Milton Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milton, Pennsylvania.
- Location
- 743 Mahoning Street, Milton, Pennsylvania 17847
- CMS Provider Number
- 395570
- Inspections on file
- 31
- Latest survey
- March 15, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Milton Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to notify resident representatives of significant changes in condition and care for three cognitively impaired residents, despite a policy requiring notification of the resident, MD, and representative. One resident with dementia and traumatic brain injury experienced multiple episodes of large emesis, blood in stool, and full body tremors with slurred speech, with no documented contact to the representative. A second resident with dysphagia and Alzheimer’s disease had vomiting, MD notification, and progressive weight loss over several months with dietary changes, but no documented notification of the representative about these changes. A third resident with CAD, diabetes, and dementia had repeated diarrhea, skin excoriation, abnormal stool characteristics, and new lab orders, again without documentation that the representative was informed. The NHA and DON acknowledged that representatives were not notified in these cases.
Three residents with significant physical and cognitive impairments were found to have their call bells placed out of reach or inaccessible, despite care plans requiring call bell accessibility and encouragement to use it for assistance. Observations included call bells being placed at the head of the bed, covered by blankets, clipped to the mattress perimeter, or hidden under personal items, preventing residents from calling for help when needed.
The facility's main kitchen had multiple sanitation issues, including food splatter, dirt buildup, and improper storage practices. Additionally, there was a failure to monitor dishwasher temperatures for optimal sanitization on specific days, as confirmed by a staff member.
The facility failed to adhere to physician orders and care plans for several residents. A resident with severe malnutrition did not receive ordered weekly weight checks. Another resident with dysphagia was not positioned out of bed for meals as required, despite documentation indicating compliance. Additionally, two residents with CHF were not monitored for significant weight changes as ordered, with no physician notifications made for numerous instances of weight fluctuations.
The facility failed to provide necessary dental services for three residents, resulting in unresolved dental issues. One resident experienced jaw swelling and tooth pain but was not referred to an oral surgeon as recommended. Another resident was not seen by an oral surgeon despite repeated referrals and complaints of pain. A third resident did not receive recommended fluoride treatment and faced scheduling issues for oral surgery. These deficiencies were identified through interviews and record reviews.
A resident was observed multiple times with an uncovered catheter bag full of urine hanging under his wheelchair, compromising his dignity. The issue was addressed only after a surveyor's intervention.
The facility failed to maintain a clean and homelike environment in the West Side Nursing Unit. Observations revealed a significant build-up of a black substance on an air unit, debris accumulation on a resident lift, and various debris in a canvas storage bag. The shower stall had black stains, dead insects, and a stained shower curtain. These issues were reported to a nurse aide and the DON.
The facility failed to ensure accurate assessments for four residents, leading to discrepancies in clinical records. Two residents were incorrectly documented as receiving insulin, while another had dental issues not reflected in their MDS. Additionally, a resident's discharge location was inaccurately recorded.
A resident requiring partial/moderate assistance for bathing did not receive showers for over a month after admission, despite preferences documented in their clinical record. The facility's task documentation showed no showers were provided, and there were no refusals recorded. The DON confirmed the absence of documentation for the resident's showers.
A facility failed to provide trauma-informed care for a resident with PTSD, as they did not identify triggers or collaborate with the resident and relevant parties to develop interventions. The care plan was delayed and lacked specific measures to prevent re-traumatization until the issue was highlighted.
The facility failed to secure and label medications properly on the West Side Nursing Unit. Unlabeled pills were found in the medication cart, and the LPN was unaware of their origin or duration in the cart. Additionally, the cart had peeling adhesive tape with debris, and the LPN could not confirm how long it had been there or how it was cleaned. These issues were discussed with the DON.
Failure to Notify Resident Representatives of Changes in Condition and Care
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ representatives or responsible parties of changes in condition or care, as required by facility policy and state regulations. The facility’s policy titled “Change in Condition,” dated 6/1/25, states that the resident, attending physician, and representative must be notified of changes in the resident’s medical or mental condition and/or status. Surveyors reviewed clinical records and staff interviews and determined that this notification did not occur for three of seven residents reviewed, all of whom had severe cognitive impairment and therefore relied on their representatives for information and decision-making. For one resident with diagnoses including hypertension, dementia, and traumatic brain injury, the MDS showed severe cognitive impairment. Progress notes documented multiple significant clinical events: a large episode of emesis on 1/3/26; a report on 1/7/26 of a small amount of blood in the stool; an episode on 3/5/26 of full body tremors and slurred speech with MD notification via communication paper; and multiple episodes of large, projectile brown emesis on 3/15/26 treated with Zofran. In each of these instances, review of the progress notes did not show any documentation that the resident’s representative or responsible party was notified of these changes in condition. For a second resident with dysphagia and Alzheimer’s disease and severe cognitive impairment, a progress note on 2/9/26 documented vomiting, holding of medications, and MD notification, but there was no documentation that the resident’s representative was notified. Weight change notes showed a five‑pound loss between 11/17/25 and 12/17/25, a 7.7% loss by 2/9/26 with continued decline in oral intake and a recommendation for an enhanced diet, and a 10.4% loss by 3/6/26 with continued dietary interventions; however, there was no documentation that the representative was notified of the ongoing weight loss. For a third resident with coronary artery disease, diabetes, and dementia and severe cognitive impairment, progress notes documented episodes of diarrhea on 12/17/25, excoriation to the sacrum and groin later that day, abnormal stool characteristics and a new liver profile lab order on 12/22/25, and continued loose stools on 1/9/26. In each of these events, the progress notes lacked evidence that the resident’s representative or responsible party was notified. The Nursing Home Administrator and DON confirmed that the facility failed to notify representatives for these three residents.
