Mcmurray Hills Rehabilitation And Healthcare Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcmurray, Pennsylvania.
- Location
- 249 West Mcmurray Road, Mcmurray, Pennsylvania 15317
- CMS Provider Number
- 395032
- Inspections on file
- 29
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mcmurray Hills Rehabilitation And Healthcare Cente during CMS and state inspections, most recent first.
The facility failed to prevent misappropriation of resident property when an LPN removed multiple residents' medications from the facility without consent, despite a policy prohibiting such conduct and defining drug diversion as misappropriation. An anonymous caller reported finding a purse on the roadside containing a bag with multiple residents' medications, along with employment-related documents bearing the LPN's name. Review of MARs showed that all of the involved medications for eleven residents had been signed out by this LPN on the corresponding shifts, and the facility’s investigation substantiated misappropriation of property.
Surveyors found that the facility failed to accurately account for controlled substances for multiple residents. Review of March medication administration records and controlled drug logs showed numerous instances where oxycodone, Tramadol, and hydrocodone/acetaminophen doses were signed out but had no corresponding documentation of administration on the MARs, and in one case a higher dose was signed out than was documented as given. These discrepancies occurred across residents with scheduled and PRN opioid orders for moderate to severe pain. The NHA and interim DON confirmed that controlled substances were not accurately accounted for for the majority of residents reviewed.
A resident with a cervical incision did not receive wound care treatment as ordered by the physician, including cleansing, dressing application, and documentation, on two occasions. The DON confirmed the lapse in following the prescribed wound care protocol.
The facility failed to maintain proper hazardous area enclosures, affecting two smoke compartments. The oxygen storage room door lacked a self-closing device, and the transfer switch room door did not latch. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility failed to properly install and maintain a gas-fired oven in the main kitchen, affecting one smoke compartment. The oven was not tethered to ensure it returned to an approved location after being moved for maintenance, as required by NFPA 96 standards. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the automatic sprinkler system, with deficiencies including a missing ceiling tile in the sprinkler room, MC wire on a sprinkler line, gaps in ceiling tiles, and a missing escutcheon on a sprinkler head. These issues affected four of nine smoke compartments and were confirmed by the Facility Administrator and Maintenance Director.
A penetration in the first floor smoke barrier wall next to a steel beam, above the smoke doors to the C2 Wing, was observed, affecting two of nine smoke compartments. The Facility Administrator and Maintenance Director confirmed the issue.
A facility failed to develop a person-centered care plan for a resident with diabetes, high blood pressure, and depression. Despite receiving daily insulin injections and having specific physician orders, the resident's clinical record lacked a comprehensive care plan addressing diabetes management. This deficiency was confirmed by the RN Admission Coordinator.
The facility failed to notify physicians of abnormal blood glucose levels and did not assess two residents for hyperglycemia and hypoglycemia. Despite having care plans that required monitoring and reporting of symptoms, staff did not follow these protocols, nor did they document or assess the effectiveness of treatments. Interviews with LPNs revealed inconsistencies in managing abnormal blood glucose levels, and the DON confirmed these failures.
The facility did not notify the LTC Ombudsman of emergency hospital transfers for 24 residents, as required by policy. This oversight was confirmed by staff interviews and a review of the facility's records, which showed missing notifications for transfers occurring over several months.
A facility failed to maintain accurate clinical records for a resident with a right AV fistula, documenting blood pressure readings from the right arm despite staff awareness of the restriction. Multiple staff members attributed the error to incorrect selection in charting software, and the resident was sent to the hospital for evaluation after swelling was noted.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to protect residents from misappropriation of property when an LPN removed multiple resident medications from the facility without consent. Facility policy on identifying exploitation, theft, and misappropriation of resident property, dated 9/1/25, defines misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent, and specifically lists drug diversion as an example. Despite this policy, an anonymous male caller notified the center supervisor that he had found a purse on the side of the road containing multiple medication cards for several residents of the facility. When the DON and Administrator went to the police station, they were shown a pink bag containing multiple medications, a Tuberculin employment skin testing record, and an orientation sheet, both bearing the name of LPN Employee E1. The bag contained eleven residents' medications in individual dispense bags, with no controlled substances identified. The medication dates and assignment areas matched LPN E1's work assignments on the relevant days and shifts, and the MARs for all residents on those assignments showed that all medications were signed out by this LPN. The facility’s investigation substantiated misappropriation of property for 11 of 49 residents (R1, R2, R12, R13, R14, R15, R16, R17, R18, R19, and R20). During an interview, the Nursing Home Administrator and Interim DON confirmed that the facility failed to ensure residents were free from misappropriation of property.
