Meadows Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Pennsylvania.
- Location
- 4 East Center Street, Dallas, Pennsylvania 18612
- CMS Provider Number
- 395587
- Inspections on file
- 26
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Meadows Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, peripheral vascular disease, and ongoing lower extremity vascular wounds did not receive timely, comprehensive wound assessments as required by facility policy and best practices. Over several months, nursing progress notes repeatedly documented the same limited descriptions of a left shin wound, including slough, open areas, scattered scabs, granulation tissue, and scant serous drainage, but lacked measurements, staging, and complete weekly assessments. Despite a change in treatment orders and instructions to document the wound condition daily, the record contained no evidence of full wound assessments with location, stage, length, width, depth, or exudate/necrotic tissue details until an outside wound management provider conducted a full-body skin assessment, and the facility could not show that an RN had completed timely, comprehensive assessments of the venous ulcer before that time.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A nurse aide transported a resident with peripheral vascular disease in a shower chair through a hallway while the resident's buttocks and gluteal cleft were exposed due to inadequate covering. The aide was unaware of the exposure, and the facility did not ensure the resident's dignity was maintained during care.
A resident's bed linens remained visibly soiled with large tan stains and dark red streaks over multiple days, despite staff being responsible for changing bedding when soiled. Interviews with a nurse aide and the DON confirmed that the facility did not maintain a clean, safe, and sanitary environment in the resident's room.
The facility did not update comprehensive care plans for two residents to reflect current physician orders, including insulin administration, fluid restrictions, and oxygen therapy. This deficiency was identified through clinical record reviews and staff interviews, showing that care plans were not revised to address the residents' individualized needs.
A resident with inflammatory polyarthropathy was not consistently provided with restorative ambulation services as outlined in their care plan. Although records indicated that ambulation with a rollator walker was completed regularly, the resident reported only walking once in the past month. A nurse aide admitted to documenting the task as completed before actually performing it, leading to discrepancies between documentation and actual care provided.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, as observed by surveyors during their review.
The facility did not provide required written notices of facility-initiated hospital transfers to the State LTC Ombudsman for two residents. Although the residents and their representatives received the notices, there was no documentation that the Ombudsman was notified, as confirmed by the Nursing Home Administrator.
A resident with multiple orthopedic conditions and a non-weight bearing order suffered a right tibia and fibula fracture requiring surgery after three nurse aides transferred her without using the required mechanical lift, despite being aware of the physician's order and care plan. The aides manually transferred the resident during a shower, leading to severe pain and injury, and the facility's investigation substantiated neglect due to failure to follow safety protocols.
The facility failed to provide restorative ambulation services to residents, as evidenced by the experiences of three residents with various medical conditions. Changes in staffing and budgeting led to the removal of designated restorative aides, placing the responsibility on nurse aides. Residents expressed that they were not receiving their scheduled ambulation programs, and records confirmed limited participation. Interviews with facility leadership revealed an inability to explain the lack of services, despite acknowledging the facility's responsibility.
A resident with severe cognitive impairment and a history of skin tears was not provided with prescribed Geri Sleeves to protect her arms, despite a physician's order. Observations confirmed the absence of these protective devices, and staff were unable to explain or locate them, indicating a failure to adhere to professional standards of practice.
A resident with dementia and congestive heart failure exceeded their physician-ordered fluid restriction multiple times over several weeks. The facility's policy required notifying the physician if fluid restrictions were exceeded, but there was no documentation of such notifications. An interview with the DON confirmed the lack of adherence to the fluid restriction order, indicating a deficiency in maintaining the resident's care plan.
The facility failed to monitor and document IV therapy according to professional standards for two residents. One resident's IV site was not labeled with the date of insertion, and the catheter was not removed after completing medication. Another resident's IV site dressing was not dated, and there was no documented evidence of a dressing change. The DON confirmed these deficiencies.
A facility failed to communicate necessary resident information to a receiving health care provider during a transfer. A resident was transferred to a hospital with the expectation of returning, but there was no documented evidence that the resident's care plan goals and necessary information were communicated. The Nursing Home Administrator confirmed this deficiency during an interview.
The facility did not provide written notification of its bed-hold policy to two residents or their representatives upon hospital transfer, as required. This deficiency was confirmed through a review of clinical records and an interview with the administrator, which revealed a lack of documented evidence for the provision of the necessary information.
A resident with a history of kidney transplant received incorrect doses of Tacrolimus due to a transcription error by a nurse, leading to Tacrolimus toxicity and subsequent hospitalization. The error was discovered after the resident showed symptoms of altered mental status and low blood oxygen saturation.
