
Summary
The facility failed to develop a care plan to address the individualized care needs of a resident who was cognitively impaired and required assistance for daily care. The resident had a physician's order to use a CPAP machine at bedtime for sleep apnea, as documented in the Medication Administration Record from August 1 through 26, 2024. However, there was no documented evidence of a care plan that included interventions for the use of the CPAP machine. This deficiency was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that a care plan should have been developed for the resident's CPAP use.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two residents. For Resident 125, a significant change Minimum Data Set (MDS) assessment indicated that she was cognitively intact and dependent on staff for personal hygiene needs, with a diagnosis of a left hip fracture. Her care plan, however, noted that she was receiving anticoagulant therapy for atrial fibrillation, but the Medication Administration Record (MAR) showed no evidence of anticoagulant medication being administered. An interview with the Assistant Director of Nursing confirmed that Resident 125 was no longer taking an anticoagulant, and her care plan should have been revised accordingly, but it was not. For Resident 191, an admission MDS assessment revealed cognitive impairment, dependency on staff for all care needs, a diagnosis of dementia, and the use of a feeding tube. Physician's orders specified a 260 ml bolus feeding of Jevity 1.2 every four hours, but the care plan indicated a different feeding regimen of 65 ml per hour. The Assistant Director of Nursing acknowledged that Resident 191's care plan was not updated when her tube feeding orders changed, which it should have been. These deficiencies were identified through a review of policies, clinical records, and staff interviews.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe environment for Resident 165, who had a history of falls and was cognitively impaired, requiring extensive assistance for daily care and transfers. The resident's quarterly Minimum Data Set (MDS) assessment indicated diagnoses including lower back pain, difficulty walking, and dementia. Despite these needs, the facility did not implement new interventions after the resident experienced falls on two separate occasions. On August 22, 2024, Resident 165 fell from her wheelchair to the side of her bed, resulting in a red, swollen right wrist, although an X-ray showed no injuries. No new interventions were documented to prevent future falls. Again, on August 25, 2024, the resident fell to the right side of her bed while the bed alarm was sounding, but no injuries were reported. Despite these incidents, the facility did not document any new interventions to prevent further falls, as confirmed by interviews with the Assistant Director of Nursing and the Nursing Home Administrator.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate or eliminate triggers. A quarterly Minimum Data Set (MDS) assessment for the resident indicated moderate cognitive impairment and diagnoses of depression and PTSD. However, the resident's care plan lacked documented evidence of identified specific triggers that could re-traumatize the resident or measures to prevent or minimize these triggers. An interview with the Assistant Director of Nursing revealed that the facility was not completing trauma-informed care assessments.
Failure to Conduct Annual Nurse Aide Evaluations
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, the personnel files of three nurse aides were reviewed, revealing that their evaluations were not conducted in accordance with their hire dates. Nurse Aide 1, hired on August 11, 1998, did not have a documented evaluation for August 2023. Similarly, Nurse Aide 2, hired on July 2, 2008, lacked documentation for a July 2023 evaluation. Nurse Aide 3, hired on August 12, 2018, also did not have a documented evaluation for August 2023. An interview with the Nursing Home Administrator confirmed the absence of these evaluations, indicating a lapse in the facility's adherence to required staff performance review protocols. The deficiency was identified through a review of personnel files and staff interviews, highlighting the facility's failure to comply with regulations regarding the timely evaluation of nurse aide performance. This oversight was confirmed by the Nursing Home Administrator, who acknowledged the lack of documented evidence for the required annual evaluations.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that controlled medications were properly secured and labeled according to their policies and professional standards. For one resident, a controlled medication, Clonazepam, was found unsecured in a medication cart without a label. The medication was intended for a resident with an order to receive 0.5 mg every eight hours for anxiety. The medication was prepared ahead of time and stored in a cart that did not have a controlled medication drawer, violating the facility's policy that requires controlled drugs to be stored under double lock and key. Additionally, the facility did not ensure proper labeling of medications for another resident. The resident was ordered to receive 17 grams of Miralax daily via a peg tube, but the medication was administered orally. The label on the Miralax had not been updated to reflect the change in administration route, as the resident no longer had a peg tube. This discrepancy was confirmed by the Assistant Director of Nursing, indicating a failure to update medication labels in accordance with the facility's policy and procedures.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as observed during a lunch meal tray line in the main kitchen. Several dietary workers, identified as Dietary Worker 6 through Dietary Worker 11, were noted to have beards that were not covered with beard nets, contrary to the facility's policy. Additionally, Dietary Worker 12 and Dietary Worker 13 did not have their hair completely covered by hair nets during food preparation. The facility's policy, dated May 8, 2024, mandates that kitchen staff maintain personal hygiene by keeping hair clean and neatly tied or pinned back under a hair net, and facial hair such as beards must be covered with a beard net. Interviews with the Dietary Manager and the Nursing Home Administrator confirmed the requirement for dietary workers to have beards covered with beard nets and hair completely under hair nets while in the kitchen. This deficiency was identified under 28 Pa. Code 211.6(f) Dietary Services.
