Morrisons Cove Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Martinsburg, Pennsylvania.
- Location
- 429 South Market Street, Martinsburg, Pennsylvania 16662
- CMS Provider Number
- 395563
- Inspections on file
- 23
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Morrisons Cove Home during CMS and state inspections, most recent first.
A resident with diabetes, ESBL UTI, bacteremia, hypertension, atrial fibrillation, orthostatic hypotension, and Alzheimer’s dementia was admitted with hospital discharge instructions for insulin per sliding scale, Metoprolol Succinate with specific BP/HR hold parameters, Levofloxacin on an every-48-hour schedule to complete a one-week course, and a consistent carbohydrate diet. Facility orders and documentation did not consistently match these instructions: insulin orders were altered and then discontinued without documented blood glucose monitoring for several days; Metoprolol was ordered and given without documented BP/HR checks as required; the Levofloxacin regimen was reduced to a single earlier dose rather than the final dose specified; and the resident was maintained on a cardiac/heart healthy diet instead of the ordered consistent carbohydrate diet despite dietitian recommendations. The DON confirmed these discrepancies between hospital discharge instructions, dietary recommendations, and the care actually provided.
The facility failed to provide written notices to the LTC Ombudsman and residents or their representatives regarding hospital transfers for five residents. These residents experienced various medical issues, including chest pain, falls, and altered mental status, leading to hospital admissions. Despite these events, there was no documented evidence of the required notifications being made.
The facility failed to update care plans for four residents, leading to unaddressed changes in care needs. A resident with dementia used Calmoseptine on dentures, another had discontinued anticoagulant medication, a third had a discontinued treatment for a skin tear, and a fourth experienced a fall due to an unaddressed intervention. The care plans were not updated to reflect these changes.
The facility failed to maintain a clean and homelike environment for two residents. One resident, who is severely cognitively impaired, had a room with damaged drywall behind the bed, with scratches and peeling paint. Another resident, who is cognitively intact, had similar damage in their room, possibly from the removal of safety padding. The Maintenance Director confirmed the need for repairs.
A facility failed to provide a resident and/or their representative with a written notice of the bed-hold policy during a hospital transfer. A nursing note indicated the transfer, but there was no documentation of the policy being communicated. The DON confirmed the lack of documentation.
A resident with dementia and a history of falls continued to self-ambulate despite staff education, resulting in a fall. The facility failed to implement new interventions to prevent self-transfers. Additionally, the resident used Calmoseptine on dentures due to inadequate supervision and management of personal care items, which were not removed as planned.
A facility failed to adhere to physician's orders and facility policy for the care and maintenance of an IV catheter for a resident receiving Meropenem for a urinary tract infection. The MARs lacked documentation of required saline flushes, and there was no evidence of catheter flushing before and after medication administration. Additionally, the resident's physician was not contacted for orders regarding catheter care from the time orders were discontinued until removal.
A facility failed to provide trauma-informed care for a resident with PTSD by not assessing specific triggers that could re-traumatize him. The resident, a war veteran with a history of trauma from a motor vehicle accident, was cognitively intact and had a care plan indicating potential mood problems related to PTSD. However, there was no documented evidence of a trauma history assessment, as confirmed by the Nursing Home Administrator.
A facility failed to document the administration of controlled medications for a resident with depression, despite doses being signed out. The resident required assistance with all care needs and had orders for Ativan for restlessness and anxiety. The Director of Nursing confirmed the lack of documentation.
The facility's QAPI committee failed to effectively address recurring deficiencies related to care plan revisions and pharmacy procedures. Despite previous plans of correction involving audits and committee reviews, the latest survey revealed ongoing non-compliance with regulations, as cited under F657 and F755.
An LPN failed to perform proper hand hygiene during wound care for a resident with a Stage 4 pressure ulcer. After completing the wound care, the LPN did not remove gloves and wash hands before adjusting the resident's pillow and bed controls, violating the facility's policy. The DON confirmed the lapse in protocol.
The facility failed to have a written policy for trauma-informed care, as revealed by a review of a resident's records and staff interviews. A resident with PTSD was identified as having potential mood problems, but the facility lacked a policy for trauma-based assessments, confirmed by the Nursing Home Administrator.