Failure to Accurately Account for Controlled Substances Across Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s management and accounting of controlled substances, as required by its policy and state regulations. The facility’s controlled substances policy, last reviewed on 9/1/25, stated that controlled substance inventory is to be monitored and reconciled to identify loss or potential diversion in a timely manner. However, review of multiple residents’ March 2026 Medication Administration Records (MARs) and corresponding Controlled Drug Records showed repeated instances where controlled medications were signed out but had no corresponding documentation of administration on the MAR. For one resident with an order for oxycodone 10 mg scheduled every morning and every six hours as needed, three PRN administrations were documented on the MAR, but six additional oxycodone doses were signed out on the Controlled Drug Record without matching MAR entries. Another resident with an order for Tramadol 50 mg every six hours as needed had no administrations documented on the MAR, yet two doses were signed out on the Controlled Drug Record. A third resident ordered oxycodone 5 mg every six hours had seven administrations documented on the MAR, while nine additional doses were signed out without corresponding MAR documentation. A fourth resident with an order for oxycodone 5 mg every six hours as needed had five administrations documented, but thirteen additional doses were signed out without matching MAR entries. Similar discrepancies were found for seven additional residents. One resident ordered oxycodone 5 mg every six hours as needed for moderate pain had eight administrations documented, but sixteen more doses were signed out without MAR documentation. Another resident with orders for oxycodone 5 mg for moderate pain and 10 mg for severe pain had four 5 mg administrations documented, while four additional doses, including a 10 mg dose signed out but documented as 5 mg on the MAR, lacked accurate or corresponding MAR entries. Other residents with PRN orders for Tramadol, oxycodone, or hydrocodone/acetaminophen had one to three administrations documented on their MARs, yet multiple additional doses were signed out on Controlled Drug Records without matching MAR documentation. During an interview, the Nursing Home Administrator and Interim Director of Nursing confirmed that the facility failed to ensure controlled substances were accurately accounted for for eleven of sixteen residents reviewed.
Failure to Provide Physician-Ordered Wound Care Treatment
Penalty
Summary
The facility failed to provide wound care treatment as ordered by the physician for one resident with a cervical incision. According to the facility's wound treatment management policy, wound treatments are to be performed in accordance with physician orders and documented in the Treatment Administration Record (TAR) or electronic health record. The resident, who had a history of spinal fusion, hypertension, and falls, had a physician order for daily cleansing of the cervical incision with normal saline, application of calcium alginate Ag, and covering with a border dressing. Review of the TAR for September showed that the required wound treatment was not documented as completed on two specific dates, and there was no further documentation in the electronic record to indicate the treatment was provided on those days. The Director of Nursing confirmed that the treatment was not completed as ordered.
Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures in two instances, affecting two of nine smoke compartments. During an observation on December 9, 2024, it was noted that the door to the oxygen storage room on the C-2 wing lacked a self-closing device. Additionally, the door to the transfer switch room did not latch when tested. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. F-0321 1. Facility Maintenance director installed door closure and hardware for proper closure. 2. Facility Maintenance director/ designee conducted facility wide door audit to ensure doors had proper closure if needed. 3. Facility Maintenance director will audit doors for proper closure hardware 1x weekly x 4 weeks then monthly x 2 months.
Improper Installation and Maintenance of Kitchen Equipment
Penalty
Summary
The facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system, affecting one of nine smoke compartments. During an observation, a gas-fired oven on wheels in the main kitchen was found not to have an approved method to ensure it returned to an approved design location after being moved for maintenance and cleaning. This was required by section 12.1.2.3 and 12.1.2.3.1 of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. An interview with the Facility Administrator and Maintenance Director confirmed that the gas-fired cooking appliance was not tethered to prevent it from being moved from the ventilation hood and gas connection.
Plan Of Correction
1. Facility maintenance director 12/9/2024 properly tethered cooking appliance so it could not be moved and educated dietary staff after cleaning to properly tether cooking appliance. 2. Audit will be completed by maintenance director /designee daily x 4 weeks, then weekly x 2 months.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in five instances, affecting four of nine smoke compartments. During an observation on December 9, 2024, several deficiencies were noted: a missing ceiling tile in the sprinkler room, MC wire laying on top of a sprinkler line above the smoke doors to the C2 wing, and gaps greater than 1/8 inch in ceiling tiles in both the electrical room behind the Laundry room and the Dietary Manager's office. Additionally, a sprinkler head in the first-floor storage room was missing an escutcheon. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
1. Maintenance Director on 12/9/2024 removed wire from sprinkler line. 2. Maintenance Director on 12/09/2024 replaced missing ceiling tile and tile with 1/8 inch or greater gap. 3. Maintenance Director on 12/12/2024 placed missing escutcheon. Maintenance Director/ designee will audit ceiling tile weekly x 4 weeks, then biweekly x 2 months. Findings will be reported at monthly QA meeting.
