Mountain City Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hazleton, Pennsylvania.
- Location
- 403 Hazle Township Boulevard, Hazleton, Pennsylvania 18202
- CMS Provider Number
- 395582
- Inspections on file
- 30
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mountain City Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with insomnia and bipolar disorder, who was cognitively intact and initially allowed to ambulate independently, experienced multiple falls and a suspected medication overdose after reporting she had taken unknown pills and describing a pattern of keeping and later ingesting dropped medications. The facility did not conduct an internal investigation of the possible overdose and did not update elopement risk assessments or supervision despite repeated falls, unsteady gait, and changes in ambulation orders that restricted independent off-unit mobility. Doors in the building remained unlocked, the resident did not have a wander guard, and after being denied trazodone the resident independently used the elevator, exited the building, and walked outside in cold, snowy conditions to a distant gazebo without staff awareness, where she fell and required EMS transport. Hospital imaging confirmed a left femoral neck fracture and pelvic hematoma, and an elopement/wandering care plan and increased supervision were only initiated after this elopement and injury.
A resident with a history of severe cognitive impairment and aggressive behaviors repeatedly wandered into other residents' rooms and exhibited physical aggression. Despite ongoing documentation of these behaviors and interventions in place, staff did not provide sufficient supervision or monitoring, resulting in a physical altercation where one resident punched another, causing harm.
The facility did not effectively implement and sustain corrective actions through its QAPI program to prevent recurrence of abuse prevention deficiencies. Despite a corrective plan that included staff re-education, care plan updates, and monitoring of residents with aggressive behaviors, ongoing deficient practices were identified, and the QAPI committee failed to detect or prevent further similar issues affecting a resident.
A deficiency was identified in the facility's building construction, specifically a penetration in the suspended ceiling of the rated ceiling assembly within the Sprinkler Room. This issue affects one of the four floors and was confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain the exit stair tower enclosure, affecting all four floors. An umbrella stand was found in the first floor portion of the East Lobby Stair tower, violating exit requirements. The deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain the automatic sprinkler system, with several sprinkler head assemblies in the Laundry found "loaded" with lint. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain smoke-tight corridor doors in several locations, affecting multiple floors. Observations revealed that doors to resident rooms 307, 302, and 104 were not smoke-tight, as confirmed by the Facility Administrator and Facilities Manager.
The facility failed to resolve grievances and provide timely follow-up for three residents. Resident 107 filed three grievances without receiving a response, while Resident 15 and Resident 4's family reported similar issues. The grievance log for Resident 4 showed only three grievances marked as resolved, with no evidence of investigation for additional grievances. The Nursing Home Administrator confirmed the lack of documentation and prompt resolution efforts.
A resident with severe cognitive impairment and a history of aggressive behavior physically abused two other residents. The facility failed to implement adequate supervision and monitoring measures, resulting in incidents where one resident was poked and punched, and another was slapped. Despite the known history of aggression, the facility did not take sufficient proactive measures to prevent these incidents.
The facility failed to ensure accurate MDS assessments for two residents. One resident's assessment inaccurately reported no wandering behaviors, despite documentation of such incidents. Another resident's assessment incorrectly indicated hypnotic medication use and omitted a GDR attempt for antipsychotic medication, despite clinical records showing changes in medication orders. These discrepancies were confirmed by facility staff.
A resident with arthritis and morbid obesity sustained a forehead laceration during a transfer using a mechanical lift. The incident occurred when the lift's leg got caught between bed wheels, causing it to tip over and hit the resident. Despite satisfactory transfer skills of the staff involved, the improper use of the lift led to the injury.
A resident with diabetes and dementia experienced a choking incident that was not accurately documented in their clinical records. Despite life-saving measures being initiated and the resident being transferred to the hospital, the facility's records lacked details of the incident, including the Heimlich Maneuver and removal of a meatball from the airway. Inconsistencies were found between nursing notes, SBAR forms, and witness statements, confirmed by the NHA and DON.
A resident with dementia and major depressive disorder did not receive the influenza vaccine, despite the facility having obtained signed consent from the resident's representative. The facility's policy mandates offering the vaccine unless contraindicated, but there was no documentation of administration. The DON confirmed the oversight during an interview.
The facility's QAPI committee failed to correct deficiencies related to abuse prevention. Despite developing a plan of correction after a survey identified issues, a subsequent survey found continued deficiencies. Measures included discharging a resident, updating care plans, re-educating staff, and conducting audits, but these were not effectively implemented to prevent recurrence.
The facility failed to report critical incidents involving two residents to the State Licensing Agency. One resident sustained a head laceration during a mechanical lift transfer, requiring hospital transfer. Another resident experienced a choking episode, necessitating the Heimlich Maneuver, CPR, and hospital transfer, where the resident later expired. These events were not reported, compromising compliance with mandated reporting requirements.
A resident at Mountain City Nursing & Rehabilitation Center experienced significant weight loss and inadequate fluid intake, which were not timely addressed by the facility. Despite the resident's decreased appetite and use of diuretics, the facility failed to monitor and evaluate the resident's nutritional and hydration needs, leading to hospitalization for hypernatremia and acute kidney injury.
The facility failed to meet the required nurse aide to resident ratios on nine shifts, with insufficient staffing on evening and night shifts in December 2024. The Nursing Home Administrator confirmed the shortfall, and no higher-level staff were available to compensate for the deficiency.
The facility did not meet the required 3.2 hours of direct resident care per resident, providing only 3.02 hours on a specific day. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to protect two residents from abuse. A cognitively impaired resident was involved in a non-consensual sexual encounter with another resident, while another resident was physically abused by a peer. The incidents were discovered by staff, and the facility's investigation confirmed the deficiencies in protecting these residents from harm.