A cognitively impaired resident with vascular dementia ingested a small amount of perfume at the nurse's station. Although the nurse assessed the resident and attempted to contact the guardian, the physician was not notified as required by the facility's policy. The DON confirmed this oversight.
Failure to Follow Hospital Discharge Orders and Dietary Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not following hospital discharge orders and dietary recommendations for one resident. The resident was cognitively impaired, required extensive assistance with care, was incontinent, received insulin, and had multiple diagnoses including ESBL UTI, bacteremia, diabetes, hypertension, atrial fibrillation, orthostatic hypotension, and Alzheimer’s dementia. Discharge instructions from the Veterans Affairs Medical Center directed continuation of Insulin Aspart per sliding scale before meals and at bedtime, Metoprolol Succinate 12.5 mg daily with specific hold parameters, Levofloxacin 750 mg every 48 hours with the final dose due on a specified date to complete a one-week course, and a consistent carbohydrate diet. Physician’s orders on admission and subsequent days did not consistently reflect these discharge instructions. Initial insulin orders included Insulin Aspart per sliding scale before breakfast and at bedtime, plus fixed one-unit doses before lunch and dinner, which were then discontinued the next day because they did not match the hospital discharge orders. After this discontinuation, there was no documented evidence on the MAR that the resident’s blood sugars were monitored for several days until a new order for Insulin Lispro per sliding scale was written. For Metoprolol, the resident was initially ordered Metoprolol Tartrate 12.5 mg daily with hold parameters, and later, after a cardiology visit, Metoprolol Succinate ER 12.5 mg daily with the same hold parameters was ordered; however, the clinical record contained no documentation that blood pressure and heart rate were checked as ordered prior to administration. The facility also did not follow the antibiotic and diet instructions as specified. The discharge instructions required Levofloxacin 750 mg every 48 hours with the last dose due on a specific later date, but the physician’s order at the facility directed only a single 750 mg dose, which was administered earlier than the hospital’s indicated final dose date, and there was no evidence that the last scheduled dose per discharge instructions was given. Regarding diet, the hospital discharge instructions called for a consistent carbohydrate diet, but the physician’s orders and dietary documentation showed the resident was placed on a cardiac/heart healthy diet instead. The dietitian later recommended changing to a consistent carbohydrate diet and adding Glucerna supplements, and subsequent notes documented ongoing recommendations and physician agreement to liberalize the diet; however, the resident’s diet order remained cardiac/heart healthy until it was finally changed to a consistent carbohydrate diet at a later date. The DON confirmed that the insulin, metoprolol, levofloxacin, and diet were not ordered per hospital discharge instructions, that ordered BP and HR checks prior to metoprolol administration were not documented, and that the diet was not changed as recommended by the dietitian.
Failure to Provide Written Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice regarding emergency transfers to the hospital to the Office of the State Long-Term Care Ombudsman, as well as to the residents and/or their responsible parties. This deficiency was identified for five residents during the review. The lack of documentation of these notices was confirmed through clinical record reviews and staff interviews. Resident 1, who was cognitively intact, experienced chest pain on two occasions and requested to be sent to the hospital. Despite being admitted with congestive heart failure, there was no documented evidence that the required written notices were provided. Similarly, Resident 29, who was sometimes understood, was transferred to the hospital following a fall and was later admitted for altered mental status, but again, no written notices were documented. Resident 35, who was sometimes understood, was transferred to the hospital for a CT scan and admitted for an acute head injury with bleeding, yet no written notices were provided. Resident 54, who was severely cognitively impaired, experienced falls and changes in condition leading to hospital transfers, but lacked documented notices. Lastly, Resident 59, who was moderately cognitively impaired, was transferred to the hospital following a fall and subsequent admission, with no evidence of written notices being provided.
