Meadow View Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Berlin, Pennsylvania.
- Location
- 1404 Hay Street, Berlin, Pennsylvania 15530
- CMS Provider Number
- 395830
- Inspections on file
- 28
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Meadow View Nursing Center during CMS and state inspections, most recent first.
Two residents experienced harm due to staff failing to follow established care policies. One resident, who was at risk for falls, was not wearing required hip protectors after refusing them, and staff did not report the refusal or implement alternative interventions, leading to a hip fracture after a fall. Another resident, dependent for ADLs and with a history of stroke, was rolled away from the nurse aide during care, contrary to policy, resulting in a fall from bed and a head injury.
Two residents at risk for falls suffered injuries when staff failed to follow care-planned interventions and facility policies. One resident, who was confused and required hip protectors, was not reported as refusing her protective equipment, leading to a fall and hip fracture. Another resident, dependent for ADLs and with a history of stroke, was rolled away from a nurse aide during care, resulting in a fall from bed and a head injury.
Surveyors observed that three residents' bathrooms were not maintained in a clean and homelike condition, with accumulations of dried debris, stains, and missing flooring noted. The Maintenance Director confirmed that these areas required cleaning, despite facility policies and daily housekeeping routines intended to ensure sanitary conditions.
The facility failed to maintain the automatic sprinkler system, affecting two smoke compartments. Observations revealed storage above the 18-inch sprinkler plane in the Therapy Storage room and a gap in a ceiling tile in the Nourishment Room. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain corridor doors as required, with two doors not latching properly, affecting two smoke compartments. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to accurately complete MDS assessments for multiple residents, leading to discrepancies in documenting medications and services received. Errors included incorrect recording of antibiotics, opioids, dialysis, and discharge status, confirmed through staff interviews and record reviews.
The facility failed to update care plans for three residents, leading to discrepancies in documented care needs. One resident's care plan was not updated to reflect the discontinuation of oxygen therapy, another's did not reflect the end of antibiotic therapy and contact precautions for C-diff, and a third resident's care plan inaccurately indicated anticoagulant therapy. Staff interviews confirmed these issues.
A facility failed to transcribe a physician's order correctly, leading to a resident receiving an incorrect dose of escitalopram. Additionally, an agency LPN attempted to administer medications to the wrong resident due to misidentification, but the resident did not accept the medications. The DON confirmed these errors, indicating lapses in adherence to professional standards.
The facility failed to adhere to physician's orders for two residents by administering Midodrine despite blood pressure readings exceeding specified limits. For one resident, the medication was given when systolic pressure was as high as 169 mmHg, and for another, it was administered with diastolic readings of 88 mmHg. The DON confirmed these administrations were inappropriate.
The facility failed to follow physician orders for IV care, including not administering or documenting IV fluids and medications for a resident, not flushing PICC lines for two residents, and not changing a PICC line dressing for another resident. These actions were confirmed by the DON and a nurse.
A facility failed to follow physician's orders, leading to significant medication errors for two residents. One resident continued receiving a discontinued medication, while another was mistakenly given another resident's medications due to misidentification. The errors were confirmed by the DON.
The facility failed to maintain complete and accurate clinical records for three residents. A resident's scheduled showers were not properly documented, leading to incomplete records. Two other residents had missing documentation for intravenous antibiotic administration, although the pharmacy confirmed no doses were missed. The Director of Nursing acknowledged these documentation failures.
The facility failed to obtain necessary hospice documentation for three residents receiving hospice care, as required by their policy. This included missing physician certifications, hospice agreements, and coordinated plans of care. The Director of Nursing confirmed the absence of these documents, indicating a lapse in compliance.
The facility's QAPI committee failed to address repeated deficiencies, including inaccurate MDS assessments, outdated care plans, inadequate nursing services, substandard care, unsafe environments, improper medication storage, and poor infection control. Despite previous plans of correction, the current survey found these issues persisted, indicating ineffective quality assurance processes.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for residents with chronic wounds or indwelling medical devices, as required by updated CMS and CDC guidelines. A resident with a tunneled catheter, another with a feeding tube, and two others with chronic wounds did not have the necessary infection control signage or PPE in place. Staff interviews confirmed the oversight, indicating a systemic failure in adhering to infection control policies.
The facility failed to provide written notification to residents and their representatives for hospital transfers. A resident with a trimalleolar fracture, another with a femur fracture, and a third with pressure ulcers were transferred without written notice. The Nursing Home Administrator confirmed the deficiency.
The facility failed to provide bed-hold notices to three residents or their representatives during hospital transfers. One resident with cognitive impairment and a fracture, another with multiple diagnoses including atrial fibrillation, and a third with cognitive impairment and pressure ulcers were all transferred without documented bed-hold notices. The Nursing Home Administrator confirmed the oversight, which was identified as past noncompliance.
A facility failed to develop a comprehensive care plan for a resident requiring oxygen therapy. Despite a physician's order for oxygen at 2 liters per minute, there was no documented care plan addressing the resident's oxygen needs. This deficiency was confirmed by the DON.
A cognitively impaired resident, dependent on staff for care and at risk for falls, was not wearing hipsters as required by their care plan during two separate falls. The task was not correctly added to the nurse aide task list, resulting in a lack of awareness among staff.
The facility did not complete the required annual performance evaluation for a nurse aide, as confirmed by the Nursing Home Administrator. The evaluation was due based on the aide's hire date, but there was no documented evidence of its completion within the specified timeframe.
A facility failed to maintain accurate records for a resident's controlled medication, Tramadol. Although doses were signed out for administration, there was no documented evidence in the clinical record or MARs that the medication was given on several occasions. The DON confirmed the absence of documentation.
A facility failed to securely store medication for a resident on diuretic therapy, as a Spironolactone tablet was found on the resident's bed, contrary to the care plan. Additionally, a Trelegy Ellipta inhaler on a medication cart was opened without being dated, violating the facility's policy and manufacturer's instructions. These deficiencies were confirmed by staff interviews.