Incomplete Clinical Documentation for Resident
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and accurately documented. Specifically, the clinical records for a resident, who required hemodialysis treatments and was at nutritional risk due to end-stage renal disease, lacked documentation of daily weights on specific dates. The resident's care plan included an intervention to monitor and report any significant weight changes to the physician, and a physician's order required daily weights to be recorded and reported if there was a significant weight gain. An interview with the Assistant Director of Nursing confirmed the absence of documented daily weights for the resident on the specified dates. Although facility staff were obtaining the weights, there was no designated area in the clinical record to chart these weights, nor were they entered into the vitals section. This oversight resulted in incomplete clinical documentation, as required by the facility's standards and regulations.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to obtain the required information from the contracted hospice provider for a resident receiving hospice care. The hospice contract with Family Hospice, effective January 1, 2020, stipulated that the hospice agency must provide the facility with a copy of the most recent plan of care and the physician certification and recertification of the terminal illness for each hospice patient. However, for one resident, there was no documented evidence in the clinical records that the facility obtained the current hospice recertification of terminal illness or plan of care from the hospice provider for the certification period. The resident in question, who was rarely understood, had a memory problem, and was dependent on staff for daily care needs, was diagnosed with dementia and had been receiving hospice services since September 9, 2022. Despite the care plan indicating hospice care, as of August 27, 2024, the facility had not obtained the necessary hospice documentation for the certification period from June 30, 2024, through August 28, 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Repeated Deficiencies in QAPI Implementation
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in multiple surveys. These deficiencies included issues with the timely completion and accuracy of comprehensive assessments, development and revision of care plans, proper labeling and storage of medications, quality of care, food preparation and serving, and maintaining complete and accurate resident records. Despite having plans of correction that involved conducting audits and reporting results to the QAPI committee, the facility was unable to effectively address these recurring issues. The deficiencies were consistently identified across several surveys, including those ending in October 2023, April 2024, and August 2024. The facility's plans of correction, which were supposed to ensure compliance through audits and QAPI committee reviews, were not successfully implemented. This resulted in ongoing non-compliance with regulations related to comprehensive assessments, MDS assessments, care plan development and updates, medication management, food service, and medical record documentation.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to administer medication as ordered by the physician, resulting in a significant medication error for a resident. The resident, who was cognitively impaired and diagnosed with heart failure, was prescribed 40 mg of Torsemide twice a day. However, due to a failure in transcribing the physician's order into the medical record, the resident did not receive the medication from May 25 through June 7, 2024. The error was identified when a CRNP noted that the resident was fluid overloaded with severe swelling of the lower extremities, despite being on the prescribed medication regimen. An interview with the Director of Nursing confirmed that the registered nurse responsible for reviewing the laboratory results with the physician did not update the medical record with the new order, leading to the medication not being administered as required.
Failure to Transcribe Physician's Order Leads to Medication Error
Penalty
Summary
The facility failed to correctly transcribe a physician's order for a resident, leading to a medication administration error. The resident, who was cognitively impaired and diagnosed with heart failure, was supposed to receive 40 mg of Torsemide twice a day as per the physician's order. However, the registered nurse who reviewed the laboratory results with the physician did not transcribe this new order into the medical record. As a result, the resident did not receive the prescribed medication from May 25 through June 7, 2024. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the registered nurse failed to update the medical record with the new order. This oversight resulted in the resident not receiving the necessary medication to manage their condition, which included fluid overload and severe swelling of the lower extremities. The failure to transcribe the order was a violation of the Pennsylvania Code and the facility's obligation to maintain professional standards of quality care.