The facility failed to follow its procedures for responding to a sexual abuse incident between two residents. Despite policy requirements, neither resident was sent to the hospital for evaluation, and evidence was not preserved. Staff interviews revealed a lack of awareness of the policy, and Resident 16's representative was not informed of the necessity for a hospital examination. Additionally, Resident 16 was moved to another building without the representative's agreement.
A resident with moderate cognitive impairment sustained a thumb injury after accessing used razors in a shower room. The facility had removed sharps containers but left encasements with razors accessible, failing to maintain a safe environment. The DON acknowledged the issue during a survey.
The facility failed to ensure nursing staff had the necessary competencies to conduct thorough assessments following a sexual abuse incident involving two residents. The facility's policy required hospital evaluations, which were not conducted. An RN performed incomplete assessments and lacked training for sexual assault examinations. The DON and NHA confirmed these deficiencies.
The facility's QAPI committee failed to implement effective corrective action plans to prevent ongoing abuse-related deficiencies. Despite a plan of correction, a revisit survey revealed that a resident suffered physical abuse and another experienced sexual abuse, resulting in psychosocial harm. The facility's monitoring plans did not address these deficiencies, affecting two residents out of 11 sampled.
A resident with bipolar disorder and difficulty walking eloped from the facility without staff knowledge, highlighting inadequate supervision and safety measures. The resident left the premises unsupervised, walked to a convenience store, and was later returned by staff. The facility lacked proper procedures for monitoring residents' whereabouts, and there was no documentation or investigation of the incident.
A resident with dysphagia was served improperly pureed shrimp scampi, leading to a choking incident and aspiration pneumonia. The resident required a pureed diet with nectar thickened liquids, but the meal was not prepared according to these specifications. No staff was present to assist the resident during the meal, despite the care plan indicating the need for assistance. The resident was hospitalized with acute respiratory failure and aspiration pneumonia.
The facility failed to effectively monitor a resident's whereabouts, resulting in an elopement incident. This deficiency was due to the administration's failure to implement established procedures, placing 65 residents at risk. The Administrator and DON did not fulfill their responsibilities to ensure compliance with guidelines and resident safety.
Two residents reported significant delays in staff response to call bells, with one waiting an hour for assistance during the second shift and another experiencing similar delays after 6:00 PM. Both residents are cognitively intact, and the NHA confirmed the expectation for timely responses to promote residents' quality of life.
A resident with dysphagia was not provided with necessary feeding assistance during a meal, as required by their care plan. Despite having a physician's order for a pureed diet and nectar consistency liquids, the resident was left unsupervised, resulting in coughing up a piece of shrimp. The facility's records and staff interviews confirmed the lack of compliance with the care plan.
A resident with diabetes and hypertension did not receive a requested bedtime snack, which was not documented in the clinical records. The facility's policy requires the availability of snacks, but the resident's request over several days was unmet, as confirmed by the DON.
The facility failed to protect six residents from physical abuse by other residents, resulting in serious harm and injury to one resident. Incidents involved residents with severe cognitive impairments and behavioral disturbances, including dementia and anxiety. The facility did not implement sufficient supervisory measures to monitor residents with known aggressive behaviors, leading to multiple instances of resident-to-resident physical abuse.
The facility failed to maintain sanitary practices for food storage and service, leading to potential contamination and microbial growth. Observations included soiled garbage cans, dust accumulation, improper food labeling, and unsanitary conditions in both kitchen areas and a resident food pantry. These issues were confirmed by the foodservice director, RD, an LPN, and the Nursing Home Administrator.
The facility failed to maintain a clean and orderly environment on four of five resident units, with issues such as broken closet door handles, strong odors, missing ceiling blocks, unattended tools, improperly stored personal items, and unclean medical equipment. The Director of Nursing confirmed the expectation for daily maintenance, which was not met.
The facility failed to provide accessible information and forms regarding the grievance/complaint process and the residents' rights to file grievances anonymously on four of seven floors. The Blue Building's first, second, and third-floor nursing units, as well as the [NAME] Building Lobby, lacked necessary postings and forms. The Nursing Home Administrator acknowledged this deficiency.
The facility failed to administer oxygen as ordered and maintain sanitary oxygen delivery systems for six residents. Issues included incorrect oxygen flow rates, undated and improperly stored oxygen tubing, and empty oxygen tanks. Interviews confirmed non-compliance with physician orders and improper equipment maintenance.
The facility failed to provide sufficient staff with the necessary competencies and skills to meet the behavioral health needs of residents, leading to incidents involving aggressive behaviors and inadequate supervision. Three residents exhibited severe cognitive impairments and behavioral issues, which were not adequately addressed by the facility, resulting in physical altercations and safety concerns.
The facility failed to develop and implement individualized plans to manage dementia-related behavioral symptoms for four residents, leading to deficiencies in promoting resident safety and well-being. Despite increased supervision and care plans, interventions were not effective or consistently implemented, resulting in incidents of physical abuse, falls, and self-injurious behavior.
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for its resident population. The assessment did not accurately reflect the current resident population, including 73 residents with Alzheimer's/dementia and 54 with mental disorders. There were also seven incidents of resident-to-resident abuse. The assessment lacked comprehensive data and resources to address behavioral health and dementia care needs, compromising resident safety.
The facility failed to incorporate preferred resident schedules into daily routines and allow residents to make choices about important aspects of their lives. One resident could not go outside for fresh air, another faced conflicts between showering and smoking schedules, and a third had to choose between preferred activities and smoking breaks. Staff confirmed the lack of accommodation for these preferences.
The facility failed to develop and implement an individualized person-centered plan for a resident with PTSD. The care plan did not identify PTSD symptoms, triggers, or specific interventions to minimize triggers and prevent re-traumatization. This was confirmed by the Nursing Home Administrator.