The facility did not meet the required nurse aide-to-resident staffing ratios over a 21-day period. On the day shift, staffing fell short with one nurse aide per 12 to 15 residents instead of the required one per 10. The afternoon shift had one nurse aide per 12 to 15 residents, failing the one per 11 requirement. Overnight, staffing was one aide per 19 residents, not meeting the one per 15 standard. These deficiencies were confirmed by nursing schedules and staff interviews.
The facility did not meet the required LPN-to-resident staffing ratios during specific shifts over a 21-day period. On two occasions, the day shift had one LPN per 27 and 28 residents, instead of the required 25. Additionally, the overnight shift had one LPN per 46 residents, instead of the required 40. These deficiencies were confirmed through nursing schedules and an interview with the Nursing Home Administrator.
The facility did not meet the required 3.20 hours of direct resident care per resident for eight days within a 21-day period. Nursing schedules showed that the facility provided less than the required hours on several days, with the lowest being 3.00 hours. This was confirmed by the Nursing Home Administrator.
The facility failed to complete accurate MDS assessments for seven residents due to discrepancies between electronic medical records and paper charts. The RNAC confirmed that vaccine information was not correctly coded, leading to inaccuracies in the assessments.
The facility failed to clarify physician's orders for pain management for a resident, leading to multiple instances of administering Norco outside the specified pain rating range. The orders specified Norco for pain ratings of 4-10, but staff administered it for ratings of 0, 2, and 3 without clarification from the physician.
The facility failed to follow its policy requiring the checking and documentation of gastric residual volume before administering tube feedings for a resident with a feeding tube. This was confirmed by the Registered Dietician.
The facility failed to ensure that non-pharmacological interventions were attempted before administering anti-anxiety medications to a resident with dementia. Multiple instances of administering Ativan without prior non-medication interventions were documented, as confirmed by staff interviews.
The facility failed to serve food items at appetizing temperatures, with observations showing food temperatures below the required standards and residents expressing dissatisfaction with the food quality. The Registered Dietitian confirmed that hot foods should be at a minimum of 135 degrees F.
The facility failed to store food under sanitary conditions, with ice accumulation in the walk-in freezer and food debris in the main kitchen. A dietary worker did not follow handwashing protocols, and the ice machine had a buildup of a black substance. These issues were confirmed by the Registered Dietitian and the Director of Maintenance.
The facility's QAPI committee failed to correct recurring quality deficiencies, including issues related to abuse/neglect, MDS assessments, professional standards, quality of care, safety hazards, food palatability, food procurement/storage/preparation, and infection control. Despite previous plans of correction, the current survey revealed ongoing non-compliance in these areas.
The facility failed to follow infection control standards and DOH guidelines, as staff did not properly use PPE. A nurse educator and an agency LPN were observed with masks improperly positioned while in areas with COVID-19 positive residents. The Nursing Home Administrator confirmed the staff should have been wearing the appropriate PPE.
The facility failed to protect two residents from abuse. One resident reported that a nurse aide removed his call bell, and another resident reported that a nurse aide withheld his urinal and made derogatory comments. Both nurse aides were not immediately removed from duty despite the severity of the allegations.
The facility failed to follow its abuse policy by not immediately removing staff involved in abuse allegations and did not timely verify new employees' credentials, compromising resident safety and regulatory compliance.
The facility failed to revise the care plan for a resident with a pacemaker to include individualized interventions for pacemaker monitoring, despite the resident's diagnoses of coronary artery disease and heart failure. This deficiency was confirmed through an interview with the RN Assessment Coordinator.
The facility failed to administer medications as ordered by the physician for a resident. The resident was supposed to receive 10 mg of Oxycodone HCL every six hours for pain but was given only 5 mg on two occasions. This was confirmed by a nurse during an interview.
A facility failed to ensure fall prevention interventions were in place for a resident with a history of CVA and multiple falls. The resident was ordered to have bilateral fall mats, but observations revealed only one mat was placed on the right side of the bed, while the left side had no mat. This was confirmed by an agency nurse aide, despite nursing notes indicating the resident had been found out of bed on the fall mat multiple times.
The facility failed to complete a safety assessment for a resident who used top side rails for mobility. The resident, who had arthritis and was capable of understanding, was observed with bilateral top side rails. A review of the clinical record showed no documented evidence of a side rail safety assessment. The Nursing Home Administrator confirmed the assessment was not completed.
The facility failed to ensure proper labeling of medications for a resident. The physician's order for 10 mg of Oxycodone every six hours did not match the label on the pill card, which contained 5 mg tablets. This discrepancy was confirmed by an RN.
Failure to Prevent Resident Neglect Resulting in Falls and Injuries
Penalty
Summary
The facility failed to protect two residents from neglect, resulting in harm. One resident, who was confused, required assistance with daily care, and had a history of falls, was care planned to wear hip protectors at all times. On the day of the incident, the resident refused to wear the hip protectors after a shower, and the nurse aide providing care did not notify other staff of this refusal. As a result, no alternative interventions were implemented, and the resident later fell, sustaining a left hip fracture. Documentation confirmed that the nurse aide did not re-approach the resident to apply the hip protectors and failed to follow the facility's policy for reporting refusals of care. Another resident, who had a history of stroke and was dependent on staff for activities of daily living, was being provided peri care by a nurse aide. During care, the aide rolled the resident away from herself, contrary to facility policy and standard of care, which requires rolling the resident toward the attendant when only one person is assisting. The resident rolled off the bed, hit her head on a trash can, and sustained a hematoma. The nurse aide admitted to rolling the resident away from herself and was unable to prevent the fall. Both nurse aides involved had received prior education on abuse and neglect. The facility's investigations substantiated neglect in both cases, as staff failed to follow established policies and procedures designed to prevent harm, resulting in significant injuries to the residents.
