Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mid-valley Health Care Center during CMS and state inspections, most recent first.
Unclean Resident Pantry: The resident unit pantry was observed with two resident breakfast trays left on the counter, food splatter and debris inside the microwave, a sticky floor with red and brown staining, heavy dirt and debris along the perimeter, and white-chalky material under the counter with deterioration to the left wall corner. The DON confirmed housekeeping was responsible for maintaining the pantry and acknowledged the findings.
A resident with Type 1 DM and intact cognition was admitted after an insulin pump malfunction and was managed with sliding-scale insulin lispro in the facility. When the pump was repaired, the facility told the resident pumps were not allowed, and the resident left AMA to resume pump use; the record showed no documented discharge goal or individualized discharge plan addressing the resident’s preference, goals, or discharge needs.
A resident with severe cognitive impairment and a right femur fracture was observed wearing hearing assistive devices that helped her communicate clearly and effectively. The DON said the family supplied the devices and that they were used daily, but the comprehensive care plan did not identify the devices or include staff interventions for storage, assessment, cleaning, maintenance, function checks, or assistance with application and removal; the DON also confirmed the clinical record did not address the devices or their care implications.
Failure to Individualize Bladder Continence Care: A resident with dementia, psychotic disturbance, mood disturbance, and anxiety was admitted as continent but later developed worsening urinary incontinence. Although an initial toileting diary showed daytime and evening incontinence with nighttime continence, the care plan was not further individualized as the resident declined to frequent then total incontinence. The record lacked additional assessment of causes or a new continence program, and the DON confirmed the facility failed to provide individualized services to maintain bladder continence to the highest extent possible.
Failure to Assess Pain and Use Non-Pharmacological Measures Before PRN Oxycodone: A cognitively intact resident with a left ankle fracture had a PRN oxycodone order for moderate to severe pain, but staff administered the medication six times without documenting a pain severity rating or attempting/documenting non-pharmacological interventions first. The DON and NHA confirmed the facility did not follow its pain management policy.
Failure to provide routine dental care and obtain needed dental clearances delayed treatment for two residents. One resident with encephalopathy had no documented routine dental evals and, after reporting a broken partial bridge and sharp pain, no dental appt or treatment was arranged by survey exit. Another resident with dementia and severe cognitive impairment had a broken molar with infection; although the dentist prescribed antibiotics and the physician clearance was completed, the record did not show the required consent forms were completed so the recommended extraction could proceed.
The facility did not conduct or document a comprehensive assessment to ensure licensed nursing staff were trained and competent in providing care for residents with PICC lines or other central venous access devices. There was no evidence of staff training, competency evaluations, or established policies and procedures for safe PICC line management, and the DON confirmed the absence of a training program or documentation of staff competencies in this area.
Licensed nursing staff administered IV antibiotics via a PICC line to a resident with multiple infections without documented training or competency in PICC line care. The facility did not have a training program or include PICC line management in annual competency reviews, and could not provide records of staff education or compliance with state nursing regulations.
A resident with congestive heart failure, who was cognitively intact, expressed a desire to be discharged home during care plan and resident council meetings. The facility did not document follow-up or revise the discharge plan to reflect the resident's wishes, and the care plan continued to indicate a need for long-term care without individualized discharge planning or regular re-evaluation.
Surveyors identified that two residents did not have accurate or timely MDS assessments. One resident's seizure disorder was not coded on the MDS despite clinical evidence and ongoing treatment, while another resident's MDS was completed outside the required 14-day window. Staff interviews confirmed these issues, and supporting documentation was not provided.
The facility did not ensure that nursing services were provided in accordance with professional standards of quality, as identified by surveyors during their review of facility practices.
The facility did not meet the required nurse aide to resident ratios on five occasions, with understaffing noted on both day and night shifts. The night shift was consistently short by a fraction of a nurse aide for a census of 32 to 34 residents, and the day shift was short on one occasion. No additional staff were available to cover the deficiency, as confirmed by the Nursing Home Administrator.
The facility did not meet the required RN to resident ratio of 1:250 during the night shift for seven consecutive nights, with no RNs on duty despite a census of 32 to 34 residents. This staffing deficiency was confirmed by facility records and an interview with the Nursing Home Administrator.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan lacked documentation of symptoms, triggers, and specific interventions. The Director of Social Services confirmed the facility did not adhere to professional standards for culturally competent care.