A resident with psychosis and dementia was given 12 additional doses of risperidone after it was supposed to be discontinued, despite the availability and administration of a new medication, Asenapine. The error was confirmed by the DON and Nursing Home Administrator.
The facility failed to effectively use its resources to prevent physical abuse of six residents by other residents, despite having a policy against abuse. The Administrator and DON did not fulfill their essential job duties to ensure resident safety and adherence to regulatory guidelines, leading to a cited deficiency under F600.
The facility failed to respond timely to residents' requests for assistance, as reported by 15 out of 33 interviewed residents. Residents experienced extended wait times for care, including incontinence care and pain management, across various shifts. The Nursing Home Administrator acknowledged the issue but could not explain the widespread reports of untimely staff responses.
The facility failed to maintain a clean and orderly environment in resident areas, with multiple instances of unclean and worn furniture observed. The DON and NHA confirmed the facility's environment should be kept in good repair and maintained in a clean and homelike manner.
Failure to Supervise Resident and Address Medication Hazard Leading to Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate supervision and implementation of safety interventions to protect a resident from accident hazards related to medications and elopement. The resident was cognitively intact, diagnosed with insomnia and bipolar disorder, and had physician orders allowing independent ambulation in the room and on the unit, and at one point off the unit and on facility grounds with a rollator. The resident experienced multiple falls in late November and December, including a fall in another building and a fall by the sink, and was later observed with an unsteady gait. Despite these events and changes in ambulation orders, an elopement risk assessment initially identified the resident as not at risk for elopement, and the facility did not revise supervision or safety interventions in response to the resident’s changing condition and mobility status. On December 29, the resident was found walking back from the bathroom with an unsteady gait and an oxygen saturation of 84%. The resident told staff she had taken pills but could not identify what type. She was transferred to the ED for evaluation of a possible medication overdose and received two doses of Narcan, after which she became more responsive. Upon return, trazodone was discontinued. The resident later reported that during medication administration she sometimes dropped pills on the floor or bed, kept dropped pills in her drawer, and took them later if she chose, and that pills were found on her floor around the time of the suspected overdose. The NHA and DON acknowledged that the facility did not complete an internal investigation of this potential medication overdose because the ED did not confirm an overdose, despite documentation and resident statements indicating she had consumed unknown pills. On December 30, the resident fell from bed while reaching for the call bell and later was found on the floor in the social services office on another floor, after having positioned her walker at the office door and lying on the floor to hide from staff. Following these events, her ambulation status was changed to require assistance of one person with a rollator and independence off the unit within the building was discontinued, but the facility did not complete a new elopement risk assessment or revise supervision and safety interventions to reflect her increased need for monitoring and restricted off-unit mobility. In the early morning hours of December 31, after requesting trazodone that had been discontinued, the resident was last seen in bed around 4:30 a.m. and then independently used the elevator and exited through the unlocked front doors without a wander guard. Security camera footage showed her leaving the building, crossing the parking lot, and walking toward a gazebo in snowy, cold conditions. She fell near the gazebo, called 911 from her cell phone, and was found outside by EMS and staff with complaints of leg pain and feeling cold. Hospital imaging confirmed a left femoral neck fracture requiring surgery and a left pelvic hematoma with active extravasation. An elopement/wandering care plan and elopement risk assessment identifying potential risk and need for increased supervision were not initiated until after this elopement and injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse perpetrated by another resident, despite a documented history of aggressive and intrusive behaviors by the perpetrator. The resident who committed the abuse had a history of dementia with behavioral disturbances, bipolar disorder, and parkinsonism, and was known to exhibit behaviors such as wandering into other residents' rooms, aggression, verbal and physical abuse toward staff, and previous altercations with other residents. The care plan for this resident included interventions such as redirection, psychiatric referrals, and activity engagement, but nursing documentation showed that these measures were not effective in preventing ongoing aggressive incidents. Prior to the incident, the resident continued to display escalating behaviors, including physical altercations with other residents, urinating in hallways, and threatening staff. On the day of the incident, staff found both the perpetrator and the victim lying on the floor outside the victim's room. The victim reported that a fight had occurred after the perpetrator entered the room and was interfering with the curtain, resulting in both residents punching each other. Documentation confirmed that the perpetrator had a pattern of entering other residents' rooms and being difficult to redirect, with frequent episodes of aggression and noncompliance with staff interventions. Despite the known risks and repeated documentation of aggressive behaviors, the facility did not implement adequate supervision or monitoring to prevent the physical abuse of the victim. The lack of effective preventive measures allowed the perpetrator to access other residents' rooms and engage in physical altercations, resulting in harm to another resident.
Failure to Sustain Abuse Prevention Measures Through QAPI
Penalty
Summary
The facility failed to implement and sustain corrective actions through its Quality Assurance and Performance Improvement (QAPI) program to prevent the recurrence of deficiencies related to abuse prevention for one resident. Despite having developed a plan of correction following a previous survey, which included updating activity assessments, identifying residents at risk, reviewing care plans, and re-educating staff on abuse policy and behavior interventions, the facility did not ensure these measures were effectively carried out. The QAPI committee was responsible for monitoring compliance and reviewing audit results, but ongoing deficient practices were identified during a subsequent survey. The revisit survey found that the facility's QAPI monitoring process did not detect ongoing risks to residents or prevent further similar deficiencies. Specifically, the facility failed to protect residents from those with aggressive behaviors, as the QAPI committee did not successfully implement the plan to prevent abuse. This resulted in continued risk and recurrence of the same deficiencies previously cited.
