Mount Carmel Senior Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Mt Carmel, Pennsylvania.
- Location
- 2616 Locust Gap Highway, Mt Carmel, Pennsylvania 17851
- CMS Provider Number
- 395589
- Inspections on file
- 28
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Mount Carmel Senior Living Community during CMS and state inspections, most recent first.
A resident sustained a fracture to her lower leg after being transported in a wheelchair without leg rests by an agency LPN who was unaware of facility policy. The resident's legs were covered by a blanket and not properly supported, leading to her leg becoming stuck and subsequent injury. Ongoing pain and swelling were documented before a repeat x-ray confirmed the fracture.
Surveyors observed improper food storage and unsanitary conditions in the main kitchen and two pantries, including rusty shelving, unlabeled thawing meat, soiled equipment, undated snacks, missing refrigerator/freezer temperature logs, and significant ice buildup in cold storage units. These deficiencies were confirmed by the NHA and DON.
The facility did not provide required written transfer notices or bed-hold policy information to several residents and/or their representatives during hospital transfers. In multiple cases, residents transferred for medical reasons did not receive documentation about the facility's bed-hold policy or complete transfer notices, as confirmed by staff interviews and record review.
Two residents with PTSD did not receive trauma-informed or culturally competent care, as the facility failed to identify trauma triggers, complete trauma assessments, or develop individualized care plans to address their needs. The DON confirmed awareness of the traumatic events affecting these residents.
A review of staff education records and interviews revealed that three nurse aides did not complete the required 12 hours of annual in-service training, with only six hours documented since the start of the year. The DON confirmed that in-service trainings for nurse aides had only recently started, resulting in insufficient training hours for these staff members.
A binder containing survey results, deficiency letters, and Statements of Deficiencies with resident names and identifiers was left accessible in a public area, resulting in a breach of confidentiality for multiple residents' personal health information.
A resident was prescribed an antipsychotic medication without documented evidence of a schizophrenia diagnosis or monitoring of target behaviors to justify its use. The resident's record only supported a history of depression, and staff confirmed the absence of documentation and appropriate behavior monitoring for the antipsychotic regimen.
Facility staff completed an MDS assessment indicating that a resident was discharged to a short-term general hospital, when in fact the resident had signed out against medical advice and was not discharged to a hospital. This inaccuracy was confirmed by the RNAC during staff interview.
A resident with a physician's order for supplemental oxygen was repeatedly observed without oxygen therapy, and both the resident and clinical staff confirmed that oxygen was not being used due to consistently high oxygen saturation levels. Despite this change, the care plan was not updated to reflect the resident's current needs and interventions.
A resident with physical limitations and vision loss was not consistently assisted out of bed for meals or provided with required feeding support, despite physician orders and care plan directives. Staff failed to follow care instructions, did not always document care, and were unaware of the resident's specific needs, resulting in the resident remaining in bed for all meals and experiencing significant weight loss.
Two residents did not receive care as ordered by their physicians: one was given Metoprolol despite a low apical pulse, with no documented reason for the deviation, and another did not have Geri-sleeves applied as ordered for skin protection, with observations showing sleeves were either missing or ill-fitting.
A resident with Alzheimer's dementia experienced ongoing hearing difficulties due to the facility's failure to ensure proper treatment and access to assistive hearing devices. Staff were aware of issues with the resident's hearing aid, including malfunction and missing parts, but did not coordinate with audiology services or accurately document the resident's needs in care plans and assessments. As a result, the resident did not receive appropriate support to maintain hearing ability.
A deficiency was found when a resident's room was observed to contain a block of large scissors and knives in plain view, while the resident reported frequently leaving the room and the door did not lock. This resulted in the environment not being free from accident hazards, as the items were accessible when the resident was not present.
A resident with severe cognitive impairment and a diagnosis of dementia was admitted and assessed, but the facility only provided general interventions in the care plan, lacking individualized, person-centered strategies to address the resident's dementia and cognitive loss.
An unlocked and unattended treatment cart containing multiple tubes of creams was found on a hallway outside a resident's room. The cart remained unsupervised for several minutes while two residents moved independently nearby. The DON confirmed the cart should have been locked.
A resident was observed in a state of undress during a brief change because the privacy curtain did not fully extend around the bed, preventing complete visual privacy. An LPN waited to pass by until the resident was no longer exposed, but the resident was still uncovered and wearing only a brief. The resident stated the curtain had not provided full coverage since admission, and the issue was confirmed by observation and discussed with the DON.
Mount Carmel Senior Living Community failed to correct infection control deficiencies, as observed during a revisit survey. Two residents under contact and droplet precautions were not adequately protected due to improper disposal systems for contaminated materials and staff not adhering to required PPE protocols. A nurse aide served lunch to a resident without wearing a gown and gloves, and a physical therapy assistant improperly handled used PPE. These actions indicate non-compliance with infection prevention standards.
The facility failed to administer bowel protocol medications and insulin as ordered, leading to prolonged constipation and hypoglycemia in residents. A resident with Type 2 diabetes was hospitalized due to early insulin administration relative to meal times. Other residents also experienced improper timing of blood sugar assessments and insulin administration, posing significant health risks.
The facility failed to provide a clean and homelike environment across four nursing units. Observations revealed rust, dirt, and black substances in the shower room, and cluttered and unclean conditions in residents' rooms. A resident's room had a brown substance on the floor that remained for hours despite staff presence. Housekeeping staff confirmed the oversight and addressed it only after being informed by the surveyor.
A facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, as required by CMS guidelines. A nurse aide did not wear a gown while providing care, despite the presence of a sign indicating the need for such precautions. The deficiency was confirmed through staff interviews and was previously cited, indicating a recurring compliance issue.
Mount Carmel Senior Living Community failed to accurately post nurse staffing data, showing discrepancies in the number of nurse aides and hours worked during the dayshift. The posted data indicated 11 nurse aides and 88 hours, while only 10 aides and 70 hours were confirmed. This was verified by the DON.
The facility did not meet the required nurse aide-to-resident ratios from December 26, 2024, to January 2, 2025. The day shift was understaffed on six of eight days, the evening shift on five of eight days, and the night shift on four of eight days. This deficiency was confirmed through a review of staffing hours and an interview with the Nursing Home Administrator and DON.
The facility did not meet the required LPN-to-resident ratios, failing to provide adequate staffing on several occasions. On one day, the day shift was short of the required LPNs for 103 residents, and the overnight shift was understaffed on five days. Interviews with the Nursing Home Administrator and DON confirmed these deficiencies.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day for four days during a review period. The nursing care hours fell short on specific days, with the lowest being 2.44 hours PPD. This was confirmed by reviewing staffing hours and through an interview with the Nursing Home Administrator and DON.