Two residents suffered injuries due to neglect in a facility. One resident with severe cognitive impairment fell because an LPN failed to lower the bed as per the care plan, resulting in a head injury. Another resident was injured during transport when the van driver did not secure the wheelchair properly, causing it to flip. Both incidents were confirmed by the DON.
Failure to Perform and Document Comprehensive Wound Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, comprehensive assessment and monitoring of a resident’s lower extremity vascular wounds and to implement necessary practices to prevent worsening skin breakdown. The resident was admitted with dementia and peripheral vascular disease and had ongoing skin integrity issues related to vascular wounds on both lower extremities. An Annual MDS showed the resident was cognitively moderately impaired and required substantial/maximal assistance with mobility-related ADLs and used a wheelchair for mobility. Progress notes showed that from late October through late January, wound documentation for the resident’s left lower extremity was repetitive and lacked comprehensive assessment details. Entries on October 30 and November 7 documented a left lower extremity wound partially covered with slough, scant serous drainage, no infection, and stated wounds were improving with a directive to continue treatment, but did not include measurements or staging. On December 24, a new treatment order for the left shin wound was documented, including cleansing with antiseptic spray and application of Silvadene, with instructions to document the wound condition daily. Subsequent notes on January 6 and January 14 described five open areas with scattered scabs and scant serous drainage without signs of infection, but again did not include measurements or staging. Further progress notes dated January 15, 20, 22, and 27 repeated essentially identical descriptions of the left shin wound as vascular in appearance with five open areas, scattered scabs, pink granulation tissue, scant serous drainage, and no signs of infection, without additional or updated assessment information. The clinical record lacked documentation of required wound measurements, staging, or complete weekly assessments between October and early February, despite facility policy requiring assessment and documentation of location, stage, length, width, depth, and presence of exudate or necrotic tissue. Interviews with the NHA and the designated wound nurse confirmed that an outside wound management provider performed full-body skin assessments on all residents on February 2, and the wound nurse acknowledged that weekly full wound assessments with all required elements were expected but had not been fully documented for this resident’s venous ulcer prior to that date. The facility was unable to provide documentation that an RN completed timely and comprehensive wound assessments for the resident’s venous ulcer before February 2.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming.
Resident Exposed During Hallway Transport
Penalty
Summary
A nurse aide was observed transporting a resident with peripheral vascular disease in a shower chair through a public hallway while the resident was only wearing a black t-shirt that extended to the waist and was not wearing pants. A white cloth was loosely draped across the resident's lap, but the resident's buttocks and approximately four inches of the gluteal cleft were visibly exposed during the transport to the shower room. The nurse aide was unaware of the exposure at the time. The Nursing Home Administrator confirmed that residents have the right to be provided care with dignity and acknowledged that the resident should have been properly covered and provided with appropriate clothing to prevent exposure. The facility failed to ensure that the resident received care in a manner that maintained his dignity, as required by regulations.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Facility staff failed to provide necessary housekeeping and maintenance services to ensure a clean, safe, and sanitary environment for a resident. Multiple observations over two consecutive days revealed that the resident's fitted bed sheet had large tan stains and several long streaks of a dark red substance. These stains were consistently present on the bed sheet during each observation, indicating that the bedding had not been changed despite being visibly soiled. A nurse aide confirmed during an interview that bedding is typically changed on shower days or when visibly soiled, and acknowledged responsibility for the resident's care on the day in question but did not notice the soiled sheets. The DON also confirmed the failure to maintain a safe, sanitary, and orderly environment in the resident's room. The deficiency was cited under relevant state codes for management and licensee responsibility.
Failure to Update Comprehensive Care Plans with Current Medical Orders
Penalty
Summary
The facility failed to fully develop and revise person-centered comprehensive care plans to address the individualized needs of two residents. For one resident with diagnoses including congestive heart failure and diabetes, the clinical record showed recent physician orders for both short-acting and long-acting insulin, as well as a specific daily fluid restriction. However, the resident's comprehensive care plan, last revised after these orders were issued, did not reflect these updated medical treatments and interventions. Similarly, another resident with hypertension and hypoxemia had a physician's order for oxygen therapy due to shortness of breath. Despite this, the resident's comprehensive care plan, last revised after the order, did not include the updated intervention. These findings were confirmed through clinical record reviews and staff interviews, indicating that the facility did not ensure care plans were updated to reflect current physician orders and resident needs.