Building Construction Deficiency in Sprinkler Room
Penalty
Summary
The facility failed to maintain building construction requirements, as evidenced by an observation made on February 11, 2025. During the inspection, a penetration was found in the suspended ceiling portion of the rated ceiling assembly within the Sprinkler Room. This deficiency affects one of the four floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
Plan Of Correction
Penetration in sprinkler room was corrected. Facility wide audit was completed for like penetrations and addressed. Maintenance will be educated re: K-0161 by NHA/Designee. Maintenance director or designee will audit all areas for 3 months and then quarterly. All findings will be reported at Monthly QPI meeting.
Improper Item Placement in Stair Tower Enclosure
Penalty
Summary
The facility failed to maintain the exit stair tower enclosure, which affected all four floors of the building. During an observation on February 11, 2025, at 11:01 a.m., it was noted that an umbrella stand was improperly placed within the first floor portion of the East Lobby Stair tower. This placement violated the requirements for stairways and smokeproof enclosures as exits. The deficiency was confirmed during an exit interview conducted on the same day between 12:20 p.m. and 12:30 p.m. with the Facility Administrator and Facilities Manager, who acknowledged the issue with the stair tower enclosure.
Plan Of Correction
Umbrella stand was removed at time of survey from the stairway. In-service was completed to all staff that no item can be stored in stair towers. Maintenance will be educated re: K-0025 by NHA/Designee. Daily Audits will be conducted by Maintenance director or designee.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in one location, specifically affecting one of the four floors. During an observation on February 11, 2025, at 11:15 a.m., it was noted that several sprinkler head assemblies located within the Laundry were "loaded" with lint. This deficiency was confirmed during an exit interview on the same day between 12:20 p.m. and 12:30 p.m. with the Facility Administrator and Facilities Manager.
Plan Of Correction
Lint was removed from Sprinkler Head Located in Laundry. Facility Audit was completed of all Sprinkler Head for Lint. Maintenance will be educated by NHA/Designee regarding K-0353. Maintenance director or designee will audit all Sprinkler for 3 monthly and then quarterly. All findings will be reported at Monthly QPI meeting.
Facility Fails to Maintain Smoke-Tight Corridor Doors
Penalty
Summary
The facility failed to maintain smoke-tight corridor openings in several locations, affecting multiple floors. During an observation on February 11, 2025, it was noted that the doors to resident rooms 307 and 302 were not smoke-tight. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager. Additionally, another observation on the same day revealed that the door to Resident Room 104 on the first floor was also not smoke-tight. This issue was similarly confirmed during the exit interview with the Facility Administrator and Facilities Manager. These deficiencies indicate a failure to comply with the requirements for corridor doors to resist the passage of smoke, as outlined in NFPA 101 and CMS regulations.
Plan Of Correction
Room 307 and 302 Doors were adjusted to be smoke tight. Facility Door Audit was completed of all doors to ensure they are smoke tight. Maintenance will be educated by NHA/Designee re: K-0363. Maintenance director or designee will audit all doors for 3 months and then quarterly. All findings will be reported at Monthly QPI meeting. Room 104 Door was adjusted to be smoke tight. Facility Door Audit was completed of all doors to ensure they are smoke tight. Maintenance will be educated re: K-0363 by NHA/designee. Maintenance director or designee will audit all doors for 3 months and then quarterly. All findings will be reported at Monthly QPI meeting.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances and provide timely follow-up with residents and/or their representatives regarding the status of grievance resolutions for three of seven residents reviewed. The facility's policy, titled "Resident Grievances and Concerns Policy," outlines that upon receipt of a grievance, the Grievance Official should take immediate action to prevent further potential violations and complete the grievance review within a reasonable time frame, not exceeding thirty days. However, interviews with residents and family members revealed that grievances were filed but not addressed, and no responses were received from the facility. Resident 107 reported filing three grievances within the last two months without receiving any response. An aide assisted her in filling out the concern forms, which were then placed in the grievance box. Similarly, Resident 15 stated that she filed a written grievance about six months ago and never received a response. Additionally, Resident 4's family member reported filing 30-40 concern forms since admission in April 2024, with only 2-3 being addressed. The family member expressed concerns about dietary issues, lack of fresh water, staff treatment, wandering residents, and other care concerns, noting that staff members would fill out paperwork but fail to follow up. The grievance log for Resident 4 showed only three grievances on file since admission, all marked as resolved, but there was no documented evidence of investigation or resolution for additional grievances. The Nursing Home Administrator confirmed the lack of documentation and was unable to provide evidence of prompt efforts to resolve grievances or keep residents and families informed of progress. This deficiency highlights the facility's failure to adhere to its grievance policy and ensure residents' rights to voice grievances without fear of reprisal and receive timely resolutions.
Plan Of Correction
Step 1 R4, R107, & R15 will be interviewed to determine if they have any unresolved grievances. Follow up will occur based on the findings of the interviews. Step 2 To identify other residents that have the potential to be affected, the DON / designee will interview residents with a BIMs of 12 or greater to determine if they have any unresolved grievances. The residents with a BIMs less than 12 will have their representative contacted to determine if they have any unresolved grievances. Follow up will occur based on the findings. Step 3 To prevent this from reoccurring, the staffing educator / designee will educate community staff on the grievance process. Step 4 To monitor and maintain compliance, the IDT team will interview 10 residents and 10 resident representatives to ensure that any grievances that they have voiced have been followed up on. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from physical abuse perpetrated by another resident. Resident 366, who was cognitively intact, reported that Resident 180 entered her room and physically assaulted her by poking and punching her thigh, causing pain. Despite the facility's policy against abuse, Resident 180, who had a history of aggressive behavior and severe cognitive impairment, was not adequately monitored or redirected, leading to this incident. Resident 180, diagnosed with severe vascular dementia and metabolic encephalopathy, exhibited a pattern of aggressive and intrusive behaviors, including wandering into other residents' rooms and physical aggression towards staff and residents. The facility's documentation indicated that Resident 180's behaviors were known, yet proactive measures to prevent incidents were insufficient. On another occasion, Resident 180 approached Resident 52 in the hallway and slapped him on the cheek, despite the resident being seated and not posing any threat. The facility's failure to implement sufficient supervision and monitoring measures for Resident 180, given his known history of aggression, resulted in physical abuse of Residents 366 and 52. The incidents highlight a lack of effective intervention strategies to manage Resident 180's behaviors, leading to harm and distress for other residents.