A facility failed to ensure accurate administration and documentation of controlled medications for a resident. A nurse administered Percocet outside the prescribed schedule, mistakenly believing it was a PRN order, and failed to document it in the MAR. This error occurred despite the PRN order being discontinued, compromising the integrity of medication records.
A resident was administered an unnecessary antibiotic regimen due to the facility's failure to adhere to McGeer's criteria for diagnosing UTIs. Despite showing only one symptom of dysuria and a urine culture that did not meet the threshold for a UTI, the resident was prescribed Cipro. Concerns were raised by a nurse about the appropriateness of this treatment, but the CRNP continued the antibiotic citing urinary frequency and a positive urine culture.
The facility failed to meet the required nurse aide staffing ratios for several shifts, with staffing levels below the mandated minimums. This deficiency was identified through a review of nursing time schedules and resident census data, revealing that the facility did not have sufficient nurse aides to meet the regulatory requirements. The Nursing Home Administrator confirmed the facility's failure to provide the minimum nurse aide staffing ratios.
The facility failed to meet state-mandated LPN staffing requirements across multiple shifts from late November to December 2024. On several nights, no LPNs were on duty despite the census indicating the need for at least one. Additionally, the facility fell short of required LPN levels during day and evening shifts, with no higher-level staff available to compensate. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not consistently provide the required minimum of 3.2 hours of direct nursing care per resident daily. On a specific date, the facility only provided 2.92 hours per resident, as confirmed by the NHA.
The facility failed to prevent and manage pressure ulcers for three residents. One resident developed a deep tissue injury that evolved into an unstageable pressure ulcer due to lack of care plan and interventions. Another resident, at risk due to decreased mobility, developed a Stage 3 pressure wound without adequate preventative measures. A third resident's heel blister deteriorated into a Stage 3 ulcer without timely assessment or notification to physicians.
A resident with multiple diagnoses, including anxiety, was prescribed a reduced dose of Lorazepam. However, the facility failed to administer the correct AM dose due to a lack of updates on the narcotic sheet and medication card, and the pharmacy not sending the correct medication card due to insurance issues. The error was identified by an LPN, and no adverse reactions were reported.
A resident with multiple health conditions did not receive the correct morning dosage of Lorazepam due to a pharmacy delay in delivering the medication card, despite the script being received on time. The facility failed to ensure timely medication administration, resulting in a medication error.
A facility failed to create an individualized care plan for a resident with PTSD, neglecting to identify symptoms, triggers, and specific interventions to prevent re-traumatization. The DON confirmed the lack of culturally competent, trauma-informed care according to professional standards.
A resident with dementia and anxiety was prescribed Macrobid as a prophylactic treatment for a UTI without documented clinical necessity. Despite receiving 25 doses, there was no repeated urinalysis or culture and sensitivity tests to justify the continued use of the antibiotic. The facility's infection prevention protocol was not followed due to the attending physician's insistence.
Unclean Resident Pantry
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the resident unit food pantry room. The facility policy titled Pantry Cleaning Protocol stated that all staff were responsible for keeping the unit pantry clean and sanitary, including removing soiled dishes and plates from counters, documenting refrigerator and freezer temperatures daily, labeling and dating food items, discarding foods seven days old or older, cleaning and sanitizing countertops, sweeping and mopping floors, cleaning the microwave, ensuring the ice machine was clean with no scoops left inside, removing dietary trays or plates, and cleaning drawers and cabinets of expired items. During observation, two resident breakfast trays were left on the pantry counter, the microwave contained food splatter and debris, the floor felt sticky with red and brown staining on some tiles, heavy dirt and debris were present in the corners and along the perimeter, and several pieces of white-chalky material were accumulated under the counter in the left corner with evidence of deterioration to the left wall corner. The DON confirmed that housekeeping was responsible for maintaining the resident pantry and acknowledged the observations.
Failure to Develop Discharge Plan Aligned With Resident’s Insulin Pump Preference
Penalty
Summary
The facility failed to develop and implement a discharge planning process that aligned with the resident’s goals for one resident who was cognitively intact with a BIMS score of 14 and had Type 1 diabetes managed with an insulin pump. The resident was admitted after a hospitalization in which the insulin pump malfunctioned, and the facility initially provided insulin lispro on a sliding scale order while the resident was in the facility. While the resident was in the facility, the insulin pump was repaired, and the facility informed the resident that insulin pumps were not permitted in the facility. The resident then chose to discharge home against medical advice in order to resume use of the repaired insulin pump. The record did not show that the facility assessed or discussed the resident’s desire to resume pump use during admission, incorporated that preference into discharge planning, or developed a discharge plan addressing the resident’s goals, treatment preferences, or discharge needs. The comprehensive care plan did not include a discharge care plan, and the Nursing Home Administrator confirmed there was no documented discharge goal or discharge plan for the resident.