Failure to Provide and Accurately Document Restorative Nursing Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain or improve mobility for a resident diagnosed with inflammatory polyarthropathy. According to the resident's care plan, a restorative nursing walking program was initiated, requiring staff to assist the resident in walking with a rollator walker for distances up to 350 feet or as tolerated. Despite this plan, the resident reported that she had only walked once in the past month and was not regularly asked to participate in the walking program, contrary to the documented interventions. Clinical record review showed that the ambulation task was marked as completed multiple times, but the resident denied receiving the service on those occasions. Further investigation revealed that a nurse aide admitted to documenting the ambulation task as completed before actually performing it, intending to provide the service later. The facility's policy requires ongoing monitoring and accurate documentation of restorative nursing programs, but there was a discrepancy between the documentation and the resident's account. The Nursing Home Administrator confirmed that staff should not document care tasks as completed if they have not occurred and was unable to explain the inconsistency between the records and the resident's statements.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the potential for accidents to occur. The deficiency was based on direct observations and findings by surveyors during their review of the facility's practices and physical environment. No additional details regarding the specific hazards, the number of residents affected, or the medical conditions of those involved were provided in the report.
Failure to Notify Ombudsman of Facility-Initiated Transfers
Penalty
Summary
The facility failed to provide copies of written notices of facility-initiated hospital transfers to the representative of the Office of the State Long-Term Care Ombudsman for two residents. Clinical record reviews showed that both residents were transferred to the hospital and later readmitted to the facility. While written notices of the transfers were given to the residents and their representatives, there was no documented evidence that these notices were also sent to the Ombudsman as required. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of documentation for sending the required notices to the Ombudsman.
Failure to Follow Transfer Protocols Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order requiring the use of a mechanical lift for all transfers of a resident with significant mobility and orthopedic issues. The resident, who had diagnoses including osteoarthritis, rheumatoid arthritis, osteoporosis, and a periprosthetic fracture around a right knee prosthesis, was documented as non-weight bearing on the right lower extremity and required total staff assistance for transfers and showers. The care plan and physician's order specifically mandated the use of a Hoyer lift with a green sling for all transfers. Despite these clear directives, three nurse aides transferred the resident from her wheelchair to a shower chair without using the mechanical lift. Witness statements from the aides confirmed that they were aware of the requirement to use the lift but chose to manually transfer the resident instead. The aides cited reasons such as time constraints and the resident's position in the wheelchair, and one aide admitted to not wanting to upset coworkers. During the transfer, the resident experienced severe pain and reported feeling as though her leg was giving out. She subsequently complained of right leg pain, which was documented by nursing staff. An X-ray revealed a comminuted fracture of the right tibia and a displaced fracture of the right fibula, necessitating hospital transfer and surgical intervention. The facility's internal investigation substantiated that the aides knowingly failed to implement the required safety protocols, directly resulting in serious physical injury to the resident. The incident was classified as neglect, as the staff did not provide the necessary goods and services to avoid physical harm, as required by facility policy and physician orders.
Failure to Provide Restorative Ambulation Services
Penalty
Summary
The facility failed to ensure that residents received appropriate services and assistance to maintain or improve mobility, as evidenced by the experiences of three residents. The facility's policy, last reviewed on April 3, 2024, mandates a restorative nursing program to help residents achieve and maintain optimal function. However, changes in staffing and budgeting led to the removal of designated restorative aides, placing the responsibility of ambulation programs on nurse aides. This change was communicated to residents, who were instructed to inform staff if they were not being walked. Resident 79, who has a history of cerebral infarction and moderate cognitive impairment, was discharged from physical therapy with instructions to continue a restorative nursing program for ambulation. Despite this, records show that Resident 79 declined participation in the program 36 times and participated only 19 times between August 22, 2024, and September 20, 2024. Similarly, Resident 78, with diagnoses of muscle wasting and inflammatory polyarthropathy, also declined participation 30 times and participated 25 times in the same period. Both residents expressed during a group interview that they were not receiving their scheduled ambulation programs, attributing this to staff changes. Resident 40, with conditions including polyosteoarthritis and diabetes with neuropathy, also reported not receiving restorative ambulation services. Her records indicated that she was only provided with the ambulation program 5 times out of 36 opportunities in September 2024. Interviews with the Nursing Home Administrator and Director of Nursing revealed an inability to explain why residents were not receiving their restorative programs, despite acknowledging the facility's responsibility to provide such services.
Failure to Implement Physician's Orders for Skin Protection
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for Resident 34, who was admitted with diagnoses including degenerative disease of the nervous system and ataxia. The resident was severely cognitively impaired, as indicated by a BIMS score of 4. A physician's order was in place for the resident to wear Geri Sleeves on both arms at all times to protect against skin tears, following incidents where the resident had sustained skin tears on her arms. Despite the physician's order and care plan intervention, observations on multiple occasions revealed that Resident 34 was not wearing the protective skin devices. The resident was seen with bare arms during these observations, and staff interviews confirmed the absence of the protective sleeves. The registered nurse and the Nursing Home Administrator acknowledged the facility's responsibility to implement physician's orders and maintain the resident's skin integrity, yet the protective devices were not in use, and the staff could not explain or locate them.