Plan Of Correction
Step 1 - No ill side effects noted with R52. R366 was discharged with no ill effects. R180's POC was reviewed and an updated activity assessment was completed to assess possible diversional activity interests. Step 2 - To identify other residents that have the potential to be affected, residents that exhibit aggressive behaviors will be reviewed by the IDT. Care plans will be updated, as necessary. Step 3 - To prevent this from reoccurring, re-education of the abuse policy and behavior interventions will be completed with facility staff by the staff educator/designee. Step 4 - To monitor and maintain compliance, the DON/designee will review 10 residents that exhibit aggressive behaviors to ensure that behaviors are addressed and care plan interventions are appropriate for behaviors exhibited. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their documented clinical status. Resident 179, who was admitted with chronic obstructive pulmonary disease and dementia, had a quarterly MDS assessment that inaccurately indicated no wandering behaviors, despite clinical records documenting multiple incidents of wandering into other residents' rooms. This discrepancy was confirmed by the Nursing Home Administrator. Resident 159, admitted with psychosis, had inaccuracies in their MDS assessment regarding medication management. The assessment incorrectly indicated the use of a hypnotic medication and failed to document a Gradual Dose Reduction (GDR) attempt for antipsychotic medication. Clinical records showed a physician's order to discontinue and later reinstate the antipsychotic medication Secuado, following a failed GDR attempt. The Director of Nursing confirmed the inaccuracies in Resident 159's MDS assessment.
Plan Of Correction
Step 1- R 159 and R179's MDS's were corrected and submitted. Step 2- To identify other residents that have the potential to be affected, the regional MDS staff will audit MDS assessments completed in the last 7 days will be reviewed for accuracy- areas of concern will be corrected and resubmitted. Step 3- To prevent this from reoccurring, education will be completed with the members of the IDT by the regional MDS re: ensuring all MDS assessments are completed accurately. Step 4- To monitor and maintain compliance, 10 residents Quarterly, Admission, or Significant Change MDS assessments will be completed by the MDS nurse/designee for accuracy. The audits will be completed weekly times 4 weeks and then monthly times 4. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Improper Use of Mechanical Lift Causes Resident Injury
Penalty
Summary
The facility failed to implement effective safety measures during a transfer, resulting in an injury to a resident. Resident 157, who was admitted with diagnoses including arthritis and morbid obesity, required extensive assistance with mobility and transfers. The care plan specified the use of a mechanical lift with two staff members for all transfers. However, during a transfer to a bariatric bed with a new air mattress, the resident sustained a forehead laceration. The incident occurred when Employee 1 and Employee 2 were transferring Resident 157 using a mechanical lift. During the transfer, the leg of the lift got caught between the wheels of the bed, causing the lift to tip over. Employee 2 attempted to stabilize the situation, but the lift hit Resident 157 in the head, resulting in a laceration. The resident was subsequently evaluated at an emergency department, where a head CT scan was performed and found to be negative. Interviews and facility investigation confirmed that the injury was due to improper placement and use of the mechanical lift. Both employees involved had satisfactory transfer skills and knowledge, yet the incident still occurred. The Nursing Home Administrator acknowledged the facility's responsibility to ensure safety measures were in place to prevent such accidents.
Plan Of Correction
Past noncompliance: no plan of correction required. To monitor and maintain ongoing compliance, the DON/designee audits and assesses 5 residents weekly x 4 to ensure proper lift technique is used during transfers and air mattresses are inflated without issues. Any negative findings will be immediately corrected. Results of audits will be forwarded to facility QAPI for review and recommendation as indicated. The facility's immediate corrective action plan was completed on September 2, 2024. 28 Pa. Code 211.18 (e)(1) Management. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.
Inaccurate Documentation of Choking Incident
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for Resident 266, as evidenced by inconsistencies in documentation related to a critical incident. Resident 266, who had diagnoses including diabetes and dementia, was admitted to the facility and had a physician's order for a low concentrated sweets regular texture diet. On January 19, 2025, the resident was found unresponsive after a choking incident during dinner, which led to life-saving measures being initiated and the resident being transferred to the hospital, where they later expired. The clinical records for Resident 266 lacked documentation of the choking incident, the Heimlich Maneuver performed, and the removal of a full-size meatball from the resident's airway by EMT personnel. The SBAR Communication Form completed by Employee 7 (RN) inaccurately indicated that Employee 5 (LPN) completed the form, further contributing to the inconsistencies. Witness statements from staff members provided details of the incident, including the actions taken by the nurse aide and LPNs, but these were not reflected in the resident's clinical record. An interview with the Nursing Home Administrator and Director of Nursing confirmed the failure of the nursing staff to accurately and consistently document the incident in the resident's clinical record. The lack of documentation and inconsistencies between the nursing notes, SBAR Communication Form, witness statements, and the facility's investigative report highlighted the deficiency in maintaining accurate and complete medical records in accordance with professional standards of practice.