Care Plan Did Not Address Resident’s Hearing Assistive Devices
Penalty
Summary
The facility failed to develop and maintain a comprehensive, person-centered care plan that accurately reflected Resident 3’s communication needs. Review of the facility’s Comprehensive Care Planning policy showed that care plans should include measurable goals and address a resident’s medical, nursing, mental, and psychosocial needs, with a focus on resident choices and abilities to maintain or improve function and quality of life. Resident 3 was admitted with a displaced intertrochanteric fracture of the right femur and, on the quarterly MDS dated February 26, 2026, was identified as severely cognitively impaired with a BIMS score of 5. During observation on June 10, 2026, Resident 3 was seated in a wheelchair wearing small devices in her ears with lightweight speakers around her neck. The resident demonstrated the ability to communicate clearly and effectively, both understanding and expressing verbal information. The DON stated the family supplied the hearing devices and that they were used daily to assist with hearing and communication, but was uncertain when the resident received them and believed she had them since admission. Review of the current comprehensive care plan, initially developed September 26, 2025, did not identify the hearing devices or include staff interventions for storage, assessment, maintenance, cleaning, verification of proper function, or assistance with application and removal. The DON later confirmed the clinical record did not identify the communication/hearing assistive devices or the implications associated with their care.
Failure to Individualize Bladder Continence Care
Penalty
Summary
The facility failed to develop and implement an individualized plan to restore bladder continence to the best extent possible for one resident. The resident was admitted with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety. On admission, the resident was documented as always continent, but the admission MDS later showed occasional urinary incontinence, and the care plan identified the resident as at risk for incontinence due to impaired mobility and generalized weakness. The care plan goal was to maintain the current level of bladder continence, with interventions including medications as ordered, moisture barrier use, and a 3-day bladder record on admission, quarterly, and as needed. A 72-hour toileting diary completed in late October and early November 2025 showed the resident was incontinent during daytime and evening hours but continent and dry overnight. A nursing progress note summarized this pattern and stated the resident would be assisted with toileting every two hours during the day and evening, and the care plan was updated to reflect this approach. However, later quarterly MDS assessments showed worsening bladder incontinence, progressing from frequent incontinence to always incontinent with no episodes of bladder control in the seven days before the assessment. A quarterly observation bundle dated December 25, 2025, noted medical conditions and medications contributing to incontinence, along with long-term memory difficulties, neurological conditions, wheelchair use, and that the resident remained consistently aware of the need to use the bathroom. Despite the documented decline and identified risk factors, there was no evidence of further evaluation such as a bladder diary, no assessment to identify the type or possible causes of urinary incontinence, and no evidence of additional care plan interventions or a continence program to address the decline. A March 2026 toileting diary showed incontinence during day, evening, and nighttime hours, representing further decline from the earlier pattern, and the DON confirmed the facility failed to ensure individualized services and assistance to maintain bladder continence to the highest extent possible.
Failure to Assess Pain and Use Non-Pharmacological Measures Before PRN Oxycodone
Penalty
Summary
Safe, appropriate pain management was not provided for Resident 29, who was admitted with a displaced fracture of the medial malleolus of the left tibia and was cognitively intact with a BIMS score of 15 on the admission MDS. The facility policy required assessment of pain using an appropriate scale and attempted non-pharmacological interventions before administering pain medication. Resident 29 had a physician order for oxycodone 2.5 mg every six hours as needed for moderate to severe pain. A review of the May MAR showed the oxycodone was administered six times, and documentation did not show that staff attempted or documented any non-pharmacological interventions before any of those administrations. The record also did not show that pain severity was assessed using a numeric rating scale, faces scale, or verbal descriptor scale prior to giving the medication. The DON and NHA confirmed during interview that the facility failed to follow its policy regarding rating Resident 29's pain and using non-pharmacological interventions before administration of the pain medication.