The facility failed to administer insulin according to professional standards, resulting in residents receiving insulin significantly earlier than their meals. Staff conducted blood glucose assessments and administered insulin before the end of their shift, leading to insulin being given more than an hour before breakfast. The facility lacked a policy to guide staff on proper timing for insulin administration relative to meals.
The facility failed to provide adequate bathing support for three residents requiring assistance. A resident did not receive a shower for 22 days despite her preference, while another received only two showers since admission. A third resident, dependent on staff for bathing, did not receive any showers or tub baths in the last 30 days. These issues were discussed with the Nursing Home Administrator and DON.
A resident at high risk for skin breakdown was not consistently assessed for pressure ulcers, with the last documented assessment on September 30, 2024. Despite a complaint of wound bleeding on October 2, 2024, no further assessments were documented until October 16, 2024, when the ulcers were noted as resolved. This lack of timely assessments led to a deficiency, as confirmed by a wound nurse.
The facility failed to serve meals at a palatable temperature and in a timely manner across four resident hallways. Meal carts were significantly delayed, with early trays arriving 45 minutes late and others over an hour late. A test tray revealed the shepherd's pie was lukewarm at 122.7°F. This issue was discussed with the Nursing Home Administrator and DON.
The facility failed to maintain the range of motion for three residents due to inadequate implementation and documentation of restorative nursing programs. Despite care plans in place, staff did not consistently document completion of tasks or noted them as not applicable, with frequent refusals by residents and no documentation of current levels of function.
The facility failed to implement fall prevention measures for two residents, leading to multiple falls and injuries. One resident did not have recommended supervision, resulting in falls and ER visits. Another resident's bed and chair alarms were not properly managed, leading to several falls, including a fracture. Staff interviews confirmed lapses in alarm application and documentation.
The facility failed to assess entrapment risks for bed rails in eight out of nine residents reviewed for accident concerns. Despite having a policy requiring Bed System Measurement Device Tests, the facility did not conduct these assessments for residents using air mattresses and bariatric beds. Observations and interviews revealed that residents were using assistive devices without documented risk assessments, and the facility could not provide evidence to support the safety of these configurations. Additionally, residents who had moved rooms did not have updated safety assessments for their bed and rail systems.
The facility did not complete annual performance evaluations for three nurse aides, as required. The employees had hire dates in 2007, 2020, and 2023, but there was no documented evidence of evaluations being conducted. This was confirmed by the Nursing Home Administrator.
The facility's arbitration agreements for three residents failed to ensure a neutral arbitration process, allowing the facility to select the arbitrator if parties couldn't agree within 30 days. This was confirmed by the Nursing Home Administrator and admissions director, who noted that revisions were underway but not yet signed by the residents.
The facility failed to implement proper isolation precautions for residents requiring transmission-based and enhanced barrier precautions. Two residents received wound care without staff donning isolation gowns, and another resident with an ESBL infection lacked appropriate signage for contact precautions. Additionally, a resident with C. Diff did not have contact isolation signage, and a staff member worked after testing positive for COVID-19 without evidence of contact tracing. The facility's water management program lacked documentation, and a resident stored a bed pan on the floor, contrary to infection control practices.
The facility failed to administer COVID-19 vaccines to three residents who had consented to receive them. A resident's son initially declined vaccines but later consented, yet the resident did not receive any boosters. Another resident received a booster in March 2023, but no further doses were given despite consent in August 2024. A third resident completed initial vaccinations in February 2022 and consented to more in June 2024, but no boosters were administered.
A resident with mobility issues and dementia was found to have their call bell inaccessible, as it was on the floor with the cord stuck under the bed wheel, contrary to their care plan which required the call light to be within reach. This deficiency was noted during a survey and reported to the facility's administration.
A facility failed to honor a resident's right to choose activities, specifically smoking, by not completing a required smoking assessment upon admission. The resident, who had no cognitive impairments, was restricted from smoking unless accompanied by staff, leading to dissatisfaction and refusal of medication. The facility only addressed the issue after surveyor questioning.
The facility failed to maintain consistent advance directives for three residents, leading to discrepancies between POLST forms and physician orders. A resident's POLST indicated a wish for CPR, but a physician's order marked them as DNR, with no documentation of a change in wishes. Another resident's POLST indicated DNR, but the physician's order was for CPR, again without documentation of a change.
A resident's dental status was inaccurately assessed in both admission and significant change MDS assessments, leading to a lack of appropriate care planning. The resident, who had broken and missing teeth, was incorrectly recorded as edentulous with no dental issues. Interviews with assessment coordinators confirmed these inaccuracies and the absence of a suitable care plan.
The facility failed to administer PRN medications for constipation as per physician orders for two residents. One resident had no bowel movements documented for several days, and although a suppository was offered and refused, no other PRN medications were documented as offered. Another resident also had no bowel movements for several days, and while a Bisacodyl tablet was administered, no further PRN medications were documented as offered. These deficiencies were reported to the facility's administration.
The facility failed to provide proper respiratory care for two residents using supplemental oxygen. One resident had undated oxygen tubing and no record of when it was last changed, while another had a CPAP machine with an unbagged mask on a cluttered bedside stand. These issues were discussed with the Nursing Home Administrator and DON.
The facility failed to provide timely pharmaceutical services, resulting in missed medication doses for three residents. A resident missed doses of phenobarbital due to delayed delivery, while another resident experienced multiple missed doses of oxycodone due to issues with receiving a new script. A third resident also missed oxycodone doses due to late pharmacy delivery. These incidents reflect the facility's inability to meet residents' medication needs promptly.
A facility's medication error rate was 6.06%, exceeding the acceptable limit. An LPN administered Dulera and Spiriva Respimat to a resident with COPD and chronic respiratory failure but failed to ensure the resident rinsed their mouth as required. Additionally, the LPN administered only one puff of Dulera instead of the prescribed two. These errors were confirmed during an interview with the LPN.
A resident experienced symptoms such as coughing with meals, pocketing food, and increased lethargy, leading to a downgrade in diet and difficulty in medication administration. Despite these changes, the resident's daughter was not informed until several days later. The delay in communication was confirmed during an interview with the DON and Nursing Home Administrator.
Failure to Prevent Neglect During Wheelchair Transport Resulting in Fracture
Penalty
Summary
A resident was being transported in a wheelchair by an agency LPN after attending an outside activity. During the transport, the resident's legs were not placed on leg rests and were covered by a blanket, which prevented the LPN from seeing their position. The resident complained of pain in her left leg after stating that her leg got stuck. Initial x-rays taken the same day were negative for fracture, but the resident continued to experience pain, swelling, and discomfort in her left ankle over the following days. Despite ongoing complaints and visible symptoms, it was not until a repeat x-ray several days later that an acute fracture of the distal left tibia and fibula was identified. The facility's investigation revealed that the LPN was unaware of the policy requiring the use of leg rests for residents unable to self-propel during wheelchair transport. The lack of adherence to this policy resulted in the resident's legs not being properly supported, leading to the incident and subsequent injury. The deficiency was identified as a failure to protect the resident from neglect by not providing necessary services to prevent physical harm.