Failure to Prevent Accidents Due to Non-Compliance with Care Plans and Policies
Penalty
Summary
The facility failed to provide an environment free from accident hazards for residents at risk for falls by not following care-planned interventions and facility policies. For one resident with confusion, a history of falls, and a care plan requiring the use of hip protectors at all times, staff did not report the resident's refusal to wear the hip protectors after a shower. This lack of communication prevented other staff from implementing alternative interventions, and the resident subsequently experienced a fall resulting in a fractured hip. Another resident, who had a history of stroke and required assistance with activities of daily living, was being provided peri care when a nurse aide rolled the resident away from herself, contrary to facility policy and standard of care. This action resulted in the resident rolling off the bed, hitting her head, and sustaining a hematoma. The nurse aide involved had received training on proper bed mobility but did not follow the correct procedure during the incident. In both cases, the failure to adhere to established care plans and facility policies directly contributed to the residents' injuries. The incidents were confirmed through review of clinical records, staff interviews, and facility investigation reports, which documented the sequence of events and the specific lapses in following required protocols.
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the bathrooms of three residents. Observations revealed that the base of the toilet in one resident's bathroom had a heavy accumulation of dried, yellowish/brown, removable debris encompassing all sides of the toilet base. Another resident's bathroom had an accumulation of dried, crusted, yellowish debris at the base of the toilet, with pieces of caulking coming off. The Maintenance Director confirmed that these areas were in need of cleaning and stated that housekeeping is responsible for daily cleaning of the bathrooms, which should have included the toilet bases. Additionally, a third resident's bathroom was observed to have black debris scattered along the baseboard, a black stain under the water shut-off valve, a golden/brown stain beside the toilet, and an area of missing vinyl flooring near the door hinge. The Maintenance Director confirmed the need for cleaning in this bathroom as well and noted that there is a schedule for routine and deep cleaning, including after resident discharge. The facility's policy requires a sanitary and homelike environment, which was not met in these instances.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in two instances, affecting two of sixteen smoke compartments. During an observation on February 12, 2025, it was noted that the facility did not maintain storage below the 18-inch horizontal sprinkler plane in the Therapy Storage room. Additionally, there was a gap greater than 1/8 inch in a ceiling tile in the Nourishment Room on the third floor. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. A storage in the therapy room will be moved to a lower shelf to maintain the horizontal sprinkler plane. Therapy staff will be educated on the importance of following the 18-inch rule. Random audits will be completed monthly X3. Results will be reported at the monthly Quality Assurance and Improvement meeting. Ceiling will be sealed with an approved sealant. Random audits will be completed monthly X3. Maintenance staff will be educated on the importance of maintaining a smoke/heat resistive ceiling. Results will be reported at the monthly Quality Assurance and Improvement meeting.
Failure to Maintain Corridor Doors
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as evidenced by two specific instances where doors did not latch properly. During an observation on February 12, 2025, it was noted that the door to resident room 127 and the door to the Staff Lounge on Level 2 would not close and latch in their frames. This deficiency affects two of the sixteen smoke compartments within the facility. The issue was confirmed through an interview with the Facility Administrator and Maintenance Director on the same day. The inability of these doors to latch properly indicates a failure to meet the requirements for corridor doors, which are essential for resisting the passage of smoke and ensuring safety in the event of a fire. The report does not mention any specific residents' medical history or conditions related to this deficiency.
Plan Of Correction
Adjustments and repairs will be made to the following doors: 127 and level 2 staff lounge. Random audits will be completed monthly for three months. Maintenance staff will be educated on the importance of the latching of the doors. Results will be reported at the monthly Quality Assurance and Performance Improvement meeting.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for nine residents, leading to discrepancies in the documentation of medications and services received. For instance, Resident 3's MDS inaccurately indicated that no antibiotics were received, despite physician orders and the Medication Administration Record (MAR) showing that piperacillin was administered. Similarly, Resident 9's MDS incorrectly recorded opioid use, which was not supported by the MAR. Other residents also experienced inaccuracies in their MDS assessments. Resident 12's MDS failed to document the administration of Tramadol, an opioid, which was given according to the MAR. Resident 18's MDS inaccurately reflected opioid use and omitted hospice services, despite physician orders indicating otherwise. Resident 45's MDS incorrectly noted the receipt of antibiotics and opioids, which were not administered during the look-back period. Further discrepancies were noted for Resident 58, whose MDS did not reflect dialysis services received, and Resident 85, whose diuretic medication was not documented despite being administered. Resident 88's MDS inaccurately recorded the use of antibiotics and anticonvulsants, and Resident 131's discharge status was incorrectly coded as home instead of the hospital. These errors were confirmed through interviews with facility staff, including the Registered Nurse Assessment Coordinator and the Director of Nursing.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect specific care needs for three residents. For one resident, the care plan was not updated to reflect the discontinuation of oxygen therapy after it was noted that the resident's oxygen saturation was adequate on room air. Despite the physician being notified and the oxygen being discontinued, the care plan remained unchanged. Another resident's care plan was not revised to indicate the discontinuation of antibiotic therapy and contact precautions for a C-diff infection, even though the contact precautions signage was still present on the resident's door. There was no documented evidence of an antibiotic order in the resident's clinical record. Additionally, a third resident's care plan inaccurately indicated that the resident was receiving anticoagulant therapy, although there was no documented evidence in the clinical record or medication administration record to support this. Interviews with facility staff confirmed these discrepancies, indicating a failure to update care plans in accordance with the residents' current medical needs and treatments.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to correctly transcribe physician's orders for a resident, leading to a medication error. A cognitively intact resident with coronary artery disease was prescribed 20 mg of escitalopram daily for depression. However, due to a transcription error, the resident received a combined dose of 30 mg daily from October 30, 2024, to November 5, 2024. Additionally, a subsequent order to decrease the dose to 10 mg daily was not entered into the clinical record, resulting in the resident not receiving the correct dose on December 17 and 18, 2024. Another deficiency involved a medication administration error by an agency LPN. A resident with dementia, who had communication deficits, was mistakenly identified as another resident and was almost given the wrong medications. The LPN attempted to administer medications to this resident, believing she was another resident, but the resident did not accept the medications and spit them out. The error was discovered when the resident was found in the wrong room, and the LPN admitted to the mistake. The Director of Nursing confirmed the errors in both cases. The transcription errors and failure to follow medication administration protocols led to these deficiencies, highlighting lapses in the facility's adherence to professional standards and policies.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not following physician's orders for two residents. For Resident 10, the physician's orders specified that Midodrine should be administered only if the resident's systolic blood pressure was 120 mmHg or less and diastolic blood pressure was 80 mmHg or less. However, the medication was administered multiple times when the resident's blood pressure readings exceeded these parameters. This included instances where the systolic blood pressure was as high as 169 mmHg and the diastolic pressure reached 100 mmHg. Similarly, for Resident 57, the physician's orders also required that Midodrine be withheld if the systolic blood pressure was greater than 120 mmHg or the diastolic blood pressure was greater than 80 mmHg. Despite this, the medication was administered on several occasions when the blood pressure readings were above the specified limits, such as a diastolic pressure of 88 mmHg. Interviews with the Director of Nursing confirmed that the medication should not have been administered under these circumstances.