Plan Of Correction
Step 1 - Resident 266 d/c from the facility. Step 2 - To identify other residents that have the potential to be affected, the DON/Designee will review the last 14 days of incident and accident events to ensure the resident's record accurately reflects the resident's status. Step 3 - To prevent this from reoccurring, re-education will be provided by the staff educator/designee to the nursing staff re: ensuring that the documentation in the resident record accurately reflects the resident's status. Step 4 - To monitor and maintain compliance, the DON/designee will complete weekly audits of the resident incident and accident events to ensure that the resident record accurately reflects the resident record. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Failure to Administer Influenza Vaccine Despite Consent
Penalty
Summary
The facility failed to offer and administer the influenza immunization to a resident, despite having obtained the necessary signed consent from the resident's representative. The facility's policy requires that each resident be offered the influenza vaccine unless it is medically contraindicated, and that educational information be provided to the resident or their representative prior to vaccine administration. However, there was no documented evidence that the influenza vaccine was administered to the resident, even though the consent form was signed and authorized. The resident in question was admitted to the facility with diagnoses including dementia and major depressive disorder. The resident's representative had signed an informed consent form authorizing the administration of the influenza vaccine, along with other vaccines. An interview with the Director of Nursing confirmed that the facility did not provide the influenza immunization to the resident, despite having the required consent. This oversight was identified during a review of the facility's policy, clinical records, and staff interviews.
Plan Of Correction
Step 1 - R110 was administered the flu vaccine. Step 2 To identify other residents that have the potential to be affected, the DON/designee reviewed residents to ensure that they were offered the flu and pneumonia vaccine and were administered if elected. Step 3 To prevent this from reoccurring, re-education will be provided by the staff educator/designee re: the facility flu/pneumonia vaccine policy. Step 4 To monitor and maintain compliance, the DON/designee will audit new/re-admissions residents to ensure that the flu/pneumo vaccines were offered and administered if needed. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to the QAPI committee for further review and recommendations.
Failure to Implement Abuse Prevention Measures
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address quality deficiencies related to abuse prevention effectively. During a survey conducted on February 7, 2025, deficiencies were identified concerning the implementation and adherence to procedures designed to prevent abuse. The facility developed a plan of correction, which included a quality assurance monitoring component to ensure the sustainability of solutions. However, during a subsequent survey on March 27, 2025, it was found that the facility continued to exhibit deficient practices in the same areas. The plan of correction included several measures, such as discharging a resident without ill effects, reviewing and updating care plans for residents with aggressive behaviors, re-educating staff on abuse policy and behavior interventions, and conducting audits to monitor compliance. Despite these efforts, the revisit survey revealed that the QAPI committee did not successfully implement the plan to prevent abuse and protect residents from aggressive behaviors. The quality assurance monitoring plan failed to identify and prevent the recurrence of similar deficient practices.
Failure to Report Critical Incidents
Penalty
Summary
The facility failed to notify the State Licensing Agency, Department of Health, Division of Nursing Care Facilities, of reportable events involving two residents. Resident 157 sustained a head laceration during a mechanical lift transfer, which required emergency medical evaluation and transfer to a hospital. This incident was documented in the nursing records and a facility investigative report dated August 30, 2024. Additionally, Resident 266 experienced a choking episode that necessitated the Heimlich Maneuver, CPR, and transfer to a hospital, where the resident subsequently expired. This incident was documented in the nurse's notes and a facility investigative report dated January 19, 2025. Upon review, it was confirmed that the facility did not submit these reportable events to the Department of Health, compromising compliance with mandated event reporting requirements.
Plan Of Correction
Step 1- R266 & R157's events were reported. Step 2- To identify other residents that have the potential to be affected, the NHA/Designee will review the last 14 days of incident and accident events to ensure any events that meet the criteria of a state reportable event are reported to the state agency as required. Step 3- To prevent this from reoccurring, re-education was provided by the regional nurse to the NHA/ANHA/DON re: state reportable events. Step 4- To monitor and maintain compliance the NHA/Designee will audit incident and accident reports to ensure any events that meet the criteria of a reportable event to the state is submitted as required. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Failure to Monitor Nutritional and Hydration Needs
Penalty
Summary
Mountain City Nursing & Rehabilitation Center was found to be non-compliant with federal and state regulations regarding the maintenance of nutritional and hydration status for a resident. The facility failed to adequately monitor and evaluate the weight and hydration needs of a resident, identified as Resident A1, who was admitted with diagnoses including dementia, congestive heart failure, and chronic kidney disease. The resident experienced significant weight loss shortly after admission, dropping from 114 pounds to 107 pounds within a week, and continued to lose weight over the following weeks without documented re-evaluation or intervention by the facility's dietitian. The facility's records showed that the resident's fluid intake was consistently below the required range, with daily intake ranging from 320 cc to 1140 cc, while the resident's needs were between 1375 ml and 1650 ml per day. Despite the resident's decreased appetite and fluid intake, and the use of a diuretic medication that increased the risk of dehydration, there was no evidence that the facility took timely action to address these issues. The resident's condition deteriorated, leading to lethargy and poor appetite, and eventually required hospitalization for treatment of hypernatremia, acute kidney injury, and a urinary tract infection. The facility's failure to monitor and address the resident's nutritional and hydration needs was further highlighted by the lack of documented evidence of physician or resident representative notification regarding the significant weight changes. Interviews with the director of nursing confirmed the absence of timely identification and reassessment of the resident's nutritional and hydration needs, which contributed to the resident's adverse health outcomes.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Step 1 RA1 was discharged on 1/4/2025. Step 2 To identify other residents that have the potential to be affected, the DON / designee audited current in house residents for significant weight changes. Those identified with significant weight changes were addressed as necessary. Current residents were assessed by nursing for hydration status via visual observation. Follow up completed based on findings of the audits as needed. Step 3 To prevent this from reoccurring, the DON/ designee will educate nursing staff on s/s of dehydration and weight policy. The Registered Dietician will be educated by the Regional Dietician on the weight policy. Step 4 To monitor and maintain compliance, the DON / designee will randomly audit 25 residents per day to review weight, meal consumption, and fluid intake to ensure concerns related to hydration and significant weight changes are addressed. The audits will be completed 5 days per week times 4, then weekly times 4, then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on nine out of 21 shifts reviewed. Specifically, the facility did not provide the minimum number of nurse aides needed for the evening and night shifts on several dates in December 2024. For instance, on December 3, 2024, the facility had 19.53 nurse aides on the evening shift, whereas 19.91 were required for a census of 219 residents. Similar deficiencies were noted on subsequent days, with the number of nurse aides consistently falling short of the required ratios based on the facility's census. The deficiency was confirmed during an interview with the Nursing Home Administrator on January 3, 2025. The administrator acknowledged that the facility did not meet the mandated nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the shortfall in nurse aide staffing during these shifts.