Deficient Food Storage and Sanitation in Kitchen and Pantries
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards for food safety in the main kitchen and two nursing unit pantries. In the main kitchen, open wire rack shelving in the walk-in cooler was found to be rusty with the exterior finish worn off, and food products were stored on lower shelves without barriers to protect from mop water splash or floor debris. A black plastic tub containing multiple clear plastic bags of chicken thighs was observed thawing in water without any labeling to indicate the product, date placed, or use-by date. Additional issues included a plate warmer with dust and dried food debris, bulk flour and sugar bins with soiled exteriors, and a buildup of dirt and debris on the floor under and around kitchen equipment. In the Oak/[NAME] pantry, a bin of individually packaged cookies was stored without any date to indicate when they were placed or needed to be used by, and refrigerator/freezer temperature logs had not been recorded for several days. In the Marble/Maple pantry, soiled meal trays, a package of graham crackers, and used plastic lids were stored in a cabinet with a large dried brown liquid spill and soiled door rims. The refrigerator and freezer in this pantry also had no recent temperature logs, and both units had significant ice and frost buildup. These findings were confirmed during an interview with the Nursing Home Administrator and DON.
Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notifications to residents and/or their representatives regarding transfers and the facility's bed-hold policy during hospitalizations. Specifically, for one resident who requested transfer to the hospital due to rectal pain, there was no documented evidence that either the resident or her responsible party received written notice of transfer or information about the facility's bed-hold policy. Interviews with facility staff confirmed that these notifications were not provided. Additionally, for two other residents who were transferred to the hospital for medical reasons, there was no documentation that they or their representatives received written notice of the facility's bed-hold policy at the time of transfer. Further review revealed that another resident was transferred to the hospital on two separate occasions for hypotension, and in both instances, there was no evidence that the resident received written information regarding the facility's bed-hold policy or a transfer notice containing all required information, such as contact details for the State Long-Term Care Ombudsman. Staff interviews confirmed the absence of these required notifications and documentation for all affected residents.
Failure to Provide Trauma-Informed and Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). For one resident, who had a diagnosis of PTSD since admission, the care plan did not identify any triggers or interventions to address individualized needs, and there was no documentation of a trauma assessment. For the second resident, who was diagnosed with PTSD following the murder of her two daughters, the facility did not identify her trauma, complete a trauma assessment, or develop a care plan to address triggers or interventions. These deficiencies were confirmed through clinical record review and staff interview, with the DON acknowledging awareness of the traumatic events affecting the residents.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of annual in-service training, as evidenced by a review of employee education records and staff interviews. Specifically, three nurse aides, all hired prior to the current year, had only completed six hours of in-service training since January 2025, with no documentation showing completion of the full annual requirement. The Director of Nursing confirmed that in-service trainings for nurse aides had only recently begun in January 2025, resulting in insufficient training hours for the reviewed staff. This deficiency was identified through review of personnel files and confirmed in an interview with the Director of Nursing.
Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal health information by placing a binder in the main lobby that contained full health survey letters, complaint deficiency letters, and Statements of Deficiencies (Form CMS-2567) from previous surveys. These documents included specific resident identifiers and associated resident names for cited deficiencies, making personal and medical information accessible to anyone in the lobby. The binder was observed to contain deficiency letters and survey results from four previous surveys, each listing multiple residents by name and identifier. This breach of confidentiality was confirmed during an interview with the Nursing Home Administrator.
Failure to Ensure Psychotropic Medication Use Was Clinically Justified
Penalty
Summary
A resident was prescribed the antipsychotic medication Loxapine Succinate for a diagnosis of unspecified schizophrenia, according to her medication regimen and care plan. However, clinical record review and interviews revealed that there was no supporting documentation in the resident's medical record to confirm a diagnosis of schizophrenia. The facility's consulting psychiatric provider's progress notes only referenced a history of depression and did not mention schizophrenia or provide justification for the use of an antipsychotic. The care plan addressing psychotropic medication use did not include any target behaviors to support the indication for antipsychotic use, and behavior monitoring was limited to tracking if the resident was withdrawn. The resident herself reported a history of depression following her mother's death and denied ever experiencing symptoms such as delusions, hallucinations, or disorganized thinking. Interviews with facility staff confirmed the absence of documentation supporting a schizophrenia diagnosis and the lack of monitoring for specific target behaviors related to antipsychotic use. As a result, the facility failed to ensure the resident's medication regimen was free from potentially unnecessary psychotropic medication, as required by regulation.
Inaccurate MDS Discharge Assessment
Penalty
Summary
Facility staff failed to ensure that the assessment for one resident accurately reflected the resident's discharge status. Clinical record review showed that the Minimum Data Set (MDS) assessment documented the resident as being discharged to a short-term general hospital. However, further review revealed that the resident had actually signed out of the facility against medical advice and was not discharged to a hospital on the date in question. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), who acknowledged that the MDS did not accurately represent the resident's actual discharge status.
Failure to Revise Care Plan Following Change in Oxygen Therapy Needs
Penalty
Summary
A deficiency was identified when the facility failed to revise the comprehensive care plan for a resident following a significant change in their condition. Clinical record review showed that the resident had a recent MDS assessment indicating the use of oxygen therapy, with a physician's order for supplemental oxygen at two liters per minute via nasal cannula every shift, and instructions to monitor oxygen saturation to keep it above 90 percent. The care plan included interventions for continuous oxygen use and medication administration as ordered, with monitoring for side effects and effectiveness. However, during observations on two separate occasions, the resident was found in bed without supplemental oxygen being administered. The resident confirmed in an interview that they were not utilizing the supplemental oxygen. Further interviews with the DON and Regional Director of Clinical Services revealed that the oxygen order was based on oxygen saturation, which had consistently been above 95 percent. Despite these changes in the resident's needs and interventions, the care plan was not updated to reflect the current status, resulting in a failure to revise the comprehensive care plan as required.