Plan Of Correction
The facility cannot retroactively correct this deficiency. Residents discharged via emergency transfer have the potential to be affected by this deficient practice. The facility is initiating a notice of discharge or transfer policy. This will include notifying residents or their responsible parties in writing about the reason for the emergency transfer. Nursing staff will receive mandatory training by the Director of Nursing or designee on the new policy, and the Social Services department will oversee the process to ensure compliance. The social services director will resume monthly notification to the Office of Long-term Care Ombudsman. All transfers and discharges will be audited by the administrator for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas of improvement and/or continued auditing.
Failure to Update Care Plans for Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in resident care needs for four residents. Resident 8, who has dementia, mistakenly used Calmoseptine on her dentures instead of denture cream. Despite a new intervention to remove creams from the bedside, the care plan was not updated, and Calmoseptine was still found in the resident's bathroom. Resident 26, who was on an anticoagulant, had her medication discontinued, but her care plan was not updated to reflect this change. Resident 53, who has a catheter due to neuromuscular dysfunction of the bladder, had a treatment for a skin tear that was discontinued, yet the care plan still indicated ongoing treatment. Resident 66, who is at risk for falls, experienced a fall from a high bed, and the immediate intervention was to remove the bed remote from reach. However, the care plan was not updated to include this intervention. Interviews with the Director of Nursing confirmed that the care plans for these residents were not updated as required.
Plan Of Correction
The facility corrected the care plans for residents R8, R26, R53, and R66 immediately when notified of the errors. No other care plan errors affecting other residents have been identified. All licensed staff will be re-educated on the care plan policy. The Director of Nursing or designee will review five care plans weekly for four weeks and then five care plans monthly for three months.
Facility Fails to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents, as observed during a survey. Resident 53, who is severely cognitively impaired and requires assistance with daily care needs, was found to have a room with damaged drywall behind the bed. The area measured approximately seven inches long by ten inches wide, with multiple scratches, gouges, and nicks, and the paint was peeling off. The Maintenance Director confirmed that the condition of the drywall was not homelike and required repair and painting. Similarly, Resident 61, who is cognitively intact and also requires assistance with daily care needs, was found to have a room with damaged drywall. The area behind the bed measured approximately three inches wide by five feet long, with multiple scratches, gouges, and nicks, exposing the brown layer of drywall and peeling paint. A Nurse Aide indicated that the damage might have resulted from the removal of padding previously installed for safety. The Maintenance Director confirmed the need for repair and painting to restore a homelike environment.
Plan Of Correction
The wall repairs for both R53 and R61 have been completed. A house-wide audit will be conducted to identify other residents' rooms in need of repair. A new process referred to as Room Rounds will be initiated to ensure the repairs needed are identified quickly. The Nursing Home Administrator or designee will audit 5 rooms a week times 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide a written notice of its bed-hold policy to a resident and/or the resident's representative at the time of transfer to a hospital. This deficiency was identified during a review of clinical records and staff interviews. Specifically, a nursing note dated March 16, 2024, documented that a resident was transferred to the hospital due to a change in condition. However, there was no documented evidence that the resident or their representative received written information about the facility's bed-hold policy at the time of transfer. An interview with the Director of Nursing on January 24, 2025, confirmed the absence of such documentation.
Plan Of Correction
The facility cannot retroactively correct this deficiency. A house-wide audit will be conducted to ensure the bed hold policies were reviewed with resident or resident representatives. All licensed staff will be educated on the updated Bed Hold policy with emphasis on including the policy at the time of transfer and leave. The Nursing Home Administrator or designee will audit all transfers and therapeutic leaves for 4 weeks. Also, the administrator will audit 3 months of the monthly reports to the Office of the State Long-Term Care Ombudsman. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to maintain a safe environment for a resident with dementia, who was at risk for falls due to gait and balance issues. Despite being educated by staff on the importance of using the call bell for assistance, the resident continued to self-ambulate. On one occasion, the resident fell while attempting to self-transfer to the bathroom, and there were no new interventions implemented to prevent such incidents prior to the fall. Additionally, the resident mistakenly used Calmoseptine on her dentures instead of denture cream, indicating a lack of supervision and proper management of personal care items. Although a new intervention was suggested to remove bedside creams, this was not documented in the care plan, and the Calmoseptine remained accessible in the resident's bathroom. Interviews with staff confirmed these oversights, highlighting a failure to adequately address the resident's safety and care needs.