Smoke Barrier Wall Penetration
Penalty
Summary
The facility failed to maintain smoke barrier walls, as evidenced by a penetration in the first floor smoke barrier wall next to a steel beam, above the smoke doors leading to the C2 Wing. This deficiency was observed on December 9, 2024, at 11:05 a.m. The issue affected two of the nine smoke compartments within the facility. During an interview conducted on the same day at 1:30 p.m., both the Facility Administrator and the Maintenance Director confirmed the presence of the smoke barrier penetration.
Plan Of Correction
1. Maintenance Director on 12/9/2024 sealed opening with 3M Fireblock caulking.
Failure to Develop Person-Centered Care Plan for Diabetes Management
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident, identified as Resident R38, who was admitted with diagnoses including diabetes, high blood pressure, and depression. The facility's policy requires the development of a comprehensive care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. However, a review of the clinical record revealed that no such care plan was developed for Resident R38 to address interventions related to diabetes care. Resident R38's Minimum Data Set (MDS) indicated that the resident received insulin injections daily, and physician orders were in place for glucose gel and Humulin R insulin administration. Despite these medical needs, the clinical record lacked a person-centered care plan addressing diabetes management. This deficiency was confirmed during an interview with the Registered Nurse Admission Coordinator, who acknowledged the absence of person-centered interventions for diabetes in the resident's care plan.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. F-0656 1. RNAC/Designee completed diabetic comprehensive care plan on [R] 38 12/4/2024. 2. RNAC/Designee completed audit on 12/4/2024 of current diabetic residents to have a diabetic comprehensive care plan. 3. RNAC/Designee will audit new admissions with diabetes to have a comprehensive diabetic care plan q-day weekly x 2 weeks, then monthly x 3 months. 4. RNAC educated by DON/Designee on diabetic comprehensive care plans.
Failure to Notify Physicians and Assess Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting two residents. Resident R7, diagnosed with diabetes, depression, and high blood pressure, had multiple instances of abnormal CBG levels that were not reported to the physician as required by the facility's policy. The resident's care plan included monitoring and reporting signs of hypo/hyperglycemia, but staff did not follow these interventions, nor did they document or assess the effectiveness of treatments. Similarly, Resident R38, also diagnosed with diabetes, depression, and high blood pressure, experienced low CBG levels that were not properly addressed according to the physician's orders. The resident's care plan required monitoring and reporting of hypo/hyperglycemia symptoms, but staff failed to follow these protocols. The physician was not notified of the abnormal CBG levels, and there was no documentation of assessment or intervention. Interviews with Licensed Practical Nurses (LPNs) revealed inconsistencies in the management of abnormal blood glucose levels, with some LPNs stating they would provide juice or snacks for low blood glucose and call the doctor for high levels, but these actions were not consistently documented or followed. The Director of Nursing confirmed the facility's failure to notify physicians, document assessments, and follow physician orders for the residents involved.
Plan Of Correction
1. Audit completed 12/11/2024 by DON/Designee for abnormal blood sugars and MD notifications. 2. All RN and LPN educated by DON/Designee on MD notification and follow up related to abnormal blood glucose levels. 3. DON/Designee will audit residents' diabetic glucose levels daily x 1 week. 4. DON/Designee will audit 10 residents' blood glucose levels weekly x 4 weeks, then monthly x 3 months.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the emergency transfers of 24 residents. According to the facility's policy, the Social Services Director or their designee is responsible for sending notices of emergency transfers to the Ombudsman. However, a review of the facility's Hospital Tracking Portal report revealed that these notifications were not sent for residents who were transferred to the hospital between June and September 2024. Interviews with the Business Officer Manager and the Director of Nursing confirmed the oversight. The facility's Discharge Log for the months of June through September 2024 did not include the transferred residents, further indicating a lapse in communication. This deficiency was identified during a survey, highlighting the facility's failure to adhere to its own policy and regulatory requirements regarding resident rights and notification procedures.
Inaccurate Documentation of Blood Pressure Readings
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented, specifically for one resident who had a right AV fistula for dialysis access. The facility's policy requires that each resident's medical record accurately represent the resident's experience, with documentation being factual, objective, and resident-centered. However, the clinical records for this resident showed multiple instances where blood pressure readings were documented as being taken from the right arm, despite the presence of a fistula, which should not be used for such procedures. This discrepancy was identified through a review of the clinical records and staff interviews. Interviews with several registered nurses and a licensed practical nurse revealed that they were aware of the importance of not using the fistula arm for blood pressure readings or blood draws. Each staff member involved stated that the documentation indicating the use of the right arm was an error, attributing it to the selection of the wrong option from a drop-down menu during charting. The resident was described as alert and would inform staff not to use the right arm. The Director of Nursing confirmed that the right arm swelling began on a specific date, leading to the resident being sent to the hospital for evaluation. The Nursing Home Administrator acknowledged the facility's failure to ensure accurate and complete documentation for the resident.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
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