Failure to Ensure Call Bell Accessibility for Multiple Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents regarding the accessibility of their call bells, as identified through clinical record review, observation, and interviews. For one resident with dementia, blindness, muscle weakness, and unsteadiness, the care plan required the call bell to be within reach and encouraged its use for assistance. However, observations showed the resident was seated in a wheelchair at the foot of the bed, with the call bell placed at the head of the bed, at least six feet away and later covered by blankets, making it inaccessible. The resident was heard loudly calling for assistance, indicating the inability to use the call bell. Another resident with muscle wasting, unsteadiness, and a history of falls had a care plan instructing staff to keep the call bell and frequently used objects within reach. During observation, the resident was lying in bed and unable to locate the call bell, which was clipped to the outer perimeter of the mattress and hanging away from the bed, out of the resident's reach. The resident attempted to search for the call bell but was unsuccessful in accessing it. A third resident with dementia, repeated falls, and muscle weakness also had a care plan requiring the call bell to be within reach. Observation found this resident sitting in a wheelchair at the foot of the bed, with the call bell not visible and later discovered underneath a large stuffed animal at the head of the bed, making it inaccessible. The care plan did not include any intervention regarding the resident's preference for call bell placement. These findings were reviewed with the Nursing Home Administrator, confirming the lack of accommodation for resident needs regarding call bell accessibility.
Sanitation and Monitoring Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed during a survey. The right side of the food steamer was covered in dried food splatter, and the flooring under the steamer, two-door cooler, and stove area contained a buildup of dirt, dried food, and debris. Potholders in the meal service area were blackened and stained, and dust and debris were present on the shelves in the dry storage area. Additionally, a set of plastic risers in the dry storage area had crumbs and debris in the crevices, and a lunch bag used for residents going out for dialysis was improperly placed, causing a wet area on the riser. Peeling paint was noted on the walls in the dry storage area, and a ceiling light cover was broken. The walk-in freezer had dust buildup on wire shelving units, and a pork loin was found on the floor. Dust was also observed on condenser units in the walk-in coolers, and a wooden shelf used for meal services was damaged. Furthermore, the facility did not adequately monitor dishwasher temperatures to ensure optimal sanitization. Although a completed log for October 2024 was available, there was no evidence of temperature checks for November 1 or 2, 2024, despite washing resident tray items and food service items on those days. Employee 3 confirmed the absence of a new form for November and acknowledged the lack of monitoring. These deficiencies were reviewed with the Director of Nursing.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to provide the highest practicable care for several residents, as evidenced by deficiencies in following physician orders and care plans. For Resident 84, who was diagnosed with severe protein-calorie malnutrition, the facility did not complete the physician-ordered weekly weights despite a significant weight loss being documented. The care plan aimed to maintain the resident's nutritional status, but the lack of adherence to the weight monitoring order was confirmed by both the nutritional technician and the Director of Nursing. Resident 105, who had diagnoses including dysphagia and cognitive impairment, was not positioned out of bed for meals as per physician orders and speech therapy recommendations. Despite documentation indicating compliance, observations showed the resident eating meals in bed, which contradicted the orders meant to facilitate safe swallowing. There was no documentation of the resident refusing to be out of bed or any reason for not following the orders. For Residents 22 and 51, both with orders for daily weights due to congestive heart failure, the facility failed to notify the physician of significant weight changes on multiple occasions. The orders required notification of weight changes of three pounds in a day or five pounds in a week, but this was not done on numerous specified dates. These failures were acknowledged during interviews with the Director of Nursing.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for three residents, leading to deficiencies in their care. Resident 63 experienced jaw swelling and tooth pain, and although the dentist recommended a referral to an oral surgeon for extractions, the facility did not follow through with the referral. Despite multiple visits to the dentist and a prescription for antibiotics, the resident's condition was not adequately addressed, as they had not seen an oral surgeon by the time of the survey. Similarly, Resident 46 was referred to an oral surgeon for extractions but had not been seen by one despite repeated dental visits and complaints of tooth pain. The facility also failed to implement the dentist's recommendation for Resident 36 to use a high-concentrate fluoride toothpaste, and despite attempts to schedule an appointment with a medical facility oral surgeon, the resident had not received the necessary dental care. These failures were identified during interviews with the residents and staff, and through clinical record reviews.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one resident. Observations on November 3, 2024, revealed that the resident was seen wheeling himself down the hallway, participating in an activity, and outside his room with an uncovered catheter bag full of urine hanging under his wheelchair. This situation persisted throughout the day, indicating a lack of attention to the resident's dignity and privacy. An interview with the resident confirmed that the facility only placed a catheter bag covering after the surveyor discussed the issue with him on November 4, 2024. The findings were reviewed with the Director of Nursing on November 5, 2024.