Failure to Administer and Document IV Care as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration and management of intravenous (IV) fluids and medications for several residents. For Resident 8, the facility did not document the administration of the ordered sodium chloride solution intravenously, nor did they flush the resident's intravenous line with normal sterile saline (NSS) before and after administering ceftriaxone, an antibiotic. The Director of Nursing confirmed the lack of documentation for these actions. Resident 117 also experienced deficiencies in care, as the facility did not document flushing the resident's peripherally inserted central catheter (PICC) with NSS and Heparin as ordered by the physician. Additionally, there was no evidence that the resident's midline was flushed with saline before and after the administration of antibiotics such as Vancomycin and Ceftriaxone. The Director of Nursing confirmed these lapses in documentation and care. For Resident 122, the facility failed to change the PICC line dressing as ordered by the physician. The dressing, which was due to be changed every seven days, was not changed on the scheduled date, as confirmed by both a Registered Nurse and the Director of Nursing. These deficiencies highlight a pattern of non-compliance with physician orders and inadequate documentation of care provided to residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that physician's orders for medications were followed, resulting in significant medication errors for two residents. Resident 3, who had moderate cognitive impairment and a diagnosis of a displaced trimalleolar fracture, continued to receive Xarelto for four days after it was discontinued and replaced with Lovenox. This error occurred despite the facility's policy requiring medications to be administered according to orders and verified three times before administration. The Director of Nursing confirmed that Resident 3 received Xarelto after it was supposed to be stopped. Additionally, Resident 81, who had dementia and communication deficits, was mistakenly given another resident's medications. An agency LPN attempted to administer medications to Resident 81, believing she was another resident, due to a misidentification at the beauty salon. Resident 81 did not accept the medications and spit them out. The incident was confirmed by the Director of Nursing, who acknowledged that the agency LPN did not follow the facility's medication administration policy.
Incomplete Clinical Records and Documentation Failures
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents. For Resident 45, the Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and required assistance for daily care needs, including scheduled showers. However, documentation for several dates in December 2024 and January 2025 showed 'not applicable' for showers/baths, with no record of the resident being offered or refusing a shower or bed bath. The Director of Nursing confirmed that the resident's showers were scheduled for the daytime, but the charting system inaccurately reflected this, leading to incomplete documentation. For Resident 117, physician's orders required the administration of Ceftriaxone intravenously every 24 hours. However, the Medication Administration Records (MARs) for September and October 2024 lacked documentation of administration on specific dates. The Director of Nursing verified with the pharmacy that there were no missing doses, indicating that the nurses failed to sign off on the administration. Similarly, Resident 122 had orders for Vancomycin IV every 12 hours, but the MAR for January 2025 did not show administration on two dates. Again, the Director of Nursing confirmed with the pharmacy that doses were not missing, suggesting a failure in documentation by the nursing staff.
Failure to Obtain Required Hospice Documentation for Residents
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for three residents receiving hospice care. The facility's policy mandates that hospice documentation, including the physician's certification of terminal illness, hospice agreement, and coordinated plan of care, be provided within 48 to 72 hours of admission and be part of the resident's medical record. However, for Residents 18, 57, and 93, this documentation was missing, indicating a lapse in compliance with the facility's policy. Resident 18, who is cognitively impaired and has medical diagnoses including dementia and a history of stroke, was receiving hospice services as per physician's orders. Despite this, there was no documented evidence in the resident's clinical record or the hospice provider's record that the facility obtained the necessary physician certification form and nursing notes. The Director of Nursing confirmed the absence of these documents in the resident's hospice chart. Similarly, Resident 57, who has alcoholic cirrhosis and COPD, and Resident 93, who has peripheral vascular disease and diabetes, were also receiving hospice services. For Resident 57, there was no current hospice plan of care or hospice visit notes after the last documented visit. For Resident 93, there were no hospice records in the clinical record since the resident's admission to hospice. The Director of Nursing confirmed the lack of documentation for both residents, highlighting a systemic issue in obtaining and maintaining required hospice documentation.