Failure to Provide Required Transfer and Eating Assistance to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent for activities of daily living following right leg surgery and had significant vision loss, was not provided with the required assistance for transfers and eating. Despite an active physician's order and care plan interventions specifying that the resident should be out of bed for all meals and required two staff for transfers and repositioning, staff consistently failed to get the resident out of bed for meals. Observations and interviews confirmed that the resident remained in bed for all meals and was not routinely asked if she wanted to get out of bed, contrary to her care plan and physician's orders. Additionally, the resident, who was dependent for feeding, reported that not all staff stayed to assist her with meals, and staff interviews revealed a lack of awareness regarding her need for feeding assistance and transfer out of bed for meals. Documentation was inconsistent or missing for care provided, and staff were unclear about the resident's care requirements. The resident experienced significant weight loss since admission, and dietary documentation noted the need for meal assistance to ensure adequacy. The failure to provide necessary services for eating and transfer assistance constituted a deficiency in care for a dependent resident.
Failure to Follow Physician Orders for Medication Administration and Skin Protection
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician orders for two residents. For one resident with a history of atrial fibrillation and hypertension, Metoprolol Succinate ER was administered on multiple occasions despite the resident's apical pulse being below the physician-ordered threshold of 60 beats per minute. There was no documentation explaining why the medication was given outside of the specified parameters, and staff interviews confirmed there was no reason for this deviation from the order. Another resident, who was prone to easy bruising and had a physician's order for Geri-sleeves to be applied to both arms every shift for skin protection, was repeatedly observed without the sleeves in place. The resident reported not having the sleeves applied for several days and denied refusing them. When sleeves were eventually applied, they were ill-fitting and slid down to the wrists, failing to provide the intended protection. These findings were confirmed through observations and interviews with the resident and facility staff.
Failure to Ensure Resident Access to Hearing Services and Devices
Penalty
Summary
The facility failed to ensure that a resident with Alzheimer's dementia received proper treatment and assistive devices to maintain hearing abilities. The resident reported difficulty hearing and was observed using a headphone amplifier, which he removed to answer his mobile phone, further decreasing his ability to hear. Documentation showed that staff were aware of issues with the resident's hearing aid, including a non-working device, an occluded filter, and battery corrosion. The resident's daughter was informed of these issues and questioned whether the facility could handle the service, but was told the facility could not and was encouraged to contact the hearing aid provider. Subsequent documentation indicated ongoing problems, such as the need for batteries, a missing hearing aid, and confusion about the device's whereabouts. The resident was described as a poor historian, and there was no evidence in the clinical record that staff contacted the audiology provider to arrange necessary services or confirm the status of the hearing aid. The resident's care plan and assessments did not accurately reflect the use of a hearing aid or include interventions for the hearing deficit, despite documentation of hearing difficulties. The Minimum Data Set (MDS) assessments failed to indicate the use of a hearing aid, and the care plan lacked individualized interventions addressing the resident's hearing needs. Additionally, after a VA appointment, there was no documentation regarding the repair or possession of the hearing aid, nor any follow-up communication with the audiology provider. These actions and omissions resulted in the facility's failure to accurately complete assessments, develop an individualized plan of care, and coordinate professional audiology services to assist the resident in maintaining hearing ability.
Unsecured Knives and Scissors Found in Resident's Unlocked Room
Penalty
Summary
A deficiency was identified when a resident's room was observed to contain a countertop wooden block with large scissors and seven knives visible near the television. The resident confirmed that he frequently leaves his room during the day to go outside or on leaves of absence, and that his room door does not lock. This situation resulted in the resident's environment not being free from accident hazards, as the unsecured knives and scissors were accessible in an unlocked room while the resident was often absent. The deficiency was confirmed through observation, resident interview, and review of the clinical record.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized, person-centered care plan for a resident diagnosed with unspecified dementia and severe cognitive impairment. Clinical record review showed that the resident was admitted with dementia and had a BIMS score of three, indicating severe cognitive impairment. The resident's care plan only included general interventions such as cueing, reorienting, therapy staff as needed, and lab work as needed, without any evidence of individualized interventions tailored to address the resident's specific dementia-related needs. This deficiency was identified through clinical record review and staff interview, and was confirmed during a review with the Director of Nursing.
Unattended, Unlocked Treatment Cart with Medications on Hallway
Penalty
Summary
A deficiency was identified when an unlocked treatment cart was observed on the Maple Hallway, positioned against a wall outside a resident's room. Upon inspection, multiple tubes of creams were found inside the cart's drawers. The cart remained unattended for five minutes, during which time two residents were seen moving independently in the hallway. No staff member was present to supervise the cart during this period. In an interview, the Director of Nursing confirmed that the cart should have been locked, as required by facility policy and regulations.
Failure to Ensure Full Visual Privacy During Personal Care
Penalty
Summary
A deficiency was identified when a resident was observed in their room during a brief change, and the privacy curtain did not fully extend around the bottom of the bed, resulting in a lack of full visual privacy. During a medication pass for the resident's roommate, a staff member waited until the resident was no longer exposed before proceeding, but the resident was still observed in bed, uncovered, and in a state of undress. Further observation confirmed that the curtain was not large enough to provide complete privacy, and the resident reported that the curtain had not extended around the bed since their admission. These findings were discussed with the Director of Nursing.
Infection Control Deficiencies at Mount Carmel Senior Living
Penalty
Summary
Mount Carmel Senior Living Community failed to correct previously identified deficiencies related to infection prevention and control, as observed during a revisit survey. The facility did not ensure an environment free from the potential spread of infection for two residents. Resident 15, who was under contact precautions for suspected C. diff infection, had inadequate disposal systems for contaminated materials. The cardboard receptacle used for disposing of gowns and gloves was porous and could not be properly disinfected, posing a risk of harboring bacteria. Additionally, a nurse aide was observed serving lunch to Resident 15 without wearing the required gown and gloves, contrary to the contact precautions in place. Resident 14, who had recently returned from a hospital stay for human metapneumovirus pneumonia, was under droplet precautions. However, the facility failed to provide appropriate disposal bins for personal protective equipment (PPE) within the resident's room. A physical therapy assistant was observed improperly handling used PPE, including carrying a contaminated glove under his arm due to the lack of disposal bins. Furthermore, a nurse aide entered Resident 14's room without wearing a gown, gloves, or mask, despite the droplet precautions, while delivering meal trays to both Resident 14 and their roommate. These observations indicate that the facility did not adhere to the required infection control protocols, as evidenced by the improper handling and disposal of PPE and the failure of staff to follow precautionary measures. The deficiencies were reviewed with the Nursing Home Administrator, highlighting ongoing non-compliance with infection prevention and control standards.