Plan Of Correction
Step 1 Facility can't retroactively correct. Step 2 To identify other areas of concern, the facility reviewed 1 week's worth of schedules to review CNA staffing ratios. Step 3 To monitor and maintain ongoing compliance, the NHA/Designee will educate staff responsible for the nursing schedule related to the required CNA ratios. Step 4 To monitor and maintain ongoing compliance, the NHA/designee will audit the nursing schedule related to CNA staffing ratios 5x's/week for 2 weeks and then weekly for 4 weeks, and monthly for 3 months. The facility currently has a plan in place for recruitment and retention of nursing staff members (RNs, LPNs, CNAs). Sign-On and Referral Bonuses are being utilized. Incentives for shift pick up are in place as well as staffing agency. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. On December 7, 2024, the facility provided only 3.02 hours of direct care nursing per resident, which is below the mandated minimum. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 3, 2025, who acknowledged the facility's failure to consistently provide the required nursing care hours.
Plan Of Correction
Step 1 Facility can't retroactively correct. Step 2 To identify other areas of concern, the facility reviewed 1 week's worth of schedules to review PPD's. Step 3 To monitor and maintain ongoing compliance, the NHA/Designee will educate staff responsible for the nursing schedule related to the required PPD's. Step 4 To monitor and maintain ongoing compliance, the NHA/designee will audit the nursing schedule related to the PPD ratios 5x's/week for 2 weeks and then weekly for 4 weeks, and monthly for 3 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in significant deficiencies. Resident 16, who was severely cognitively impaired with a BIMS score of 7, was involved in a non-consensual sexual encounter with Resident 91, who was cognitively intact. The incident occurred when a nurse aide discovered both residents naked in Resident 16's room. Despite Resident 16's severe cognitive impairment, which rendered her unable to consent, Resident 91 admitted to engaging in sexual intercourse with her. The facility's investigation revealed that Resident 16 had no recollection of the event, and her cognitive impairment was further confirmed by a subsequent BIMS score of 3. Additionally, the facility failed to protect Resident 106, who was also severely cognitively impaired, from physical abuse by Resident 12. An incident report indicated that Resident 12, who had a history of intermittent explosive disorder, was observed hitting Resident 106 in the stomach. Although no physical injuries were noted, the incident was witnessed by another resident, and both residents were subsequently separated and placed under increased supervision. The facility's failure to prevent this physical abuse resulted in psychosocial harm and humiliation for Resident 106. The nursing home administrator confirmed the facility's failure to ensure the safety and protection of Residents 16 and 106 from abuse. The facility's policies on abuse prohibition were not effectively implemented, leading to these incidents of sexual and physical abuse. The report highlights the facility's inability to safeguard its residents, particularly those with severe cognitive impairments, from harm and abuse by other residents.
Failure to Implement Abuse Response Procedures
Penalty
Summary
The facility failed to implement its established procedures for responding to an incident of sexual abuse involving two residents. Resident 16, who was severely cognitively impaired, was found in bed with Resident 91, who was cognitively intact. The incident was discovered by a nurse aide, and the residents were immediately separated. However, the facility did not follow its policy to send both residents to the hospital for evaluation and testing following the incident. The facility's policy required that both residents be evaluated in the emergency room and that evidence be preserved, but these steps were not taken. The facility's policy also required that the residents' clothing and bedding be preserved as evidence, but this was not done. Interviews with staff revealed a lack of awareness and understanding of the facility's policy regarding the preservation of evidence following a sexual incident. Employee 2, an RN, conducted a head-to-toe assessment of Resident 16 but did not document a comprehensive examination of her mouth, anus, or genitalia, nor did she obtain orders for STI testing until two days later. Additionally, Resident 91 was allowed to shower shortly after the incident, further compromising the preservation of evidence. The facility's failure to adhere to its policy was compounded by the lack of communication with Resident 16's representative regarding the necessity of a hospital examination. The representative declined the hospital transfer, unaware that it was a requirement of the facility's policy. The facility also moved Resident 16 to another building without the representative's agreement, citing safety concerns. These actions and inactions highlight the facility's failure to follow its own procedures for handling incidents of sexual abuse, resulting in a deficiency in the care and protection of its residents.
Inadequate Supervision and Hazardous Environment
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free of accident hazards, resulting in a minor injury to a resident. The resident, who was moderately cognitively impaired and had a history of chronic alcoholism and hypertension, sustained a cut to the thumb after accessing used razors in a shower room. The incident report indicated that the resident was found holding multiple used razors, which he had retrieved from the shower room, leading to a cut on his thumb. During an onsite survey, it was observed that the facility had removed sharps containers from the walls but left the encasements, which still contained razors, accessible to residents. This situation was noted in multiple locations, including the third-floor shower room, lounge area bathroom, and a second-floor nursing unit. The director of nursing acknowledged that staff continued to place razors in the encasements, allowing residents access to sharp objects, thus failing to maintain a safe environment.
