Millcreek Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Erie, Pennsylvania.
- Location
- 5535 Peach Street, Erie, Pennsylvania 16509
- CMS Provider Number
- 396072
- Inspections on file
- 28
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Millcreek Manor during CMS and state inspections, most recent first.
A resident’s privacy rights were violated when staff, following the direction of a former administrative staff member, opened the resident’s delivered packages without obtaining consent. The facility’s Mail/Package Screening policy required written consent before opening items and recognized residents’ rights to receive unopened mail and packages, including those delivered by non-postal carriers. The resident reported that they were told they had no right to unopened deliveries if not sent via the U.S. Postal Service, and the Nursing Home Administrator confirmed that the resident’s deliveries had been opened without the resident’s knowledge or permission, in violation of facility policy and privacy requirements.
A resident with multiple medical conditions, including bladder CA, diabetes, pain, HTN, and muscle wasting, had a physician order to hold daily Aspirin for five days prior to a scheduled colonoscopy. Nursing staff continued to administer the Aspirin instead of holding it as ordered, and the colonoscopy was canceled as a result. The NHA confirmed that the physician’s orders were not followed, leading to this deficiency under nursing services and management regulations.
A resident with diabetes and a history of pancreatectomy and Hodgkin's lymphoma was administered Lispro insulin by staff when their blood sugar was below the physician-ordered threshold. The insulin was given at two separate times despite clear orders to hold the medication if blood sugar was under 270 mg/dL, and the DON confirmed the error.
A resident with diabetes and other health conditions did not receive insulin according to physician's orders. Insulin was administered when blood glucose was below the ordered threshold, and on multiple occasions, insulin was not given when blood glucose was above the levels specified in as-needed orders. Staff confirmed these discrepancies and noted possible confusion regarding the orders.
A resident with diabetes and other conditions had multiple high blood sugar readings that required physician notification per orders, but the clinical record lacked documentation that the physician was notified. The facility's practice of texting physicians was not incorporated into the permanent medical record, resulting in incomplete documentation.
A resident with diabetes and a history of pancreatectomy and Hodgkin's lymphoma received Lispro insulin and Glucagon IM injections that were not in accordance with physician orders. Insulin was given when blood sugar was below the ordered threshold, and Glucagon was administered when blood sugar was above the ordered limit, with no documentation of symptoms or physician notification. These medication errors were confirmed by the DON.
The facility failed to maintain the essential electrical system for its emergency generator, as the annual fuel analysis report showed particle count results exceeding acceptable limits. The maintenance supervisor confirmed the deficiency, indicating a lapse in maintenance and testing procedures.
The facility failed to maintain cooking equipment properly, as it lacked documentation for one of the two required semi-annual kitchen suppression testings or maintenance. This deficiency was confirmed by the maintenance supervisor during a survey.
The facility did not maintain electrical receptacles as per NFPA 70 standards in one room. A water cooler was plugged into a non-GFCI protected outlet in the conference room, confirmed by the maintenance supervisor.
A facility failed to ensure consistency between a resident's POLST, physician's orders, and care plan. The resident's POLST indicated Full Code, while the physician's orders stated DNR, and the care plan also reflected Full Code. The DON confirmed the inconsistency, which violated the facility's policy requiring alignment with the resident's documented treatment preferences.
A facility failed to document non-pharmacological interventions before administering PRN Hydroxyzine to a resident with anxiety and other diagnoses. Despite frequent use of the medication, the clinical record lacked evidence of attempted interventions, as confirmed by the DON.
The facility failed to store a controlled medication, Lorazepam, in a locked compartment and did not discard an expired vial of Lispro Insulin as required. An LPN confirmed these deficiencies during observations in two medication rooms.
A facility failed to provide a resident and/or their representative with a written notice of the bed-hold policy upon transfer to a hospital. The deficiency was identified for a resident with Diabetes and Alzheimer's Disease, as there was no documentation of the required notice during two hospital transfers. The Nursing Home Administrator confirmed the lack of evidence and acknowledged that the policy should have been provided and documented.