Failure to Provide Timely Dental Services and Required Clearances
Penalty
Summary
The facility failed to provide routine dental services and failed to obtain required dental clearances needed to facilitate recommended dental treatment for two residents. The facility policy stated it would assist residents in obtaining routine and 24-hour emergency dental care. For one resident admitted with encephalopathy, the clinical record showed no evidence of dental consultations or evaluations for routine dental services from admission through survey. When the resident reported feeling something sharp in the left lower jaw and believed a partial bridge was broken, the facility notified contracted dental services, learned the contracted provider did not accept the resident’s insurance, and then contacted the responsible party for the community dentist information, but no dental appointment or treatment had been arranged by survey exit. For another resident admitted with dementia, agitation, dysphagia, and a history of protein calorie malnutrition, the record showed severe cognitive impairment on MDS assessment and a nursing note documenting a broken molar causing oral pain. Contracted dental services evaluated the resident and identified an infection in tooth number two, prescribing Clindamycin and recommending saltwater rinses while awaiting physician and responsible party clearance for extraction. The physician clearance form was completed, and the resident received all prescribed antibiotic doses, but the record did not show that the responsible party completed the consent forms needed for the dentist to proceed. The DON stated the resident’s family lived out of the country and the responsible party was difficult to contact and struggled with medical decisions, and the record did not demonstrate timely and necessary actions to obtain the required consent and clearances for the recommended tooth extraction.
Failure to Ensure Staff Competency and Policies for PICC Line Care
Penalty
Summary
The facility failed to conduct and document a comprehensive, evidence-based facility assessment to ensure that licensed nursing staff possessed the required training and competencies necessary to provide care for residents with intravenous (IV) therapy through peripherally inserted central catheters (PICCs) or other central venous access devices. The facility assessment identified that specialized services for residents with PICC lines were provided, including IV medication administration and routine PICC line care. However, there was no documented evidence that licensed nursing staff received initial or ongoing training or competency evaluations in accessing and administering medications through central venous access devices, as required by professional standards and the facility's own assessment. Additionally, the facility lacked documented policies or procedures to guide licensed nursing staff in the safe care and management of central venous access devices, including medication administration, dressing changes, or infection prevention measures. The DON confirmed that there was no contract with advanced PICC services, no established training program for PICC line care, and no documentation of staff competencies specific to PICC line management. As a result, the facility could not demonstrate that its licensed nursing staff had the knowledge and skills necessary to provide safe care consistent with regulatory requirements and professional standards of practice.
Failure to Provide PICC Line Training and Competency for Licensed Nursing Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for licensed nursing staff regarding the care of residents with peripherally inserted central catheters (PICC). Specifically, two LPNs administered intravenous antibiotics through a PICC line to a resident diagnosed with sepsis, bacteremia, pseudomonas aeruginosa infection, and cellulitis, without documented evidence of having received mandatory education or competency assessment for PICC line management. Review of personnel files for both LPNs showed no records of PICC line training prior to their provision of care, and the facility's annual competency reviews did not include PICC line care. The Director of Nursing was unable to provide any training or competency records for staff who provided PICC line care during the survey period. Interviews with the Director of Nursing and Nursing Home Administrator confirmed that the facility had not developed or implemented a training program for PICC line care and had not included this topic in annual competency reviews, despite the requirements outlined in the facility assessment and state regulations. The facility also failed to use its facility assessment to determine the need for such training and did not ensure that staff possessed the necessary skills and competencies before providing care to residents with PICC lines. No documentation was provided to demonstrate compliance with state nursing regulations regarding intravenous therapy education and competency for licensed staff.
Failure to Update Discharge Plan Based on Resident's Stated Preferences
Penalty
Summary
The facility failed to develop and implement a discharge planning process that aligned with a resident's goals and preferences. According to the facility's own Discharge Planning Policy, discharge needs should be identified and a plan developed for each resident, with regular re-evaluation to update the plan as needed. In the case reviewed, a resident with congestive heart failure, who was cognitively intact as indicated by a BIMS score of 15, expressed a desire to be discharged home during both a care plan meeting and a resident council meeting. Despite these clear statements of intent, there was no documented follow-up or revision of the resident's discharge plan to reflect her current wishes. Clinical record review showed that the last nursing progress note regarding the resident's discharge plans and goals was several months prior, and the comprehensive care plan had not been updated to address the resident's expressed desire for discharge. The care plan continued to indicate a need for long-term care without evidence of individualized discharge planning or regular re-evaluation as required by policy. The Nursing Home Administrator confirmed the absence of a current discharge goal and plan for the resident, indicating a failure to update the discharge plan in response to the resident's stated preferences.