Plan Of Correction
The facility cannot retroactively correct the fall interventions but has corrected the care plan for resident R8. A year to date audit of incidents reports will be conducted to confirm suggested interventions have been initiated. All nursing staff, including agency staff and new hires will be educated on the facility care plan policy and procedures. Administrative nursing staff will be educated on the accidents and incident process. The 24-hour clinical nursing report will be reviewed by Director of Nursing or designee, daily for 2 weeks followed by random audits for 2 weeks. Five accidents and incident reports will be reviewed weekly times 4 to confirm interventions are in place. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.
Failure to Follow IV Catheter Care Protocols
Penalty
Summary
The facility failed to ensure proper care and maintenance of intravenous (IV) catheters for a resident, as evidenced by the lack of adherence to physician's orders and facility policy. Specifically, the facility did not follow the physician's orders for flushing the IV catheter with normal saline every shift for a resident receiving Meropenem for a urinary tract infection. The Medication Administration Records (MARs) showed no documentation of the required saline flushes on specific shifts, and there was no evidence that the IV catheter was flushed before and after the administration of Meropenem, as required by the facility's policy. Additionally, there was no documented evidence that the resident's physician was contacted for orders regarding the care and maintenance of the IV catheter from the time the orders were discontinued until the catheter was removed. The Director of Nursing confirmed these deficiencies, indicating a failure to ensure that physician's orders were followed and that the facility's policy for IV catheter care was adhered to, resulting in a lapse in the standard of care provided to the resident.
Plan Of Correction
A medication error form will be initiated for the staff who failed to administer the normal saline flush as ordered by the physician/policy. Any resident ordered a normal saline flush is at risk for this deficiency. All licensed nursing staff will be re-educated on the intravenous medication administration policy. The Director of Nursing or designee will conduct audits on all intravenous medication and flushes weekly times 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas of improvement and/or continued auditing.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) received trauma-informed care to identify and mitigate potential triggers. Resident 62, who was cognitively intact and had a history of trauma from being a war veteran and a motor vehicle accident, was not assessed for specific triggers that could re-traumatize him. Despite having a care plan indicating a potential for mood problems related to PTSD, there was no documented evidence of a trauma history assessment for this resident. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Plan Of Correction
An assessment has been conducted for resident R62 with triggers identified. A house wide audit has been done for all residents with a Post Traumatic Stress Disorder diagnosis. All identified residents will have an assessment completed to identify triggers and interventions. Nursing and social services will be educated on a newly created Trauma Informed care policy. The Nursing Home Administrator or designee will audit new resident diagnoses and new admissions for diagnoses of post-traumatic stress for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident. The facility's policy required staff to document the administration details of controlled substances, including the time, day, amount administered, and remaining quantity. However, for one resident, there was no documented evidence in the clinical records, including the Medication Administration Record (MAR), that doses of Ativan, a controlled medication, were administered on specific dates and times, despite being signed out. The resident involved had a diagnosis that included depression and required assistance with all care needs. Physician's orders indicated the resident was to receive Ativan as needed for restlessness and anxiety. Despite the orders, the controlled drug records showed discrepancies, with doses signed out but not documented as administered. The Director of Nursing confirmed the lack of documentation for the administration of these doses.
Plan Of Correction
Immediate education was provided to the licensed staff who failed to indicate on the medication administration record that an as needed medication was given. A whole house audit will be conducted to confirm narcotics that have been signed out are initialed on the medication administration record. All licensed staff will be re-educated on the facility's controlled substance policy. The Director of Nursing or designee will audit 5 narcotic sheets a week for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by the results of a survey ending January 24, 2025. The survey identified repeated deficiencies related to the revision of care plans and pharmacy procedures, services, and records. These deficiencies were previously cited in a survey ending January 4, 2024, where the facility had developed plans of correction that included quality assurance systems to maintain compliance with nursing home regulations. Specifically, the facility's plan of correction for a deficiency regarding the failure to update residents' care plans included completing audits and reporting the results to the QAPI committee. However, the current survey revealed that the QAPI committee did not successfully implement this plan, as evidenced by the citation under F657. Similarly, the plan of correction for deficiencies in pharmacy procedures, services, and records involved audits and QAPI committee reviews, but the current survey, cited under F755, showed that these measures were not effectively implemented.