A resident with diabetes and other health conditions experienced significant medication errors when staff failed to administer Lantus as ordered and improperly administered Novolog despite blood sugar levels being below the threshold to hold the medication. These errors were confirmed by the Regional Director of Nursing.
A facility failed to promptly investigate an alleged abuse incident involving a resident with multiple medical conditions. An RN allegedly grabbed the resident's wrist during a blood sugar test, causing distress. A nurse aide intervened and reported the incident, but the facility delayed the investigation until notified by the resident's family days later, violating their zero-tolerance policy.
Failure to Protect Resident Privacy by Opening Delivered Packages Without Consent
Penalty
Summary
The facility failed to ensure a resident’s privacy rights regarding personal mail and delivered packages, resulting in a breach of confidentiality for one resident (R1). The facility’s written policy on Mail/Package Screening stated that delivered items would be opened by the facility only upon written consent from the resident and acknowledged residents’ rights to send and promptly receive unopened mail and other letters, packages, and materials, including those delivered by means other than the U.S. Postal Service. During an interview, Resident R1 reported that facility staff, acting under the direction of a previous administrative staff person, were opening packages delivered to the resident without obtaining consent, and that the previous administrative staff person had told the resident that because the packages were not always delivered by the U.S. Postal Service, the resident did not have the right to receive them unopened. In a separate interview, the Nursing Home Administrator confirmed that Resident R1’s deliveries had been opened previously without the resident’s knowledge or permission, contrary to facility policy and the resident’s privacy rights. This deficiency was cited under 28 Pa. Code 201.14(a), Responsibility of licensee, based on the facility’s failure to follow its own policy and to protect the resident’s right to privacy of mail and delivered packages.
Failure to Follow Physician Order to Hold Aspirin Before Colonoscopy
Penalty
Summary
The facility failed to follow a physician’s order to hold a resident’s Aspirin prior to a scheduled colonoscopy. The resident, admitted on 5/19/25 with diagnoses including bladder cancer, diabetes, pain, hypertension, and muscle wasting, had a physician’s order dated 1/26/26 indicating that Aspirin was to be held for five days before a colonoscopy scheduled for 3/18/26. Review of the clinical record and resident interview showed that nursing staff continued to administer the daily Aspirin up to the day of the procedure instead of holding it as ordered. During an interview, the resident reported that the colonoscopy had to be canceled because staff did not stop the Aspirin, and the Nursing Home Administrator confirmed that the physician’s orders were not followed and that the procedure was consequently canceled. This deficiency was cited under 28 Pa. Code 211.12(d)(3)(5) related to nursing services and 28 Pa. Code 201.18(b)(2) related to management.
Failure to Follow Insulin Administration Orders
Penalty
Summary
Nursing staff failed to follow physician orders regarding insulin administration for a resident with diabetes, pancreatectomy, and Hodgkin's lymphoma. The physician's order specified that Lispro insulin should be held if the resident's blood sugar (BS) was below 270 mg/dL. Despite this, the Medication Administration Record (MAR) showed that the resident received 3 units of Lispro insulin at two separate times when their BS was 257 mg/dL and 157 mg/dL, both below the threshold set by the physician. The facility's policy on hypoglycemia management requires nursing staff to notify the physician if hypoglycemia signs are not resolved by protocol. However, there is no indication in the report that the physician was notified or that the protocol was followed in response to the administration of insulin when it should have been held. The Director of Nursing confirmed that the insulin was administered contrary to the physician's order on the specified dates and times.