Plan Of Correction
Unable to correct the issue identified regarding Resident 15 related to a staff member not wearing proper PPE. Unable to correct the issue identified regarding Resident 14 related to a staff member not wearing Proper PPE. Isolation bins were put in Resident 14's room at the time of survey. New isolation bins with foot pedals have been ordered. A Facility sweep will be conducted to identify residents on any type of precautions to ensure proper protocols are in place (signage, isolation bins, etc.). Staff will be educated on the PPE requirements for the different types of isolation/precautions (ex. Contact, Droplet, Enhanced Barrier Precautions). Audits will be conducted by the IP/Designee weekly x 4 weeks, then monthly x 2 months for compliance with the applicable isolation protocols. Results of the audits will be reviewed at the monthly QAPI meetings.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to administer bowel protocol medications as ordered for three residents, leading to prolonged periods without bowel movements. Resident 1 did not receive the prescribed Bisacodyl tablet after three days without a bowel movement, as documented in the Medication Administration Record (MAR). Similarly, Resident 2 did not receive any Dulcolax medications or enemas despite not having a bowel movement for several days, as per the physician's orders. Resident 4 was also not administered the Bisacodyl suppository after the oral Dulcolax was ineffective, contrary to the physician's orders. The facility also failed to adhere to physician orders for blood sugar assessments and insulin administration for five residents, resulting in hypoglycemia and hospitalization for one resident. Resident 1, who has Type 2 diabetes mellitus, received insulin significantly earlier than her breakfast meal, leading to a dangerously low blood sugar level and subsequent hospitalization. The MAR indicated that insulin was administered well before the anticipated meal delivery, which is against the recommended timing for insulin administration relative to meals. Additionally, other residents, including Residents 3, 4, 5, 7, and 8, experienced similar issues with the timing of blood sugar assessments and insulin administration. Insulin was administered too early, relative to meal times, which could potentially lead to hypoglycemic events. The facility's failure to follow proper medication administration protocols and timing resulted in significant health risks for the residents involved.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across four nursing units, as observed on March 18, 2024. In the [NAME] nursing unit shower room, there was rust around the doors, a warped and splintered door, and a brown substance with loose dirt particles on the floor. The shower stalls had black substances on the floors and walls, dirty shower chairs, rusted grab bars, and a clogged drain with hair buildup. The sink area was dirty, with a candy wrapper and hair in the sink, and the linen bins and trash bin were also dirty. The toilet area was unclean, with a bucket containing a brown substance nearby. Resident 6's room had a dirty overbed table, black areas on the floor, and a dirty privacy curtain. Resident 3's room was cluttered with personal items, including a box of instant coffee on the floor, baskets, a box, and slipper socks under the bed, and a disorganized tabletop with papers, food items, and hygiene products, hindering effective housekeeping. Resident 1's room had a brown substance smeared on the floor, which remained for several hours despite staff presence. Housekeeping staff confirmed the oversight and addressed it only after being informed by the surveyor. These environmental concerns were acknowledged by the Nursing Home Administrator and Assistant Director of Nursing during a meeting on the same day.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. The guidelines specify that enhanced barrier precautions, including the use of gowns and gloves, should be used during high-contact resident care activities for residents with chronic wounds or indwelling medical devices. During an observation, it was noted that a nurse aide, identified as Employee 6, did not wear a gown while emptying urine from the resident's catheter collection bag, although gloves were used. The deficiency was confirmed through an interview with Employee 6, who acknowledged not wearing a gown and had no extenuating circumstances preventing her from doing so. The issue was further discussed with the Nursing Home Administrator and the Assistant Director of Nursing, highlighting the facility's failure to adhere to the required infection prevention and control measures. This deficiency was previously cited in August 2024, indicating a recurring issue with compliance in this area.
Inaccurate Nurse Staffing Data Posting
Penalty
Summary
Mount Carmel Senior Living Community was found to be non-compliant with the requirements for posting nurse staffing information as per 42 CFR Part 483, Subpart B. During an observation on January 2, 2024, it was noted that the facility's posted nurse staffing data inaccurately reflected the number of nurse aides working the dayshift. The posted information indicated that 11 nurse aides were on duty, while only 10 were actually present. Additionally, the posted nurse aide hours for the dayshift were listed as 88 hours, but the facility's schedule showed only 70 actual hours worked. The discrepancy in the posted nurse staffing data was confirmed through an interview with the Director of Nursing on the same day. This failure to accurately post nurse staffing information is a violation of the federal regulation that requires facilities to maintain and display accurate daily nurse staffing data. The facility's inability to ensure the accuracy of this information was a key factor leading to the deficiency cited in the survey report.
Plan Of Correction
The error in the Staff Posting was corrected at the time of Survey. The daily Staff Posting will be reviewed for accuracy by the DON/Designee. Staff responsible for completing the Staff Posting will be educated regarding its completion and the importance of its accuracy. Random audits of the Staff Posting will be conducted by the DON/Designee weekly for 4 weeks and monthly for 2 months. Results of the audits will be reviewed at the monthly QAPI meeting.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by regulations effective July 1, 2024. During the review period from December 26, 2024, to January 2, 2025, the facility did not maintain the minimum staffing levels for nurse aides across various shifts. Specifically, the day shift required one nurse aide per 10 residents, but the facility fell short on six out of eight days. Similarly, the evening shift required one nurse aide per 11 residents, but the facility did not meet this requirement on five out of eight days. The night shift, which required one nurse aide per 15 residents, was also understaffed on four out of eight days. The deficiency was confirmed through a review of nursing staff care hours and an interview with the Nursing Home Administrator and Director of Nursing. The review highlighted specific days where the number of nurse aides scheduled was insufficient for the resident census. For instance, on December 31, 2024, during the day shift, only 5.56 nurse aides were scheduled for a census of 104 residents, whereas 10.40 nurse aides were required. This pattern of understaffing was consistent across the reviewed period, indicating a systemic issue in maintaining the mandated staffing levels.
Plan Of Correction
The Facility is unable to correct past CNA ratios. The Facility is currently in the process of trying to partner with an outside provider to offer CNA classes at the Facility with the hope of increasing the Facility staff when the participants become CNAs. Facility ancillary Nursing staff assist in filling open shifts. Nursing staff will be educated on the Facility Attendance Policy. The Facility continues to actively recruit for open CNA positions using online systems, fliers, and outside recruiters. The Facility continues to use Agency staff to fill open shifts. Agency CNA rates were recently increased as an attempt to aid with staffing. Shift bonuses continue to be offered to Facility staff as necessary to aid in filling open positions. The Facility continues to conduct daily staffing meetings to ensure all available efforts are being made to meet necessary CNA ratios. The DON/Designee will audit CNA ratios weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reported at the monthly QAPI meeting for review and recommendations.
LPN Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to meet the required LPN-to-resident ratios as per the regulation effective July 1, 2023. During the review of nursing staffing hours from December 26, 2024, to January 2, 2025, it was found that the facility did not maintain the minimum staffing levels on several occasions. Specifically, on December 29, 2024, the day shift had 4.00 LPNs for a census of 103 residents, falling short of the required 4.12 LPNs. Additionally, the overnight shift was understaffed on five of the eight days reviewed, with the number of LPNs consistently below the required ratio for the resident census. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these staffing deficiencies.