Plan Of Correction
No specific residents and/or staff were affected by these deficiencies. Currently, the core team of the Quality Assurance and Performance Improvement committee meets weekly and will work with a consultant to ensure focus on reoccurring issues. The Nursing Home Administrator and/or designee will retrain the members of the Quality Assurance and Improvement Committee on its responsibility for maintaining compliance with previously cited deficiencies. The Nursing Home Administrator and/or designee will audit open plan of corrections weekly x 4 then monthly x 2 or until substantial compliance is accomplished. Findings will be reviewed at the monthly facility Quality Assurance and Performance Improvement meeting.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for one resident, identified as Resident 53. The facility's policy required staff to perform hand hygiene when transitioning from dirty to clean tasks during wound care. Resident 53, who was severely cognitively impaired and receiving hospice care, had a Stage 4 pressure ulcer. Physician's orders specified a detailed wound care procedure, including washing around the wound with antibacterial soap, cleansing with acetic acid solution, and applying specific dressings. During an observation of wound care, an LPN washed her hands and donned gloves before starting the procedure. However, after completing the wound care, she did not remove her gloves and wash her hands before adjusting the resident's pillow, protective heel boots, and bed controls, which was a violation of the facility's hand hygiene policy. The LPN confirmed in an interview that she did not perform hand hygiene after the wound care and before providing additional care to the resident. The Director of Nursing also confirmed that the LPN should have removed her gloves and washed her hands before moving to a clean task.
Plan Of Correction
Re-education including a return demonstration has been provided to the employee. All licensed staff will be re-educated on wound care with an emphasis on handwashing. The Director of Nursing or designee will complete 5 random auditing weekly times 4. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.
Lack of Trauma-Informed Care Policy
Penalty
Summary
The facility was found to be deficient in having a written policy for trauma-informed care. This deficiency was identified through record reviews and staff interviews. A quarterly Minimum Data Set (MDS) assessment for a resident, dated December 5, 2024, indicated that the resident was cognitively intact and had a diagnosis of Post Traumatic Stress Disorder (PTSD). The resident's care plan, dated September 11, 2024, noted a potential for mood problems related to PTSD. However, during an interview with the Nursing Home Administrator on January 22, 2025, it was confirmed that the facility lacked a policy regarding trauma-based assessments, which is necessary to address the resident's needs effectively.
Plan Of Correction
An assessment has been conducted for resident R62 with triggers identified. A house wide audit has been done for all residents with a Post Traumatic Stress Disorder diagnosis. All identified residents will have an assessment completed to identify triggers and interventions. Nursing and social services will be educated on a newly created Trauma Informed care policy. The Nursing Home Administrator will audit new resident diagnoses and new admissions for diagnoses of post-traumatic stress for 4 weeks. Audits will be reviewed by the Quality Assurance Performance Improvement committee for results, areas for improvement and/or continued auditing.
Failure to Notify Physician of Resident's Perfume Ingestion
Penalty
Summary
The facility failed to notify the physician about an incident involving a resident who ingested perfume. The facility's policy requires that any incident with the potential to cause bodily harm be reported immediately to the nursing supervisor and the physician. However, in this case, the physician was not informed. The incident involved a cognitively impaired resident with vascular dementia and behavioral disturbances, who required extensive assistance for daily care. The resident was at the nurse's station, grabbed a bottle of perfume, and placed it to her lips. The nurse intervened, noting a tiny drop on the resident's lips and presumed a small amount was ingested. The nurse assessed the resident, finding no signs of distress such as gagging, nausea, or vomiting, and the resident's vital signs were normal. An attempt was made to contact the resident's guardian, but there was no answer, and a message was left. Despite these actions, there was no documented evidence that the physician was notified about the ingestion. The Director of Nursing confirmed that the physician should have been informed, indicating a lapse in following the facility's notification procedures.
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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