Failure to Follow Physician's Orders for Insulin Administration
Penalty
Summary
The facility failed to follow physician's orders regarding the administration of insulin for a resident with multiple diagnoses, including diabetes, Hodgkin lymphoma, and COPD. The resident had a physician's order for Insulin Lispro to be administered after meals only if blood glucose (BG) was above 270 mg/dL, but on one occasion, insulin was given when the BG was 212 mg/dL, contrary to the order. Additionally, there were standing orders for as-needed insulin administration if BG exceeded 400 mg/dL or 500 mg/dL, but the medication administration record (MAR) showed multiple instances where the resident's BG was above these thresholds and insulin was not administered as ordered. Staff interviews confirmed that the insulin was given when it should have been held and that as-needed orders for high BG levels were not followed. The corporate RN acknowledged the discrepancies and noted that the as-needed order may have been confusing to some nurses, suggesting a lack of clarification. The clinical record and MAR lacked evidence of compliance with the physician's orders for insulin administration, resulting in a failure to provide care as prescribed.
Failure to Document Physician Notification for Elevated Blood Sugar
Penalty
Summary
The facility failed to maintain accurate and complete documentation regarding physician notification for one resident. According to facility policy, the medical record should include care-specific details, such as notification of the physician when indicated. For a resident with Alzheimer's disease, diabetes, and high blood pressure, there was a physician's order requiring notification if blood sugar (BS) results exceeded 401 mg/dL. The resident's Medication Administration Record (MAR) showed multiple instances where BS readings were above this threshold. Despite these elevated BS readings, the clinical record did not contain evidence that the physician was notified as required by the order. During an interview, the Nursing Home Administrator confirmed that while staff may text physicians using a supervisor's phone, these communications are not included in the resident's permanent clinical record. As a result, there was no documentation in the clinical record to verify that the physician was notified in accordance with the physician's orders.
Failure to Prevent Significant Medication Errors in Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of medications not in accordance with physician orders. Specifically, a resident with a history of diabetes, pancreatectomy, and Hodgkin's lymphoma had a physician's order for Lispro insulin to be administered only if blood sugar (BS) was 270 mg/dL or higher. On one occasion, staff administered 3 units of Lispro insulin when the resident's BS was 267 mg/dL, which was below the threshold specified in the order. Additionally, the same resident had a physician's order for Glucagon IM to be given only if BS was less than 90 mg/dL. However, staff administered Glucagon when the resident's BS was 100 mg/dL, contrary to the order. There was no documentation indicating the resident was experiencing hypoglycemic symptoms or that the physician was notified. These actions were confirmed by the Regional Director of Nursing and were not in accordance with the facility's policies or the physician's orders.
Emergency Generator Fuel Quality Deficiency
Penalty
Summary
The facility failed to maintain, inspect, and test the essential electrical system for its emergency generator. During a document review on January 28, 2025, it was revealed that the annual fuel analysis report for the emergency generator, dated October 18, 2024, indicated that the particle count results exceeded acceptable limits. This finding suggests that the fuel quality did not meet the necessary specifications for the emergency generator's operation. An interview with the maintenance supervisor on the same day confirmed the deficiency noted in the annual fuel report. The supervisor acknowledged that the sample did not meet the required specifications, indicating a lapse in the facility's maintenance and testing procedures for the emergency generator. This deficiency highlights a failure in ensuring the generator's readiness and reliability in providing essential power during emergencies.
Plan Of Correction
#0918 The facility has generator inspection scheduled March 1, 2025. The findings of the fuel samples will be immediately reviewed, and corrective action will be taken should particle counts exceed acceptable limits. This inspection will be on an annual basis and monitored accordingly.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain cooking equipment in the kitchen area, as evidenced by the lack of documentation for one of the two required semi-annual kitchen suppression testings or maintenance. This deficiency was identified during a document review conducted on January 28, 2025, at 10:40 a.m. The maintenance supervisor confirmed the absence of the necessary documentation at the time of the survey, indicating a lapse in the facility's adherence to the required safety protocols for cooking equipment.
Plan Of Correction
#0324 The facility has scheduled a semi-annual kitchen suppression testing and cleaning for February 17, 2025 to bring us into compliance with the Life Safety code. Suppression testing and cleaning will be conducted on an on-going semi-annual basis. The second inspection and cleaning will be scheduled in August.