Failure to Maintain Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to maintain a physician-ordered fluid restriction for a resident diagnosed with dementia and congestive heart failure. The resident was admitted with a fluid restriction order of 1500 mL per 24 hours, divided between dietary and nursing staff. However, a review of the resident's daily fluid intake records from late August to mid-September revealed multiple instances where the resident's fluid intake exceeded the prescribed limit, with no documented evidence that the physician was notified of these excesses as required by the facility's policy. The facility's Intake and Output Monitoring Policy mandates that intake and output be documented in the Electronic Medical Record and reviewed daily by the RN Charge Nurse. If a resident exceeds fluid restrictions for two days, the physician must be informed. Despite this policy, there was no documentation indicating that the physician was notified of the resident's repeated excess fluid intake. An interview with the Director of Nursing confirmed the lack of documentation and adherence to the fluid restriction order, highlighting a deficiency in maintaining the resident's prescribed care plan.
Failure to Monitor and Document IV Therapy
Penalty
Summary
The facility failed to provide person-centered care by not monitoring intravenous (IV) therapy according to professional standards for two residents. Resident 94, who was admitted with conditions including pleural effusion and suspected pneumonia, had an IV catheter inserted for antibiotic administration. However, the IV site was not labeled with the date of insertion, and there was no documented evidence of dressing changes. The IV catheter was not removed after the completion of the prescribed medication, and there was no documented physician order for the care and monitoring of the IV site. Similarly, Resident 1, admitted with dementia and suspected septic arthritis, had an IV catheter inserted for antibiotic treatment. Observations revealed that the IV site dressing was not dated, and there was no documented evidence of a dressing change on a specific date, despite the dressing being labeled with that date. Additionally, there was no documented physician order for the care and monitoring of Resident 1's IV. The Director of Nursing confirmed the deficiencies in labeling and documentation as per facility policy.
Failure to Communicate Resident Information During Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer. This deficiency was identified through a clinical record review and staff interview, which revealed that a resident was transferred to a hospital and expected to return to the original facility. However, there was no documented evidence that the facility communicated the resident's care plan goals and all necessary information to meet the resident's specific needs at the receiving facility. During an interview, the Nursing Home Administrator confirmed the lack of evidence that the necessary information was communicated to the receiving health care institution or provider for the resident's transfer. This failure to communicate essential information was a violation of the regulatory requirements outlined in 28 Pa. Code 211.12 (d)(3)(5) regarding nursing services.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required by regulations. This deficiency was identified during a review of clinical records and staff interviews, which revealed that two residents, identified as Residents 96 and 27, were transferred to the hospital without receiving the necessary written information about the facility's bed-hold policy. Resident 96 was transferred on July 4, 2024, and Resident 27 on August 28, 2024. In both cases, there was no documented evidence that the facility provided the required written notice at the time of transfer. An interview with the administrator confirmed the absence of such documentation.
Significant Medication Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, which compromised the resident's clinical condition and health due to Tacrolimus toxicity. The resident, who had a history of a kidney transplant, was admitted from the hospital with discharge instructions to continue Tacrolimus at a specific dosage. However, upon admission to the facility, the physician orders incorrectly transcribed the dosage, leading to the administration of significantly higher doses of Tacrolimus than prescribed. The error was discovered after the resident exhibited symptoms of altered mental status and low blood oxygen saturation, prompting a transfer to the emergency room. The resident was later admitted to the hospital, where they expired, with Tacrolimus toxicity listed as a preliminary cause of death. The facility's investigation revealed that the medication was verified correctly but transcribed incorrectly by a registered nurse, leading to the administration of the wrong dosage.
Neglect Leads to Resident Injuries
Penalty
Summary
The facility failed to prevent physical injury or harm to two residents due to neglect. Resident CR2, who has severe cognitive impairment and Parkinson's disease, was at risk for falls. Despite having a care plan that required the bed to be in the lowest position to prevent falls, an LPN neglected to implement this intervention. As a result, Resident CR2 fell and sustained an open hematoma to the forehead, requiring emergency room treatment. The director of nursing confirmed that the LPN did not follow the care plan, leading to the resident's injury. Resident 26, who is cognitively intact and has diabetes and peripheral vascular disease, was injured during transport to a medical appointment. The resident's wheelchair flipped backward in the van because the front tie downs were not properly secured by the van driver. This negligence resulted in the resident striking his head on the van floor, causing a soft protrusion on the back of the head. The director of nursing confirmed that the van driver failed to ensure the resident's safety during transport.
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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