Oxygen Therapy Not Administered as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician for a resident. The facility's policy, dated May 8, 2024, required that oxygen be administered according to the physician's orders. A quarterly Minimum Data Set (MDS) assessment for the resident, dated July 4, 2024, indicated that the resident was cognitively intact and received oxygen therapy. The care plan, dated February 22, 2024, and physician's orders from July 10, 2024, specified that the resident should receive oxygen at two liters per minute (lpm) every shift for hypoxia. However, observations on August 7, 2024, revealed that the resident was receiving oxygen at a flow rate of five lpm via a nasal cannula, contrary to the physician's order. An interview with a Licensed Practical Nurse confirmed the discrepancy in the oxygen flow rate.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner for a resident who was cognitively impaired. The resident reported to the Area Agency on Aging that a family member had been verbally abusive, calling her derogatory names and expressing anger over a family matter. Despite the resident's visible distress and fear, as documented in nursing notes and staff witness statements, the facility did not report the allegation to the Department of Health as required by their policy. The Director of Nursing confirmed that the facility did not report the verbal abuse allegation, citing the lack of direct witness accounts and the resident's cognitive impairment as reasons. The facility's investigation revealed that the resident felt emotionally threatened by the family member, who was subsequently banned from visiting. However, there was no documented evidence that the incident was reported to the appropriate authorities, as mandated by state regulations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans with specific and individualized interventions for two residents. Resident 3, who was cognitively intact, had a skin tear on his left shin that required specific wound care. Despite recommendations from a wound clinic to adjust the treatment frequency and type, the facility did not update the care plan to reflect these changes. The Treatment Administration Record did not show the recommended changes, and there was no documented evidence of a comprehensive care plan addressing the wound. Resident 7 was admitted with End Stage Renal Disease and required dialysis through a right subclavian dialysis catheter. Despite receiving dialysis on multiple occasions, there was no documented evidence of a comprehensive care plan that included specific interventions for managing the dialysis catheter and the dialysis process. Interviews with the Director of Nursing confirmed the absence of these care plans for both residents.
Failure to Obtain Physician's Orders for Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis had an active physician's order to attend dialysis treatments and to obtain physician's orders for the care and monitoring of the dialysis site. The resident, who was admitted with End Stage Renal Disease (ESRD) and had a right subclavian dialysis catheter, received dialysis on multiple occasions without documented physician's orders for these treatments. This lack of documentation was confirmed through clinical record reviews and staff interviews. Additionally, there was no evidence of physician's orders for the care and monitoring of the resident's dialysis catheter and insertion site, nor for the emergency equipment to be available at the resident's bedside in case of an emergency related to the catheter. The Director of Nursing confirmed the absence of these necessary orders, indicating a lapse in the facility's protocol for managing dialysis care for the resident.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical treatments and medications. For one resident, the MDS assessment incorrectly indicated that the resident did not receive hypoglycemic medications during the assessment period, despite physician's orders and medication administration records showing that the resident was prescribed and received Metformin, Glimepiride, and Nesina for diabetes management. An interview with the Registered Nurse Assessment Coordinator (RNAC) revealed a misunderstanding, as the RNAC believed the resident did not receive hypoglycemic medications during this time. For another resident, the MDS assessment failed to document the receipt of oxygen therapy, non-invasive mechanical ventilation, and dialysis, despite physician's orders and treatment administration records confirming these treatments were administered. The RNAC confirmed that the MDS assessment should have reflected these treatments, indicating a lapse in accurately capturing the resident's care needs and treatments during the assessment period.
Failure to Follow Wound Care and Blood Sugar Monitoring Protocols
Penalty
Summary
The facility failed to provide care for wounds in accordance with professional standards of practice for one resident. Resident 3, who was cognitively intact, had a skin tear on his left shin. The wound clinic recommended specific treatment changes on two occasions, which were not followed by the facility. Initially, the wound was to be treated with Xeroform every other day, but the facility did not adhere to this schedule. Later, the clinic advised switching to medical grade honey, but the facility continued using Xeroform alongside the new treatment, contrary to the recommendations. The Director of Nursing confirmed these discrepancies in treatment. Additionally, the facility did not notify the physician about elevated blood sugar levels for another resident, Resident 7, as required by the physician's orders. The resident's blood sugar levels exceeded the threshold for notification on multiple occasions, yet there was no documented evidence that the physician was informed. This oversight was confirmed by the Director of Nursing, indicating a failure to follow the physician's orders regarding blood sugar monitoring and communication.
Incomplete Documentation for Residents' Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents. For Resident 2, a quarterly Minimum Data Set (MDS) assessment indicated cognitive impairment and a history of falls. On February 7, 2024, Resident 2 experienced an unwitnessed fall, and although a registered nurse assessed the resident and documented the assessment in the investigation documents, this information was not included in the resident's clinical record. The Director of Nursing confirmed that the assessment should have been documented in the clinical record. For Resident 9, an admission MDS assessment revealed diagnoses of schizophrenia and Parkinson's disease. Staff statements indicated that Resident 9 frequently rang his call bell, leading to an incident where a non-working call bell was given to him to prevent frequent interruptions. However, there was no documentation in Resident 9's clinical record to reflect his behavior of constantly ringing the call bell. The Director of Nursing confirmed the absence of this documentation in the clinical record.
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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