Electrical Receptacle Deficiency in Conference Room
Penalty
Summary
The facility failed to maintain electrical receptacles in accordance with NFPA 70 standards in one of over fifty rooms. During an observation on January 28, 2025, at 11:39 a.m., it was noted that the conference room (room 1506) had a water cooler plugged into an outlet that was not protected by a ground fault circuit interrupter (GFCI). This deficiency was confirmed through an interview with the maintenance supervisor at the same time.
Inconsistency in Resident's Advance Directive Documentation
Penalty
Summary
The facility failed to ensure consistency between a resident's Physician Order for Life Sustaining Treatment (POLST), physician's orders, and care plan. Specifically, for one resident, there was a discrepancy between the POLST, which indicated a Full Code status, and the physician's orders, which stated Do Not Attempt Resuscitation (DNR). The care plan also reflected a Full Code status, which was inconsistent with the physician's DNR order. The resident involved had diagnoses including Parkinson's disease and hypertension. During an interview, the Director of Nursing confirmed the inconsistency between the resident's POLST, physician's orders, and care plan. The facility's policy requires that the plan of care for each resident be consistent with their documented treatment preferences and/or advance directive, which was not adhered to in this case.
Plan Of Correction
All residents will have advanced directives that accurately reflect their wishes. Resident R121's Advance Directive was corrected immediately upon notification to reflect accuracy. The Director of Nursing/Designee will do an initial audit on all Advance Directives to ensure they are consistent with resident wishes and care plans. The Director of Nursing/Designee will educate nursing staff on how to properly care plan advanced directives and to ensure completion upon admission, quarterly, and any change of status. Moving forward, the Director of Nursing will perform an audit of 25% of all new residents, resident quarterly meetings, and resident change of status's 5 times a week for two weeks, weekly times two weeks, and monthly times two months and ongoing monthly. Results of audits will be brought to monthly Quality Assurance meetings.
Failure to Document Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted prior to administering a PRN psychotropic medication to a resident. The facility's policy on antipsychotic medication use requires that pertinent non-pharmacological interventions be attempted and documented unless contraindicated. However, the clinical record of a resident with diagnoses including anxiety, major depressive disorder, and cognitive communication deficit, showed multiple administrations of PRN Hydroxyzine for anxiety without documentation of attempted non-pharmacological interventions. The resident's Medication Administration Record indicated frequent use of PRN Hydroxyzine over December 2024 and January 2025, yet there was no evidence in the clinical record of non-pharmacological interventions being attempted before these administrations. During an interview, the Director of Nursing confirmed the absence of such documentation and acknowledged that non-pharmacological interventions should have been attempted and recorded in the clinical record.
Plan Of Correction
Resident (58) as well as all other residents will be free from unnecessary psychotropic medications. R(58)'s medication orders will be reviewed by physician to ensure applicable psychotropics are being administered. R(58)'s orders have been updated to implement non-pharmacological interventions before psychotropics are administered and will add supplemental documentation in the order. Director of Nursing/designee will educate nursing staff on what non-pharmacological interventions are and how to properly implement them before psychotropic medication is administered. All Residents on psychotropics will have orders for supplemental documentation that non-pharmacological interventions were administered before medication was given. All PRN psychotropic medications will be reviewed by the assistant director of nursing/designee to ensure that the non-pharmacological interventions are being completed once daily for five (5) days times two (2) weeks, once weekly times two (2) weeks, once monthly times two (2) months and ongoing after that to ensure compliance. Results will be brought to monthly Quality Assurance meetings to audit progress and address any ongoing concerns.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to comply with regulations regarding the storage of controlled substances and the disposal of outdated medications. In one of the medication rooms, a bottle of liquid Lorazepam, a controlled antianxiety medication, was found on the top shelf of the refrigerator without being stored in a separate locked, permanently affixed container. This was confirmed by an LPN during an observation, acknowledging that the medication should have been secured in accordance with the facility's policy. Additionally, in another medication room, an open vial of Lispro Insulin was found in the refrigerator with an expiration date that had already passed. An LPN confirmed that the expired insulin vial should have been discarded as per the manufacturer's guidelines and facility policy, which require opened vials to be used or discarded within 28 days. These findings indicate a failure in the facility's management and pharmacy services to ensure proper medication storage and disposal.
