Mid-valley Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Peckville, Pennsylvania.
- Location
- 81 Sturges Road, Peckville, Pennsylvania 18452
- CMS Provider Number
- 395644
- Inspections on file
- 19
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Mid-valley Health Care Center during CMS and state inspections, most recent first.
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.
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.
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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