Repeated Deficiencies in Quality Assurance
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 the current survey. These deficiencies included inaccurate Minimum Data Set (MDS) assessments, failure to update residents' care plans, inadequate professional nursing services, substandard quality care, unsafe environments, improper storage and labeling of medications, and poor infection control practices. The facility had previously developed plans of correction for these issues, which included conducting audits and reporting results to the QAPI committee. However, the current survey revealed that these plans were ineffective in addressing the recurring deficiencies. The deficiencies were initially identified in a survey ending March 7, 2024, and the facility's plans of correction were intended to ensure compliance with nursing home regulations. Despite these efforts, the current survey ending February 7, 2025, found that the QAPI committee was ineffective in implementing corrective actions. The repeated deficiencies were cited under various F-tags, including F641, F657, F658, F684, F689, F761, and F880, indicating a systemic failure in the facility's quality assurance processes.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) for four residents, leading to deficiencies in implementing Enhanced Barrier Precautions (EBPs). Resident 10, who had a left chest wall tunneled catheter for hemodialysis, did not have the required infection control signage or EBPs in place, as confirmed by both the Registered Nurse/Infection Control Preventionist and the Director of Nursing. Similarly, Resident 27, who had a feeding tube, also lacked the necessary infection control signage and EBPs, which was acknowledged by the Nursing Home Administrator. Resident 65, who had a chronic wound on her left lower leg, was not placed on EBPs despite having a care plan that indicated the need for such precautions. The Registered Nurse/Infection Control Preventionist incorrectly believed that EBPs were only necessary if the wound was infected or if a medical device was inserted. The Director of Nursing confirmed that Resident 65 should have been on EBPs. Additionally, Resident 93, who had an unstageable pressure ulcer and a venous ulcer, was not on EBPs, and the Licensed Practical Nurse failed to apply the appropriate PPE during wound care, despite the presence of EBP signage and PPE at the door. The report highlights a systemic failure in the facility's infection control practices, particularly in the implementation of EBPs for residents with chronic wounds or indwelling medical devices. Interviews with staff, including the Nursing Home Administrator, confirmed the oversight in applying EBPs for the affected residents, indicating a lack of adherence to updated infection control policies and guidelines.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital for three residents. Resident 3, who had moderate cognitive impairment and a displaced trimalleolar fracture, was transferred to the emergency room after a fall, but no written notice was given to the resident's representative. Similarly, Resident 45, who was cognitively intact and had multiple diagnoses including atrial fibrillation and a right femur fracture, was transferred to the hospital following a fall, yet no written notice was provided to the resident's representative. Additionally, Resident 93, who was cognitively impaired and had conditions such as an unstageable pressure ulcer and peripheral vascular disease, was also transferred to the hospital without a written notice being given to the resident's representative. The Nursing Home Administrator confirmed that the facility did not provide the required written notices for these transfers, which was identified as a deficiency during the survey.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to residents or their representatives at the time of transfer to a hospital for three residents. Resident 3, who had moderate cognitive impairment and a displaced trimalleolar fracture, was transferred to the emergency room after a fall, but there was no documented evidence of a bed-hold notice being provided. Similarly, Resident 45, who was cognitively intact and had multiple diagnoses including atrial fibrillation and a right femur fracture, was transferred to the hospital following a fall, yet no bed-hold notice was documented. Resident 93, who was cognitively impaired and had multiple health issues including an unstageable pressure ulcer and diabetes, was also transferred to the hospital without a documented bed-hold notice. The Nursing Home Administrator confirmed that the facility did not provide bed-hold notices to these residents or their representatives when they were transferred to the hospital. The issue was identified on November 24, 2024, but the deficiency was cited as past noncompliance. The lack of documentation for the bed-hold notices was a clear oversight in the facility's protocol, impacting the residents' rights to be informed about their bed-hold status during hospital transfers.
Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a comprehensive, resident-centered care plan was developed and implemented for a resident, identified as Resident 45, who was reviewed during a survey. The facility's policy, dated September 12, 2024, mandates the creation of a person-centered care plan that includes necessary and appropriate care, physician orders, and services to accommodate resident needs and preferences. However, a significant change Minimum Data Set (MDS) assessment for Resident 45, dated November 25, 2024, indicated that the resident was cognitively intact, required assistance for daily care needs, and needed oxygen therapy due to conditions such as atrial fibrillation, high blood pressure, a right femur fracture, asthma, and chronic obstructive pulmonary disease. Despite a physician's order dated November 18, 2024, for oxygen therapy at 2 liters per minute via nasal cannula, there was no documented evidence of a care plan addressing the resident's oxygen use. This deficiency was confirmed during an interview with the Director of Nursing on February 4, 2025.