Inaccurate and Untimely MDS Assessments Identified
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with a history of Type 2 diabetes mellitus, diabetic neuropathy, major depressive disorder, and seizure disorder, the clinical records, medication administration records, and care plans all indicated an active diagnosis of seizure disorder and ongoing treatment with Divalproex. However, the quarterly MDS assessment did not reflect the seizure disorder as a current diagnosis, despite multiple sources confirming its presence and treatment. For another resident with nonrheumatic aortic stenosis and cellulitis of the left lower limb, the quarterly MDS assessment was not completed within the required 14-day timeframe following the assessment reference date. The MDS was finalized 15 days after the reference date, exceeding the regulatory limit. Interviews with facility staff confirmed these deficiencies, and the facility was unable to provide documentation to support the accuracy of the MDS coding for these residents.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines and expectations for quality in nursing services. No additional details regarding specific residents, staff actions, or particular incidents are provided in the report excerpt.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on five occasions out of 21 shifts reviewed. Specifically, on January 20, 21, 22, and 23, 2025, the night shift was understaffed with only 2 nurse aides present, whereas the required number was slightly higher based on the census of 32 to 34 residents. Additionally, on January 25, 2025, the day shift was also understaffed with 3 nurse aides instead of the required 3.20 for a census of 32. There were no additional higher-level staff available to compensate for this deficiency. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during an interview on January 27, 2025.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. We are continuing to use available resources provided including Indeed, Appolli, signing contracts with nursing agencies as needed. We are attending job fairs in the area. Wages remain competitive in the industry. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to meet the required Registered Nurse (RN) to resident ratio of 1 RN per 250 residents during the night shift for seven consecutive nights. Specifically, from January 20 to January 26, 2025, the facility did not have any RNs on duty during the night shift, despite having a census ranging from 32 to 34 residents, which necessitated at least one RN per shift. The absence of RNs on these nights was confirmed by a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator. No additional higher-level staff were available to compensate for this deficiency, leading to non-compliance with the staffing regulation effective July 1, 2023.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Registered Nurses hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Registered Nurse ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Registered Nurses for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
Mid Valley Health Care Center failed to develop and implement an individualized, person-centered plan of care to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The deficiency was identified during a revisit survey conducted on January 2, 2025, which revealed that the facility did not address the resident's PTSD diagnosis in their care plan. Specifically, the care plan lacked documentation of symptoms or identified triggers related to PTSD and did not include resident-specific interventions aimed at minimizing triggers and preventing re-traumatization. An interview with the Director of Social Services confirmed that the facility did not provide culturally competent, trauma-informed care in accordance with professional standards of practice. The facility failed to consider the resident's experiences and preferences to mitigate triggers and promote emotional safety, as required by 42 CFR Part 483 Subpart B and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
Plan Of Correction
Step 1 Resident #2 was reevaluated by in-house Psych provider to accurately assess appropriateness of PTSD Diagnosis. In-house Psych Provider has provided a more appropriate diagnosis for Resident, plan of care has been updated to include same. Step 2 To identify others with the likelihood to be affected, all Residents identified with a current PTSD diagnosis were evaluated for appropriateness of diagnosis by in-house Psych provider. The DON/designee will audit care plans to ensure that the cause of trauma and triggers are identified with personalized interventions implemented to manage same or have diagnosis removed and plan of care updated if PTSD diagnosis was found to be inaccurate. Step 3 To prevent a future reoccurrence, DON/designee will educate the Interdisciplinary Team that Residents identified to have a PTSD diagnosis will have their plan of care updated with the cause of trauma and potential triggers, with personalized interventions implemented. To prevent a future reoccurrence, the DON/designee will educate the Interdisciplinary Team that if a PTSD diagnosis is identified with no known trauma or triggers identified, the in-house Psych Provider will be consulted to evaluate the appropriateness of the diagnosis, providing documentation to support or refute PTSD diagnosis. Step 4 To monitor and maintain ongoing compliance the Social Worker/designee will audit all new admissions or any Resident obtaining a new diagnosis of PTSD to ensure accuracy of the diagnosis and their plan of care contains the identified trauma and potential triggers with personalized interventions implemented to manage PTSD weekly x 4 and then monthly x 2. Results of audits will be forwarded to Facility QAPI committee for further review and provide any necessary recommendations as needed.