Plan Of Correction
The Facility is unable to correct past LPN ratios. Nursing staff will be educated on the Facility Attendance Policy. Facility ancillary Nursing staff assist in filling open shifts. The Facility continues to actively recruit for open LPN positions using online systems, fliers, and outside recruiters. The Facility also uses Agency staff to fill open shifts. Agency LPN rates were recently adjusted in an attempt to aid with staffing. Shift bonuses continue to be offered to Facility staff as necessary to aid in filling open shifts. The Facility continues to conduct daily staffing meetings to ensure all available efforts are being made to meet necessary LPN ratios. The DON/Designee will audit LPN ratios weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reported at the monthly QAPI meeting for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient day (PPD) for four out of eight days reviewed. Specifically, on December 26, 2024, the facility provided 2.97 hours PPD; on December 29, 2024, 2.65 hours PPD; on December 31, 2024, 2.44 hours PPD; and on January 2, 2025, 3.13 hours PPD. This deficiency was confirmed through a review of nursing staffing hours and an interview with the Nursing Home Administrator and Director of Nursing on January 2, 2025, at 1:17 PM.
Plan Of Correction
The Facility is unable to correct the past issue of not meeting the 3.2 daily Nursing PPD requirement. The Facility is currently in the process of trying to partner with an outside provider to offer CNA classes at the Facility with the hope of increasing the Facility staff when the participants become CNAs. Facility ancillary Nursing staff assist in filling open shifts. Nursing staff will be educated on the Facility Attendance Policy. The Facility continues to recruit for open RN, LPN, and CNA positions using online sites, fliers, and outside recruiters. The Facility continues to use Agency staff to fill open shifts. Agency CNA rates were recently increased to try to assist with staffing. Shift bonuses are also offered as necessary to Facility staff to fill open shifts. The Facility continues to conduct daily staffing meetings to ensure efforts were made to meet the daily PPD requirement. The DON/Designee will audit the daily PPD weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reviewed at the monthly QAPI meeting.
Deficiency in Insulin Administration Timing
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered blood sugar assessments and insulin administration for five of nine residents reviewed. The facility's policy on insulin administration, last reviewed without changes, did not include instructions for administering insulin per professional standards of practice, such as administering fast-acting insulin with a meal. This led to residents receiving insulin significantly earlier than their meals, which is not in line with the recommended practice of administering fast-acting insulin within five to ten minutes before a meal. Interviews with staff revealed that third-shift employees were conducting blood glucose assessments and administering insulin before the end of their shift, which was well before the residents' breakfast meals were served. For instance, Resident 1 received her insulin more than an hour before her breakfast, despite physician orders indicating insulin should be administered based on a sliding scale before meals. Similar issues were observed with Residents 2, 3, 8, and 9, where blood glucose assessments and insulin administrations were conducted significantly earlier than meal times, contrary to the recommended practice. The Director of Nursing confirmed that the scheduling of blood glucose assessments and meal delivery predisposed residents to receive insulin more than an hour before their meals. The facility lacked a policy or standard of practice to guide licensed staff on implementing physician orders that included parameters for completion before a meal. This deficiency was previously cited, indicating a recurring issue with the facility's management of insulin administration and blood glucose monitoring in relation to meal times.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing support for three residents who required staff assistance with activities of daily living. Resident 6, who was assessed as needing supervision and touching assistance for bathing, did not receive a shower for 22 days despite her preference for showers on specific days. The nursing staff documented that Resident 6 refused showers, but during an interview, she stated that she did not refuse them. Resident 5, admitted on November 11, 2024, required partial moderate assistance for bathing and preferred showers on specific days. However, since admission, he only received two showers, and he expressed confusion about receiving bed baths instead of showers. Resident 7, who was dependent on staff for bathing, did not receive any showers or tub baths in the last 30 days, contrary to her care plan. She expressed a desire for showers but was unable to walk, and she became emotional during the interview. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Promote Healing of Pressure Ulcers
Penalty
Summary
The facility failed to promote the healing of pressure ulcers for a resident identified as high risk for skin breakdown. Upon admission, the resident was assessed with a Braden score of 12, indicating a high risk for skin breakdown, and was noted to have redness and an open area on the left buttock. Despite the facility's policy requiring ongoing weekly evaluations of resident skin, the last documented assessment was on September 30, 2024, which noted unstageable slough and/or eschar on the resident's left gluteal fold and sacrum. No further assessments were documented after this date. On October 2, 2024, the resident complained of wound bleeding, prompting new orders for the sacral and left gluteal fold injuries. However, the next documentation regarding the resident's pressure ulcers was not until October 16, 2024, when it was noted that the ulcers had resolved. The lack of consistent and timely assessments and documentation of the resident's pressure ulcers led to the deficiency, as confirmed by a licensed practical nurse and wound nurse during an interview.
Failure to Serve Meals Timely and at Proper Temperature
Penalty
Summary
The facility failed to serve food at a palatable temperature and in a timely manner across four resident hallways: Maple, Marble, Oak, and [NAME] hallways. Observations revealed discrepancies between the posted meal serving times and the actual delivery times of meal carts. Specifically, early trays were scheduled for 11:45 AM but arrived at 12:30 PM, Marble Hall trays were scheduled for 12:00 PM but arrived at 1:20 PM, [NAME] Hall trays were scheduled for 12:18 PM but arrived at 1:00 PM, Oak Hall trays were scheduled for 12:10 PM but arrived at 1:35 PM, and Maple Hall trays were scheduled for 12:35 PM but arrived at 1:42 PM. During the meal service on Maple Hall, the shepherd's pie was found to be lukewarm at 122.7 degrees Fahrenheit when tested by the surveyor. This information was reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Maintain Residents' Range of Motion
Penalty
Summary
The facility failed to provide services to maintain the range of motion (ROM) for three residents, as identified through clinical record reviews and staff interviews. Resident 16 had a care plan for a restorative nursing program (RNP) to maintain ROM by ambulating 20 feet with assistance, but staff failed to document completion or marked tasks as not applicable on several dates across June, July, and August 2024. Despite documenting several refusals by the resident, there was no facility documentation identifying the current level of function (CLOF). Resident 30 had a therapy evaluation recommending an RNP for ambulation, which was not implemented until four months later. After implementation, staff failed to document completion or marked tasks as not applicable on multiple dates in July and August 2024, with frequent refusals noted, especially during evening shifts. Similarly, Resident 50's care plan included ambulation and transfer tasks, but staff did not document completion or marked tasks as not applicable on numerous dates. Frequent refusals were also documented for this resident, with no facility documentation identifying the CLOF. The surveyor reviewed these findings with the Director of Nursing.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls and injuries for two residents. For Resident 16, after a fall on May 22, 2024, occupational therapy recommended that the resident be placed in heavily supervised areas when out of bed. However, there was no documentation indicating that this recommendation was implemented. Subsequently, Resident 16 experienced falls on July 14 and August 16, 2024, resulting in injuries that required emergency room evaluations. For Resident 103, the facility did not ensure the proper functioning and documentation of bed and chair alarms, which were intended to prevent falls. On multiple occasions, alarms either did not sound due to technical issues or were not documented as part of the resident's care plan. This lack of proper alarm management led to several falls, including one on July 9, 2024, which resulted in a femur fracture. Despite a physician's order to use pressure alarms, staff failed to consistently apply and document these interventions. The facility's investigations into these incidents revealed gaps in the verification and application of fall prevention measures. Interviews with staff confirmed that alarms were not always correctly placed or activated, contributing to the residents' falls and subsequent injuries. The Director of Nursing and other staff were made aware of these findings during the surveyor's review.