Plan Of Correction
The medication Lispro was found to be expired and the nurse discarded it appropriately. All refrigerated controlled drugs will be stored inside a lockbox permanently affixed to a locked refrigerator unit. Lock boxes have been permanently affixed inside all locked refrigerator units that will house controlled substances needing refrigeration. An audit will be performed on all units for any expired medication in the facility to be discarded appropriately. The Director of Nursing will educate the nursing staff on ensuring all controlled drugs will be locked in the permanently affixed lockbox inside refrigerators and ensure medications are disposed of upon expiration timely and properly. Maintenance will add to the monthly Planned Maintenance schedule to ensure the box is secure. The Director of Nursing/Designee will audit medication expiration dates and controlled substances inside lock boxes once daily for five (5) days times two (2) weeks, once weekly times two (2) weeks, and once monthly times two (2) months but ongoing after to ensure resident safety and compliance. Results of the audit will be brought to Monthly Quality Assurance meetings.
Failure to Provide Bed-Hold Policy Notice Upon Resident Transfer
Penalty
Summary
The facility failed to provide a resident and/or their representative with a written notice of the facility's bed-hold policy upon transfer to a hospital. This deficiency was identified for one of the 26 residents reviewed, specifically Resident R4. The facility's policy, titled "Transfer or Discharge, Facility-Initiated," dated 11/12/24, mandates that notice of the bed-hold and return policies be provided within 24 hours of an emergency transfer. However, upon review of Resident R4's clinical records, it was found that there was no documentation indicating that the resident or their representative received the required notice during transfers on 3/5/24 and 7/24/24. Resident R4, who was admitted on 2/9/21, has medical diagnoses including Diabetes and Alzheimer's Disease. During an interview, the Nursing Home Administrator confirmed the absence of evidence that the bed-hold policy, including the cost per day, was provided to Resident R4 or their representative at the time of the transfers. The administrator acknowledged that the policy should have been provided and documented in the resident's clinical record during these transfers.
Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for a resident with a history of diabetes, pancreatectomy, and Hodgkin lymphoma. The resident had specific physician's orders for insulin administration, including Lantus and Novolog, with instructions to hold the medication if blood sugar levels were below certain thresholds. On one occasion, the resident's blood sugar was 226 mg/dL, and the staff failed to administer the prescribed 3 units of Lantus. On another occasion, the resident's blood sugar was 215 mg/dL, and the staff administered 3 units of Novolog despite the order to hold it if the blood sugar was below 280 mg/dL. Additionally, the resident's blood sugar was 247 mg/dL on a separate occasion, and the staff again administered Novolog contrary to the physician's order to hold it. These actions were confirmed by the Regional Director of Nursing during an interview, acknowledging that the insulin was not administered according to the physician's orders. The facility's failure to adhere to the prescribed medication administration protocols resulted in significant medication errors for the resident.
Failure to Investigate Alleged Abuse Promptly
Penalty
Summary
The facility failed to implement its established procedures for investigating and protecting residents in response to potential abuse. The incident involved a resident with a history of diabetes mellitus, colostomy, intestinal obstruction, and hemorrhage of the anus and rectum. On July 4, 2024, a registered nurse (RN) allegedly grabbed the resident's wrist while attempting to obtain a blood sugar level, causing the resident to feel as though their arm was being broken. A nurse aide witnessed the incident and intervened, reporting the RN's aggressive behavior to a supervisor. However, the facility did not initiate an investigation until July 8, 2024, after being notified by the resident's family member. The facility's records lacked evidence of an immediate investigation or assessment of the resident's arm following the incident. There was no documentation of physician notification or any investigation on the day of the incident. The Nursing Home Administrator and Director of Nursing confirmed that the investigation was only initiated four days later, indicating a failure to protect the resident and others from potential abuse. This delay in response violated the facility's policy of zero tolerance for abuse and neglect, as well as state regulations regarding resident rights and management responsibilities.
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.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
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.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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