Failure in Controlled Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure accurate accounting and administration of controlled medications for a resident, leading to a deficiency in pharmacy services. A review of the clinical records and controlled drug records revealed that a resident, admitted with cervical spondylosis, history of falls, and transient ischemic attacks, had a physician's order for Percocet 5-325 mg, ½ tablet by mouth once daily at bedtime. However, on December 25, 2024, a registered nurse signed out a dose of Percocet for the resident at 4:00 AM but failed to document the administration in the medication administration record (MAR) as required. Further investigation showed that the nurse administered the medication outside the prescribed bedtime schedule, mistakenly believing it was a PRN order, despite the PRN order being discontinued earlier in the month. This error was documented in a safety event report, and it was confirmed that the nurse did not recognize the discontinuation of the PRN order, leading to the medication error. The facility's failure to adhere to procedures and protocols for the accurate administration and documentation of controlled substances compromised the integrity of the controlled medication records.
Plan Of Correction
Step 1 Resident #1 had a head-to-toe assessment completed upon discovery of medication error, no adverse effects were identified, and MD/RP notification was completed. Step 2 To identify other Residents with the likelihood to be affected, the DON/Designee will audit Declining Count Narcotic logs of all controlled substances for the past 14 days to ensure all medications were administered and documented in the Emar logs as per physician orders. Any medication found to be administered in error will have a Medication Error event report completed with proper MD/RP notification. Step 3 To prevent a future recurrence, the DON/Designee will educate all licensed nurses on the 5 Rights of medication administration, including the proper procedure to follow if a change in direction sticker is present on a medication card or narcotic log. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will complete a Medication Pass competency on 5 Random licensed nurses weekly x 4 and then monthly x 2. To monitor and maintain ongoing compliance, the NHA/Designee will interview 3 Random licensed nurses on proper procedure to follow during medication pass, if a change in direction sticker is present on a medication card or narcotic log, weekly x 4 and then monthly x 2. To monitor and maintain ongoing compliance, the DON/Designee will audit all Declining Count Narcotic logs to ensure the medication was documented in the Emar and on the log as per physician orders, 3x/week x 4 weeks, and then weekly x 8 weeks. Results of audits will be forwarded to Facility QAPI committee for further review and provide any necessary recommendations as needed.
Unnecessary Antibiotic Administration Due to Non-Adherence to Criteria
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically antibiotics. Resident #3 was admitted with diagnoses including dementia, dysphagia, and a history of urinary tract infections (UTIs). Despite these conditions, the resident did not exhibit sufficient symptoms to meet the criteria for initiating antibiotic therapy according to McGeer's criteria, which the facility uses to guide treatment decisions for suspected UTIs. The clinical record review revealed that Resident #3 only showed one symptom of dysuria and no additional systemic urinary symptoms. A subsequent evaluation by a certified registered nurse practitioner (CRNP) noted urinary frequency but no other UTI symptoms such as burning, hematuria, fever, or mental status changes. A urine culture showed 50,000-100,000 CFU/mL of Escherichia coli, which did not meet the threshold for diagnosing a UTI. Despite this, the CRNP ordered Cipro, an antibiotic, for five days, which was administered to the resident. The decision to prescribe and administer Cipro was made despite the absence of sufficient clinical indicators for a UTI, as documented in the resident's clinical record. Employee #3, a registered nurse and former Director of Nursing, expressed concerns about the appropriateness of the antibiotic therapy and emphasized the importance of adhering to McGeer's criteria and the facility's antibiotic stewardship program. However, the CRNP confirmed the decision to continue the antibiotic treatment, citing the resident's urinary frequency and positive urine culture as justification, leading to the administration of an unnecessary antibiotic regimen.