Failure to Assess Entrapment Risks for Bed Rails
Penalty
Summary
The facility failed to assess the entrapment risk of assist bars (side rails) for eight out of nine residents reviewed for accident concerns. The facility's policy, titled 'Enabler Bar Protocol,' requires a Bed System Measurement Device Test to be completed upon admission or when initiated, and with any change in bed and/or mattress. However, for several residents, including those using air mattresses and bariatric beds, the facility did not conduct these assessments. For instance, Resident 24 had an active physician's order for halo assist rings and an alternating air mattress, but the entrapment zone measurement was not documented, and the Maintenance Director confirmed that beds with air mattresses were not assessed for entrapment risks. Observations and interviews revealed that residents, such as Resident 51, were using enabler bars for bed mobility without documented risk assessments. The facility provided documentation indicating that the bars could be used without fear of entrapment, but no evidence was provided to support this claim. Similarly, Resident 78 was observed with metal assist bars and an air mattress, yet no assessment was completed to ensure safety. The Maintenance Director stated that entrapment zones were not measured for bariatric beds with factory-installed assist bars, and no documentation was available to support the safety of these configurations. Further review showed that residents who had moved rooms, such as Residents 37 and 50, did not have updated Bed System Measurement Test Results Worksheets to confirm the safety of their current bed and rail systems. The facility's failure to reassess these systems, especially during room changes due to COVID-19, was confirmed by the Director of Nursing. Additionally, Resident 23's and Resident 26's records showed that entrapment zone assessments were not completed due to the use of air mattresses, and no documentation was available to verify the safe use of assistive devices with these mattresses.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three nurse aides. The employees in question were hired on February 15, 2007, May 23, 2023, and October 21, 2020, respectively. Upon review, there was no documented evidence that the facility conducted the required annual performance evaluations for these employees. This deficiency was confirmed during an interview with the Nursing Home Administrator on August 23, 2024.
Deficient Arbitration Agreements Compromise Neutrality
Penalty
Summary
The facility's arbitration agreements were found to be deficient in ensuring a neutral and fair arbitration process for resolving legal disputes. Specifically, the agreements for three residents, identified as Residents 39, 52, and 103, allowed the facility to select the arbitrator if the parties could not agree on a neutral arbitration service within 30 days. This stipulation was present in the agreements signed by the responsible parties of these residents on various dates in 2023 and 2024. The agreements initially designated a specific arbitrator services company to handle the arbitration, but if that company was unable or unwilling, the facility retained the right to select a neutral arbitrator, which compromised the neutrality of the arbitration process. During interviews with the Nursing Home Administrator and Employee 7, the admissions director, it was confirmed that the agreements indeed allowed the facility to select the arbitrator under certain conditions. Employee 7 mentioned that the company was in the process of revising the agreements, but the residents in question had not yet signed updated versions. The deficiency was identified as a violation of specific Pennsylvania Code sections related to the responsibility of the licensee, management, and resident rights.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper isolation precautions for residents requiring transmission-based precautions and enhanced barrier precautions. Resident 103, who had a pressure ulcer on his right heel, was observed receiving wound care without the staff donning isolation gowns, despite the presence of enhanced barrier precautions signage. Similarly, Resident 107, with open wounds on his right lower extremity, received wound care without staff wearing gowns, contrary to the requirements for enhanced barrier precautions. Resident 28, diagnosed with an ESBL infection, did not have appropriate signage indicating the necessary contact precautions outside her room. The facility downgraded her isolation precautions from contact to enhanced barrier precautions without a policy or guideline to support this decision. Additionally, Resident 30, who tested positive for C. Diff, did not have contact isolation signage outside her room, and there was no commode for individual use, despite sharing the room with another resident. The facility also failed to enforce restriction-to-work guidelines for Employee 5, who tested positive for COVID-19 but continued to work regular hours without evidence of contact tracing or testing of other staff and residents. Furthermore, the facility's water management program lacked documentation of control limits and effectiveness testing, posing a risk for Legionella growth. Lastly, Resident 29 stored a bed pan directly on the floor, contrary to infection control practices, and there was no evidence of staff ensuring proper cleaning and storage of the bed pan.
Failure to Administer COVID-19 Vaccines to Consenting Residents
Penalty
Summary
The facility failed to ensure that all residents who consented to the COVID-19 vaccine received it, as evidenced by the cases of three residents. Resident 26's son initially declined all vaccines but later consented to the influenza, pneumococcal, and COVID-19 vaccines. However, there was no documentation of this change in decision regarding the COVID-19 vaccine, and Resident 26 did not receive any booster doses despite her son’s consent. Hospital records showed that Resident 26 had received her initial COVID-19 vaccinations in 2021, but there was no evidence of any subsequent boosters. Resident 28 received her last COVID-19 booster in March 2023, and her responsible party consented to further COVID-19 vaccinations in August 2024. Despite this consent, there was no evidence of any additional COVID-19 immunizations for Resident 28. Similarly, Resident 107 completed his initial COVID-19 vaccination series in February 2022 and consented to further vaccinations in June 2024, but there was no record of any booster doses being administered. These findings were confirmed by the facility's infection control prevention coordinator.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident regarding the accessibility of a call bell. Clinical record review and observation revealed that a resident, who had diagnoses including unsteadiness on their feet, muscle weakness, abnormalities of gait and mobility, and dementia, was at risk for falls. The resident's care plan specified that the call light should be within reach and that the resident should be encouraged to use it for assistance. However, during observations, the call bell was found on the floor with the cord stuck under the wheel of the bed, making it inaccessible to the resident. This deficiency was identified during a survey and was communicated to the Nursing Home Administrator and Director of Nursing.