Failure to Ensure Use of Assistance Devices for Resident
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place for a resident who was cognitively impaired and dependent on staff for daily care needs. The resident, who had a diagnosis of dementia and was at risk for falling, was supposed to wear hipsters when out of bed as per their care plan. However, on two separate occasions, the resident was found lying on the floor without wearing hipsters. The first incident occurred in the solarium on B hall, and the second in the 1B solarium. The Director of Nursing confirmed that the resident was not wearing hipsters at the time of the falls because the task was not correctly added to the nurse aide task list, leading to a lack of awareness among the nurse aides that the resident should wear them.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, for one of the three nurse aides reviewed, Nurse Aide 4, there was no documented evidence of an annual performance evaluation being conducted between March 15, 2023, and January 15, 2025. This evaluation was due by April 8, 2024, based on the hire date of Nurse Aide 4. The Nursing Home Administrator confirmed on February 7, 2025, that the evaluation had not been completed as required, which is a violation of 28 Pa. Code 201.18(e)(1) Management.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. Physician's orders for the resident included an order for Tramadol, a narcotic medication, to be administered as needed for pain. However, the controlled drug logs indicated that doses of Tramadol were signed out for administration on several dates, but there was no documented evidence in the resident's clinical record, including the Medication Administration Records (MARs) and nursing notes, that the medication was actually administered on those dates. An interview with the Director of Nursing confirmed the lack of documentation for the administration of Tramadol to the resident on the specified dates.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to securely store medication for one resident and did not label multi-dose containers of medications with the date they were opened. For Resident 57, who was on diuretic therapy for ascites, a 100 mg tablet of Spironolactone was found lying on the resident's bed, indicating that the medication was not properly administered or stored. The resident's care plan specified that staff should administer medications as ordered, and the resident was not deemed capable of self-administering medications. This was confirmed by the Director of Nursing, who acknowledged that the medication should not have been on the resident's bed. Additionally, during an observation of the third-floor medication cart, it was found that a Trelegy Ellipta inhaler for another resident was opened but not dated with the date it was opened, as required by the facility's policy. The manufacturer's instructions for the inhaler specified that it should be discarded six weeks after being removed from the foil pouch, emphasizing the importance of dating the container upon opening. This oversight was confirmed by an LPN during the observation.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios as mandated by the regulation effective July 1, 2023. Specifically, the facility did not provide the minimum required number of nurse aides per residents during various shifts over a 21-day period. On the day shift, the facility provided one nurse aide per 12 residents on several days, and even one nurse aide per 15 residents on one occasion, instead of the required one nurse aide per 10 residents. During the afternoon shift, the facility provided one nurse aide per 12 to 15 residents on multiple days, failing to meet the required one nurse aide per 11 residents. Additionally, on the overnight shift, the facility provided one nurse aide per 19 residents on two occasions, instead of the required one nurse aide per 15 residents. These deficiencies were confirmed through a review of nursing schedules, staffing information, and staff interviews. The Nursing Home Administrator acknowledged the failure to meet the staffing ratios during an interview conducted on December 5, 2024.
Plan Of Correction
The Administrator, Director of Nursing, Scheduler and Human Resource Director will be educated on the state requirement for nurse aide hours including the nurse aide to resident ratios by the Clinical Consultant/designee. Staffing meetings will be held 5 days a week to review the nurse aide ratio for the current day and the projected nurse aide ratio for the upcoming day to ensure appropriate staffing levels by the Nursing Home Administrator/ designee. Audits of ratios will be reviewed at quality assurance and performance improvement meeting x3 months. If projected staffing ratios do not meet minimum, then the facility will reach out to current staff and local staffing agencies to enlist to meet the minimum requirement. Facility will continue to recruit staff through all platforms.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required staffing ratios for licensed practical nurses (LPNs) during specific shifts over a 21-day review period. On November 20, 2024, the facility provided one LPN per 27 residents during the day shift, which did not meet the minimum requirement of one LPN per 25 residents. Additionally, on November 21, 2024, the facility provided one LPN per 28 residents during the day shift, again failing to meet the required ratio. Furthermore, on the overnight shift of November 20, 2024, the facility provided one LPN per 46 residents, falling short of the required one LPN per 40 residents. These deficiencies were confirmed through a review of nursing schedules and an interview with the Nursing Home Administrator on December 5, 2024.
Plan Of Correction
The Administrator, Director of Nursing, Scheduler, and Human Resource Director will be educated on the state requirement for Licensed Practical Nurse hours including the LPN to resident ratios by the Clinical Consultant/designee. Staffing meetings will be held 5 days a week to review the LPN ratio for the current day and the projected LPN ratio for the upcoming day to ensure appropriate staffing levels by the Nursing Home Administrator/designee. If LPN hours cannot be secured by using in-house staff, staffing agencies will be utilized. Audits of ratios will be reviewed at quality assurance and performance improvement meeting x3 months.
Deficiency in Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.20 hours of direct resident care per resident for eight out of 21 days reviewed. Specifically, the nursing time schedules from November 13 through December 3, 2024, showed that the facility provided less than the required hours on several days. On November 16, 2024, the facility provided 3.10 hours, on November 23, 2024, 3.13 hours, on November 24, 2024, 3.11 hours, on November 27, 2024, 3.19 hours, on November 28, 2024, 3.00 hours, on November 29, 2024, 3.05 hours, on December 1, 2024, 3.16 hours, and on December 2, 2024, 3.17 hours of direct care per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 5, 2024, at 9:24 a.m.
Plan Of Correction
Administrator, Director of Nursing, Scheduler, and Human Resources will have a morning and afternoon staffing meeting 5 days per week to go over the current day's Per Patient Day hours and the upcoming day's PPD to ensure minimum number of direct care hours is met. If minimum number of hours is not met, facility will reach out to current staff and staffing agencies to obtain direct care staff and increase hours. PPD will be audited at quality assurance and performance improvement meeting x3 months.
Inaccurate MDS Assessments Due to Documentation Discrepancies
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for seven residents. The Resident Assessment Instrument (RAI) User's Manual specifies that if the pneumococcal vaccine was not received, Section O0300C should be coded with the reason. However, for Residents 1, 49, 68, 87, 90, 122, and 124, this section was incorrectly coded as 'not assessed, no information,' despite documentation in their paper charts indicating whether the vaccine was offered and declined or received. For example, Resident 1's quarterly MDS assessment did not reflect the declination of the pneumococcal vaccine documented on June 30, 2023, and Resident 90's assessment did not reflect the receipt of the vaccine on July 18, 2019, and August 10, 2020. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the inaccuracies were due to the vaccine information not being part of the electronic medical record but instead located in the residents' paper charts. This discrepancy led to the incorrect coding of the MDS assessments, violating the guidelines set forth in the RAI User's Manual. The facility's failure to accurately complete these assessments was identified during a review of clinical records and staff interviews, highlighting a significant gap in the documentation process.