Deficiency in Maintaining a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in the West Side Nursing Unit. During an observation, a white air unit on the ceiling in the resident hallway near the nurse's station was found to have a significant build-up of a black-colored substance on the interior vents. Additionally, in the shower room, a resident lift had a substantial accumulation of debris on the standing pad, and the attached canvas storage bag contained various debris, including partially dissolved pill-like objects, an open elastic bandage, an exam glove, a crushed plastic cup, and other unidentified dirt. The shower stall had black dot-like stains on the perimeter wall where it met the floor, multiple dead winged insects on the exterior of the light, and a shower curtain with multiple black stains, particularly near the bottom. These findings were communicated to a nurse aide and the Director of Nursing.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for four residents, leading to discrepancies in their clinical records. For Resident 84, a quarterly Minimum Data Set (MDS) assessment inaccurately indicated that the resident received insulin during the assessment period, despite no evidence supporting this in the clinical records. This was confirmed by Employee 4, the registered nurse assessment coordinator. Similarly, Resident 113's significant change MDS also incorrectly noted insulin administration, which was not supported by the clinical records, as confirmed by the same employee. Resident 63's annual MDS inaccurately reported no dental issues, despite prior documentation of jaw swelling and a broken molar. Additionally, Resident 115's discharge MDS incorrectly stated that the resident was discharged to an acute care hospital, while social service documentation indicated discharge to home with family. These inaccuracies were discussed with the Director of Nursing during the surveyor's interviews.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide necessary bathing support for a resident who required staff assistance. Resident 57, admitted on August 29, 2024, reported not receiving a shower for the first month of his stay. His clinical record, including the Minimum Data Set (MDS) assessment dated September 5, 2024, indicated that he required partial/moderate assistance for bathing due to conditions such as spina bifida and paraplegia. Despite his preference for showers on Mondays and Thursdays, task documentation showed that he did not receive a shower from August 29 to October 6, 2024, with no documented refusals. These findings were confirmed during a meeting with the Director of Nursing on November 5, 2024, who acknowledged the lack of documentation indicating that Resident 57 received showers according to his preference.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with chronic Post-Traumatic Stress Disorder (PTSD). Resident 25 was admitted with a history of trauma related to complications during childbirth. However, the facility did not identify potential triggers for the resident's PTSD or collaborate with the resident, their family, or mental health professionals to develop individualized interventions to prevent re-traumatization. The care plan addressing the resident's history of trauma was not added until one month after admission, and it only indicated a potential for ineffective coping without specifying triggers or preventive measures. The deficiency was identified during a clinical record review and staff interview, revealing that the facility had not taken necessary steps to understand and mitigate the resident's trauma triggers. It was only after the Director of Nursing was informed of the oversight that the social worker met with Resident 25 to identify specific triggers, such as seeing or speaking about small children or babies, which could cause increased frustration and sadness. The resident's care plan was subsequently revised to include these triggers and interventions, but this was done only after the deficiency was brought to the facility's attention.
Medication Security and Labeling Deficiency
Penalty
Summary
The facility failed to properly secure and account for resident medications and biologicals on the West Side Nursing Unit. During an observation of the resident medication pass, a clear medication cup containing three unlabeled pills was found in the top drawer of the medication cart. The identity of these pills was unknown, and the licensed practical nurse on duty was unaware of how long the cup had been there, as it was present at the start of their shift. Additionally, three unsecured pills were found in the bottom drawer of the cart, with no identification or knowledge of their duration in the cart. Further inspection of the medication cart revealed that the front left, top corner was taped with multiple pieces of adhesive tape, which were peeling and discolored, containing small debris. The licensed practical nurse was unable to provide information on how long the tape had been there or how the area was cleaned or sanitized. These observations were reviewed with the Director of Nursing, highlighting the facility's failure to adhere to proper medication storage and labeling protocols.
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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