Failure to Facilitate Resident's Right to Smoke
Penalty
Summary
The facility failed to ensure a resident's right to choose activities consistent with her interests, specifically regarding smoking. The facility's Smoking Policy required a Safe Smoking Assessment Form to be completed for any resident requesting to smoke upon admission. However, Resident 100, who had a history of smoking before admission, was not informed that smoking would be prohibited until after her admission. She expressed her desire to smoke and was on nicotine patches, but the facility did not complete the necessary assessment or update her care plan to reflect her smoking preferences until after the surveyor's inquiry. Resident 100, who had no cognitive impairments as indicated by her BIMS and SLUMS scores, was restricted from going outside to smoke unless accompanied by staff. This restriction led to her feeling like a prisoner, refusing medication and insulin, and expressing dissatisfaction with her stay at the facility. The facility only completed the smoking evaluation and updated her care plan after the surveyor's questioning, confirming that she could safely smoke and understand the facility's smoking policy.
Inconsistent Advance Directives for Residents
Penalty
Summary
The facility failed to establish clear and consistent resident wishes regarding advance directives for three residents. For Resident 102, there was a discrepancy between the POLST form, which indicated the resident's wish to have CPR, and a physician's order that marked the resident as DNR. There was no evidence of any discussion or updated advance directives to indicate that Resident 102 had changed their wishes since the POLST was completed. Similarly, Resident 16's POLST indicated a wish for CPR, but the physician's order was for DNR, with no documentation of a change in wishes by the responsible party. For Resident 101, the POLST indicated a DNR preference, but the physician's order was for CPR, again with no documentation of a change in the resident's wishes. These discrepancies were identified during a survey and discussed with the Nursing Home Administrator and Director of Nursing.
Inaccurate Dental Assessment for a Resident
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the dental status of a resident, identified as Resident 23. During an interview, Resident 23 expressed that she had not received professional dental services for some time and was embarrassed by her broken and missing teeth. However, the admission Minimum Data Set (MDS) assessment dated January 17, 2024, inaccurately recorded Resident 23 as having no teeth and no obvious cavities or broken teeth. This incorrect assessment led to the development of a care plan based on the resident being edentulous, which did not address her actual dental needs. A subsequent significant change MDS assessment also failed to accurately reflect Resident 23's dental condition, noting that she had natural teeth without obvious cavities or broken teeth. Interviews with the licensed practical nurse assessment coordinator and the registered nurse assessment coordinator confirmed the inaccuracies in both MDS assessments. They acknowledged that Resident 23 was indeed missing teeth and had natural teeth that were likely broken or had cavities. Furthermore, the facility was unable to provide a care plan that addressed Resident 23's true dental condition, indicating a lapse in accurate assessment and care planning.
Failure to Administer PRN Medications for Constipation
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered medications for two residents. For Resident 51, the physician orders required monitoring for side effects of anti-anxiety and anti-depressant medications, including constipation. The care plan included interventions to administer medications as ordered and observe for side effects. Despite having orders for Dulcolax, Biscolax suppository, and soap suds enema to promote bowel movements, the bowel elimination records showed no bowel movements from July 30 to August 5, 2024. The Medication Administration Record (MAR) indicated an attempt to administer a Biscolax suppository on August 5, 2024, which the resident refused, but there was no documentation of offering other PRN medications as per the physician orders. For Resident 72, the hospice care plan instructed staff to notify the registered nurse if there was no bowel movement. The physician orders included Bisacodyl tablets, Biscolax suppository, and soap suds enema for constipation management. The bowel elimination records showed no bowel movements from August 5 to August 9, 2024. The MAR documented the administration of a Bisacodyl tablet on August 7, 2024, but there was no indication that additional PRN bowel medications were offered or refused on subsequent days without bowel movements. These findings were communicated to the Nursing Home Administrator and Director of Nursing on August 23, 2024.
Failure to Maintain Proper Respiratory Care Standards
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents requiring supplemental oxygen. Resident 78 was observed in bed with oxygen administered via a nasal cannula, but there was no evidence of a date on the oxygen tubing or bag attached to the oxygen concentrator, nor was there documentation in the clinical record indicating when the tubing and nasal cannula were last changed. Similarly, Resident 35 was observed with oxygen administered via nasal cannula, with no date on the tubing or concentrator to indicate when it was last changed. Additionally, a CPAP machine was observed on Resident 35's bedside stand with an unbagged mask lying on top of stacks of papers and snack food bags. These observations were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to maintain proper documentation and hygiene standards for respiratory equipment, as required by 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure timely availability of medications for three residents, leading to missed doses. Resident 57 had a physician's order for phenobarbital to be administered every 12 hours for unspecified convulsions. However, on August 9, 2024, both the morning and evening doses were missed due to the medication being unavailable and awaiting delivery from the pharmacy. The refill for phenobarbital was ordered on August 7, 2024, but the medication was not delivered in time, resulting in the resident missing doses until the next scheduled administration on August 10, 2024. The Director of Nursing was unable to provide a reason for the delay in delivery. Resident 24 had a physician's order for oxycodone to manage chronic pain, but multiple doses were missed in July and August 2024 due to the medication not being available from the pharmacy. The facility documentation indicated issues with receiving a new signed script, which delayed the medication delivery. Similarly, Resident 50, who had a prescription for oxycodone for osteoarthritis, missed doses on June 29 and 30, 2024, and July 1, 2024, because the medication was not delivered on time. The medication was eventually administered on July 2, 2024, after a late delivery. These incidents highlight the facility's failure to provide timely pharmaceutical services, impacting the residents' healthcare needs and quality of life.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.06 percent based on 33 medication opportunities with two errors. During a medication administration pass, a licensed practical nurse (Employee 1) administered Dulera and Spiriva Respimat to a resident with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. However, Employee 1 did not instruct or ensure that the resident rinsed their mouth with water after the administration of both medications, as required by the physician's orders. Additionally, Employee 1 administered only one puff of Dulera instead of the prescribed two puffs. This deviation from the physician's orders was confirmed during an interview with Employee 1. The surveyor discussed these findings with the Director of Nursing and the Nursing Home Administrator, highlighting the facility's failure to adhere to proper medication administration protocols.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a resident's change in condition requiring interventions. Resident CR1 exhibited symptoms such as coughing with meals, pocketing food, and increased lethargy. A speech therapy consult was initiated, and the resident's diet was downgraded to puree texture with nectar thick liquids. Despite these changes, the resident's daughter was not informed of the condition changes until several days later, on December 1, 2023. Further clinical record review revealed that the resident had a fever and was lethargic, making it difficult to administer medications. The physician ordered immediate lab tests, and the resident's daughter was finally updated on the resident's condition and new orders. The delay in communication was confirmed during an interview with the Director of Nursing and Nursing Home Administrator.
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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