Plan Of Correction
Step 1 Resident #3 completed antibiotic course for UTI, appearing to suffer no ill effects prior to survey. Step 2 To identify others with the likelihood to be affected, the DON/designee will complete an audit of the Residents currently ordered antibiotic treatment to ensure McGeer's criteria was followed. Any Residents identified to not meet McGeer's criteria will have documentation evaluated to ensure justification from the Clinician addresses specific reasoning for continued use of antibiotic therapy. Step 3 To prevent a future reoccurrence, the DON/designee will educate all licensed nurses in the facility and Clinicians on McGeer's criteria, to ensure antibiotic initiations meet McGeer's criteria. If the order does not meet McGeer's criteria, the Clinician will be notified, and proper justification will be provided from the Clinician indicating specific reasoning for the same. Step 4 To monitor and maintain ongoing compliance, the DON/designee will audit all new antibiotic initiations to ensure new orders meet McGeer's criteria. If the order does not meet McGeer's criteria, a justification statement will be provided from the Clinician regarding the specific reasoning for continued use of the antibiotic therapy, 3x/week x 4 weeks and then weekly x 8. Results of audits will be forwarded to Facility QAPI committee for further review and provide any necessary recommendations as needed.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios for several shifts between November 24, 2024, and December 31, 2024. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility did not comply with these requirements for thirteen shifts out of the 42 shifts reviewed. This deficiency was identified through a review of nursing time schedules, resident census data, and staff interviews. On multiple occasions, the facility's staffing levels were below the required minimums. For instance, on November 24, 2024, with a census of 36 residents, only 3.0 nurse aides were available during the evening shift, whereas 3.6 were required. Similarly, on November 25, 2024, with a census of 35 residents, only 3.0 nurse aides were present during the evening shift, falling short of the 3.5 required. These staffing shortages were consistent across various shifts, including day, evening, and night shifts, with no additional higher-level staff available to compensate for the deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the minimum nurse aide staffing ratios during an interview on January 2, 2025. The report highlights that the facility did not have sufficient nurse aides to meet the regulatory requirements, and no excess higher-level staff were available to address the shortfall. This lack of adequate staffing was a recurring issue across the reviewed period, affecting the facility's ability to provide the required level of care to its residents.
Plan Of Correction
PA 5520 Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Facility Fails to Meet LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the state-mandated minimum staffing requirements for Licensed Practical Nurses (LPNs) across multiple shifts. Specifically, the facility did not provide the required number of LPNs during the day, evening, and night shifts on several occasions between November 24, 2024, and December 31, 2024. The deficiency was identified through a review of nursing time schedules and staff interviews, which revealed that the facility consistently fell short of the required LPN staffing levels. On several nights, the facility had no LPNs on duty, despite the census data indicating the need for at least one LPN. For instance, on November 24, 2024, the facility census was 36, necessitating 1.0 LPNs on the night shift, yet only 0.5 LPNs were present. Similarly, on November 25 and 26, 2024, the facility census required 1.0 LPNs, but no LPNs were on duty. This pattern of insufficient staffing continued on multiple nights, with no additional higher-level staff available to compensate for the deficiency. The deficiency was further compounded by inadequate staffing during the day and evening shifts. On several occasions, the number of LPNs on duty was below the required level based on the facility census. For example, on November 29, 2024, the day shift required 1.32 LPNs, but only 1.00 LPN was present. The facility's failure to meet the staffing requirements was confirmed by the Nursing Home Administrator during an interview on January 2, 2025.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently provide the minimum required general nursing care hours to each resident daily. A review of the facility's staffing levels revealed that on December 31, 2024, the facility provided only 2.92 direct care nursing hours per resident, which is below the mandated minimum of 3.2 hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 2, 2025, at 11:00 AM, who acknowledged the failure to meet the required staffing levels.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of general nursing care hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated general nursing hours of 3.20 hours of general nursing care to each resident. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of direct care nursing hours per resident. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum of 3.20 hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent pressure ulcer development for three residents. Resident 89, who was admitted with multiple diagnoses including chronic foot drop and cellulitis, did not receive the necessary interventions to prevent pressure ulcers despite being at moderate risk. The facility did not implement hospital discharge orders for compression and elevation of the resident's surgically repaired limb, and there was no care plan addressing the risk of pressure ulcers. Consequently, Resident 89 developed a deep tissue injury on the left heel, which evolved into an unstageable pressure ulcer. Resident 18, who was at risk for pressure ulcer development due to decreased mobility and weakness, did not have a turning/repositioning program in place. Despite being on hospice care and dependent on staff for all activities of daily living, the facility failed to provide documented evidence of preventative measures to avoid pressure ulcer development. As a result, Resident 18 developed a Stage 3 pressure wound on the left inner buttock, indicating a lack of adequate interventions to prevent skin breakdown. Resident 8, admitted with conditions including dementia and diabetes, was not thoroughly assessed upon admission, and preventative measures were not timely implemented. The resident's right heel blister deteriorated into a Stage 3 pressure ulcer without timely notification to the attending physician or podiatrist. The facility did not document applied treatments or interventions, and the resident's clinical record lacked evidence of effective preventative measures to deter the blister from worsening.