Failure to Clarify Physician's Orders for Pain Management
Penalty
Summary
The facility failed to clarify physician's orders for pain management for one resident, identified as Resident 19. According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, registered nurses are required to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals, and carry out nursing care actions that promote, maintain, and restore well-being. However, the physician's orders for Resident 19, dated January 17, 2024, specified that the resident should receive one 10-325 mg tablet of Norco every six hours for moderate to severe pain (4-10 on a pain scale). The order did not include instructions for pain ratings of 0 to 3, and there was no documented evidence that the nursing staff attempted to clarify these orders with the resident's physician. Review of Resident 19's Medication Administration Records (MARs) for February and March 2024 revealed multiple instances where staff administered Norco for pain ratings of 0, 2, and 3, which were outside the specified range of 4-10. This included numerous administrations at various times of the day, indicating a pattern of non-compliance with the physician's orders. An interview with the Registered Nurse/Staff Development/Nurse Aide Educator confirmed that the orders should have been clarified with the physician. This failure to clarify the physician's orders for pain management constitutes a deficiency in meeting professional standards of quality care as required by the Pennsylvania Code and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Failure to Follow Enteral Feeding Policy
Penalty
Summary
The facility failed to ensure that a tube feeding was administered in accordance with its policy for one resident. The policy required nursing staff to check and document gastric residual volume prior to administering the feeding. However, a review of the clinical records for a cognitively intact resident with a feeding tube revealed no documented evidence that gastric residuals were checked before administering tube feedings from January 18, 2024, through March 4, 2024. This was confirmed by the Registered Dietician during an interview on March 6, 2024.
Failure to Attempt Non-Pharmacological Interventions Before Administering Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of anti-anxiety medications for Resident 79. The resident, who was cognitively impaired and had a diagnosis of dementia, received antianxiety medications including lorazepam and Ativan. Physician's orders indicated the administration of these medications as needed for anxiety and agitation. However, the Medication Administration Records (MARs) for December 2023 through March 2024 showed multiple instances where Ativan was administered without documented evidence of any non-medication interventions being attempted first. Interviews with a Licensed Practical Nurse and the Nursing Home Administrator confirmed that non-medication interventions should have been attempted and documented prior to administering the medication. The absence of such documentation was acknowledged, indicating a failure to comply with the required protocols for managing anxiety in residents. This deficiency was identified during a review of clinical records and staff interviews, highlighting a lapse in the facility's adherence to non-pharmacological intervention protocols before resorting to medication.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures, as evidenced by observations and resident interviews. The facility's policy required hot foods to be at least 135 degrees Fahrenheit and cold foods to be 41 degrees Fahrenheit or lower. However, during an observation, the temperatures of various food items on a resident's tray were found to be below these standards: pork and gravy at 119.3 degrees F, rice pilaf at 127.6 degrees F, steamed broccoli at 117.1 degrees F, and milk at 44.6 degrees F. Interviews with residents revealed dissatisfaction with the food, with one resident reporting cold French fries and another expressing dislike for the taste of the food. The Registered Dietitian confirmed that the hot foods should be at a minimum of 135 degrees F. These findings indicate a failure to adhere to the facility's food temperature standards, resulting in unappetizing and potentially unsafe meals for residents.
Failure to Maintain Sanitary Conditions in Food Storage and Preparation
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. Observations in the walk-in freezer revealed an accumulation of ice on the ceiling, floor, metal storage racks, and on cases of food products stored below the freezer condenser. The Registered Dietitian confirmed the presence of ice on the food products. Additionally, the main kitchen had food debris, including a French fry, under a wheeled cart, which was confirmed by the Registered Dietitian. The facility's policy on handwashing was not followed by Dietary Worker 9, who did not wash her hands after returning from delivering trays to the nursing units and continued to handle food without proper sanitation. Furthermore, the Hoshizaki ice machine in the Second Floor Nourishment Station had a buildup of a black, removable substance on the end of the drain line. The Director of Maintenance confirmed this issue and indicated that the ice machines are cleaned quarterly. These deficiencies indicate a failure to maintain sanitary conditions in food storage, preparation, and distribution areas, as well as in the maintenance of ice machines.
Recurring Quality Deficiencies in Facility's QAPI Committee
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effectively implemented. The deficiencies identified in the current survey included issues related to freedom from abuse/neglect, accuracy of Minimum Data Sets (MDS) assessments, services provided to meet professional standards, quality of care, safety and accident hazards, palatability of food, food procurement/storage/preparation, and infection control. These deficiencies were previously cited in surveys ending April 13, 2023, and July 27, 2023, and the facility had developed plans of correction that included quality assurance systems to maintain compliance with nursing home regulations. However, the current survey revealed that the QAPI committee failed to successfully implement these plans, resulting in repeated deficiencies. Specifically, the facility's plan of correction for deficiencies regarding freedom from abuse/neglect, accurate MDS assessments, services provided to meet professional standards, quality of care, safety and accident hazards, palatable food, food procurement/storage/preparation, and infection control included completing audits and reporting the results to the QAPI committee for review. Despite these measures, the current survey identified ongoing non-compliance in these areas, indicating that the QAPI committee did not effectively address the recurring issues. The repeated deficiencies highlight a systemic failure in the facility's quality assurance processes and the inability to maintain compliance with essential regulations to ensure the safety and well-being of residents.