Medication Administration Error Due to Inaccurate Dose
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring that licensed nurses accurately administered prescribed medication to a resident. The resident, who was admitted with diagnoses including symbolic dysfunction, chronic atrial fibrillation, arthritis, and protein-calorie malnutrition, was prescribed Lorazepam for anxiety. A consultant pharmacist recommended a gradual dose reduction of Lorazepam, which the physician agreed to with modifications. The physician's order specified a reduction to 0.25 mg for the AM dose while maintaining 0.5 mg for the PM dose. Despite the physician's order, the resident continued to receive 0.5 mg of Lorazepam in the AM instead of the prescribed 0.25 mg. This discrepancy was due to a failure to update the narcotic sheet and medication card to reflect the new order. The pharmacy received the script for the reduced dose but did not send the 0.25 mg medication card due to insurance reasons. This error was identified by an LPN working the medication cart, and it was noted that the error had been ongoing since the physician's order was issued. The Director of Nursing confirmed that the nursing staff did not follow acceptable standards of nursing practice during medication administration, resulting in a medication error. The facility's Event Report classified the incident as a Medication Error Review, identifying the error as an incorrect dose, incorrect label, and medication not available. No adverse drug reactions were reported for the resident as a result of this error.
Medication Administration Error Due to Pharmacy Delay
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of medications for a resident, identified as Resident 18. The resident was admitted with multiple diagnoses, including symbolic dysfunction, chronic atrial fibrillation, arthritis, and protein-calorie malnutrition. A physician's order dated June 7, 2024, prescribed Lorazepam to be administered at 0.25 mg in the morning and 0.5 mg in the evening. However, a review of the clinical records and pharmacy documentation revealed that the resident continued to receive 0.5 mg of Lorazepam in the morning instead of the prescribed 0.25 mg from September 8, 2024, through September 23, 2024. This discrepancy was due to the pharmacy not sending the correct medication card because of insurance reasons, despite having received the script on time. The facility's documentation, including a nurse's note and an event report, classified this as a medication error. There was no documented evidence that the pharmacy communicated the receipt of the new physician order or when the correct dosage would be delivered. Interviews with the Nursing Home Administrator confirmed the facility's failure to ensure the timely acquisition and administration of medications as ordered to meet the residents' needs. This deficiency was noted under the relevant state codes for pharmacy and nursing services, as well as medical records.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident was admitted with PTSD, a condition characterized by symptoms such as flashbacks, nightmares, severe anxiety, and uncontrollable thoughts related to a traumatic event. Upon review, it was found that the resident's care plan did not identify specific PTSD symptoms or triggers, nor did it include resident-specific interventions to minimize these triggers and prevent re-traumatization. An interview with the Director of Nursing confirmed that the facility could not demonstrate the provision of culturally competent, trauma-informed care in line with professional standards, which should account for the resident's experiences and preferences to mitigate potential triggers.
Unnecessary Antibiotic Use for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics. Resident 8, who was admitted with diagnoses including dementia with behavior disturbances, congestive heart failure, and anxiety, was prescribed Macrobid as a prophylactic treatment for a urinary tract infection. Despite the absence of documented clinical necessity, the resident received 25 doses of the antibiotic. The attending physician ordered the medication based on the resident's ongoing behaviors, such as constant calling out and nervousness, without repeated urinalysis or culture and sensitivity tests to justify the continued use of the antibiotic. The Assistant Director of Nursing/Infection Preventionist reported that the facility's infection prevention program requires an assessment using McGreer's Criteria to determine the necessity of antibiotic therapy. However, this protocol was not followed for Resident 8 due to the attending physician's insistence on continuing the antibiotic treatment. The Director of Nursing confirmed the failure to ensure the resident's medication regimen was free from unnecessary medication, as the criteria for prophylactic antibiotic use were not met.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Peckville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aventura At Terrace View | 0.8 mi | — | 0 | 0 |
| Marywood Heights | 4.4 mi | ★★★★★ | 7 | 0 |
| Green Ridge Care Center | 4.6 mi | ★★★★★ | 3 | 0 |
| Abington Manor | 5.1 mi | ★★★★★ | 8 | 0 |
| Allied Services Transitional Rehab Unit | 5.3 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.