Failure to Follow Infection Control Standards
Penalty
Summary
The facility failed to follow infection control standards and Pennsylvania Department of Health guidelines to reduce the spread of infections and prevent cross-contamination. Specifically, the facility did not ensure that staff properly used personal protective equipment (PPE) as required. Observations revealed that a Registered Nurse/Staff Development/Nurse Aide Educator was inside a COVID-19 positive resident's room wearing a surgical mask and an N95 mask under her chin, instead of properly donning the N95 mask. Additionally, an Agency Licensed Practical Nurse was observed with her surgical mask down under her chin while in a hallway with several COVID-19 positive rooms and while handling the medication cart. Both staff members confirmed in interviews that they were not following the proper PPE protocols as required by the facility's policy and DOH guidelines. The deficiency involved Resident 45, who was in contact isolation due to a positive COVID-19 test. The resident's room had clear signage indicating the required PPE, including an N95 respirator, goggles/face shield, gloves, and gown. Despite this, the Registered Nurse/Staff Development/Nurse Aide Educator did not properly wear the N95 mask while in the resident's room. Similarly, the Agency Licensed Practical Nurse, who was new to the facility, was not aware of the facility's PPE requirements and was observed with her surgical mask improperly positioned. The Nursing Home Administrator confirmed that both staff members should have been wearing the appropriate PPE as per the facility's infection control policy and DOH guidelines.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by incidents involving two residents. Resident 88, who was cognitively intact and dependent on staff for all care needs, reported that Nurse Aide 1 removed his call bell from his reach and told him to stop ringing it so much. This incident was corroborated by statements from other staff members. Despite being aware of the situation, the staff did not immediately remove Nurse Aide 1 from duty, allowing him to continue working his shift. The Nursing Home Administrator and the Director of Nursing confirmed that Nurse Aide 1 should not have removed the call bell and should have been removed from duty immediately upon the report of the incident. Similarly, Resident 115, who was also cognitively intact and dependent on staff for all care needs, reported that Nurse Aide 4 withheld his urinal and made derogatory comments, causing him to urinate on the floor. This incident was supported by statements from other staff members. Despite the severity of the allegations, Nurse Aide 4 was not removed from duty immediately and continued to work her entire shift. The Nursing Home Administrator and the Director of Nursing confirmed that Nurse Aide 4 should not have refused care and should have been removed from duty immediately upon the report of the incident.
Failure to Follow Abuse Policy and Verify Employee Credentials
Penalty
Summary
The facility failed to follow its abuse policy regarding the immediate removal of involved staff members from duty pending a full investigation, which compromised the protection of residents. Specifically, two residents, Resident 88 and Resident 115, reported incidents of abuse by staff members. Resident 88, who was cognitively intact and dependent on staff for all care needs, reported that a nurse aide removed his call bell and told him to stop ringing it. Despite this report, the nurse aide continued to work his shift without being immediately removed from duty as required by the facility's policy. Similarly, Resident 115, also cognitively intact and dependent on staff, reported that a nurse aide withheld his urinal, mocked him, and told him to urinate on himself. This nurse aide also continued to work her shift without immediate removal following the allegations. Additionally, the facility failed to implement its abuse prohibition policies regarding the verification of new employees' standing with the Pennsylvania Nurse Aide Registry or the State Board of Nursing. Two new employees, a nurse aide and a registered nurse, were hired without timely verification of their credentials. The nurse aide's enrollment in the registry was not verified until 119 days after hiring, and the registered nurse's licensure was not verified until 62 days after hiring. This lack of timely verification is a direct violation of the facility's policy, which mandates checking the nurse aide registry and state licensure agency prior to employment. Interviews with the Nursing Home Administrator, Director of Nursing, and Human Resources Director confirmed these deficiencies. The Nursing Home Administrator and Director of Nursing acknowledged that the involved staff members should have been immediately removed from duty following the allegations. The Human Resources Director confirmed the delay in verifying the credentials of the new employees. These failures indicate a significant lapse in adhering to the facility's abuse prevention and verification policies, thereby compromising resident safety and regulatory compliance.
Failure to Update Care Plan for Pacemaker Monitoring
Penalty
Summary
The facility failed to revise the care plan for a resident with a pacemaker to include individualized interventions for pacemaker monitoring. The resident, who was cognitively intact and required maximum assistance with dressing and toilet use, had diagnoses of coronary artery disease and heart failure. Despite the facility's policy requiring the inclusion of physician's orders for pacemaker monitoring in the care plan, there was no documented evidence of an appointment for pacemaker monitoring. This deficiency was confirmed through an interview with the Registered Nurse Assessment Coordinator.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide medications as ordered by the physician for one resident. Physician's orders for the resident, dated December 14, 2023, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL every six hours as needed for pain. However, the resident's Medication Administration Record (MAR) for January 2024 revealed that the resident was administered 5 mg Oxycodone on January 17 and January 20, 2024, and not the 10 mg that was ordered. An interview with a Registered Nurse on March 7, 2024, confirmed that the resident only received 5 mg of Oxycodone on those dates, contrary to the physician's orders.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place as ordered and care planned for a resident. The resident, who had a history of cerebral vascular accident (CVA) and multiple falls, was assessed to be at risk for falls and was ordered to have bilateral fall mats. However, observations revealed that only one fall mat was placed on the right side of the resident's bed, while the left side toward the door had no fall mat. This was confirmed by an agency nurse aide. Nursing notes indicated that the resident had been found out of bed on the fall mat on multiple occasions, but the required bilateral fall mats were not consistently in place.
Failure to Complete Safety Assessment for Bed Rail Use
Penalty
Summary
The facility failed to complete a safety assessment for a resident who used top side rails for mobility. An admission Minimum Data Set (MDS) assessment for the resident revealed that the resident was understood and could understand, and had a diagnosis of arthritis. Observations of the resident lying in bed revealed the use of bilateral top side rails. A review of the resident's clinical record showed no documented evidence of a side rail safety assessment prior to the use of the side rails. An interview with the Nursing Home Administrator confirmed that the safety assessment was not completed and should have been.
Medication Labeling Discrepancy
Penalty
Summary
The facility failed to ensure that medications were properly labeled for one of 41 residents reviewed. Physician's orders for Resident 107, dated December 14, 2023, included an order for the resident to receive 10 milligrams (mg) of Oxycodone HCL every six hours as needed for pain. However, the label on Resident 107's pill card of Oxycodone revealed that the card contained 5 mg tablets, and the resident was to receive only one tablet every six hours as needed for pain. This discrepancy was confirmed during an interview with Registered Nurse 6 on March 7, 2024, at 2:43 p.m., indicating that the current physician's order did not match the label on the card of Oxycodone, which it should have.
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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