Inadequate Response to Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to conduct a thorough resident assessment following an incident of sexual abuse involving two residents. The facility's policy required that after an allegation of sexual abuse, the resident's attending physician should be notified, and if appropriate, the resident should be sent to the hospital for an examination. However, the residents involved in the incident were not sent to the hospital for evaluation as per the facility's policy. Employee 2, an RN, conducted a head-to-toe assessment but did not document examinations of the residents' mouth, anus, or genital areas, nor did she obtain orders for bloodwork to rule out sexually transmitted diseases. Employee 2 confirmed she was not trained to conduct a sexual assault examination and was unsure about the preservation and collection of evidence. The incident involved two residents, one male and one female, who were found engaging in sexual activity. The female resident did not recall the incident, and the male resident was placed on 1:1 supervision. The facility's policy outlined specific procedures for handling such incidents, including not bathing or cleaning the residents and preserving evidence, which were not followed. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the residents were not sent to the hospital according to policy and that Employee 2 did not possess the necessary competencies to perform a sexual assault exam. The report highlights deficiencies in staff training and adherence to facility policies regarding the handling of sexual abuse allegations.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement effective corrective action plans to prevent ongoing quality deficiencies related to abuse prohibition. During a standard survey completed on April 19, 2024, the facility was found deficient in ensuring residents were free from abuse and neglect. Despite developing a plan of correction, which included educating staff on identifying behaviors and placing interventions to reduce aggression, the facility did not sustain these solutions effectively. During a revisit survey ending July 10, 2024, it was revealed that the facility failed to protect one resident from physical abuse and another from sexual abuse, resulting in psychosocial harm. The facility's quality assurance monitoring plans did not identify or address these ongoing deficiencies, as evidenced by clinical records, facility incident reports, and staff interviews. This failure affected two residents out of the 11 sampled, indicating a significant lapse in the facility's ability to maintain a safe environment free from abuse and neglect.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision and effective safety measures to prevent the elopement of a resident, identified as Resident 181, who left the premises without staff knowledge. The resident, who was cognitively intact with a BIMS score of 13, had a history of bipolar disorder and difficulty walking. Despite these conditions, there was no evidence of an elopement risk assessment being completed upon the resident's admission or at any time prior to the incident. On the day of the elopement, the resident left the facility unsupervised, walked approximately 0.5 miles to a convenience store, and was later returned by staff who found him there. The report highlights that the facility's procedures for monitoring residents' whereabouts were inadequate. Staff interviews revealed that residents who were independent could sign themselves out in a book at the nursing station to go outside, but there was no procedure to ensure residents signed the book or that staff monitored their return. On the day of the incident, the resident signed out without staff presence, and the facility was unaware of his absence until informed by staff who saw him outside the facility. The facility did not document the incident in the resident's clinical record, nor did they conduct an investigation to determine the circumstances of the elopement. Additionally, the facility failed to interview staff to ascertain when the resident was last seen or how he exited the building without staff awareness. The lack of documentation and investigation into the incident indicates a failure to implement effective safety measures and supervision for residents at risk of elopement. The facility's inability to locate the sign-out sheet for the day of the incident further underscores the lack of operational procedures for monitoring residents leaving the unit.
Removal Plan
- Identify residents who go outside independently and have the ability to be affected
- Policy and procedure reviewed with residents affected to ensure they know the process for leaving the unit
- Therapy screen current residents affected to ensure they are able to leave safely
- Residents with cognitive impairment will be reviewed to ensure the elopement assessments are accurate and interventions are in place to prevent elopement
- Review of current residents to ensure residents have an appropriate LOA order, if issues identified, call Physician for appropriate orders
- Staff were made aware if a resident is not independent to go off the unit and outside and ensured they knew the policy for leaving the unit and/or LOA, Staff were educated that if a resident is not independently able to leave the unit, they must be stopped and supervision provided
- Current staff educated on the LOA policy/procedure and the elopement policy and procedure
- Elopement drill completed on all shifts
Failure to Provide Properly Prepared Diet Leads to Choking Incident
Penalty
Summary
The facility failed to ensure that a resident with swallowing difficulties was consistently served food in a form that met their individual needs, leading to a choking incident and aspiration. The resident, who was admitted with a diagnosis of dysphagia, had a physician's order for a pureed diet with nectar thickened liquids. However, during a dinner meal, the resident was served shrimp scampi that was not properly pureed, resulting in the resident coughing and eventually spitting out a small piece of shrimp. There was no documented evidence that any staff member was present to assist the resident during the meal, despite the care plan indicating the need for assistance with eating. The incident led to the resident experiencing a drop in oxygen saturation levels and being sent to the emergency room due to potential aspiration. Hospital documentation confirmed acute respiratory failure and aspiration pneumonia, requiring oxygen and antibiotic treatment. Interviews with the DON and NHA confirmed the facility's failure to provide food consistent with the prescribed diet, resulting in the choking episode and subsequent hospitalization.
Failure to Monitor Resident Whereabouts Leads to Elopement Risk
Penalty
Summary
The facility's administration failed to effectively use its resources to ensure resident safety, specifically in monitoring resident whereabouts and preventing elopement. This deficiency was identified through a review of clinical records, facility policies, investigative reports, and employee job descriptions. The facility did not implement established procedures to monitor the whereabouts of one resident, leading to an elopement incident. This failure placed 65 residents, including the resident involved in the incident, at immediate risk for elopement, jeopardizing their health and safety. The job descriptions for both the Administrator and the Director of Nursing (DON) outlined responsibilities for ensuring compliance with state and federal guidelines, maintaining resident safety, and overseeing the delivery of care. However, the Administrator and DON did not fulfill these essential duties, as evidenced by the failure to provide necessary supervision and effective safety measures. This deficiency was cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.25(d)(2), which mandates that each resident receives adequate supervision and assistive devices to prevent accidents.
Delayed Response to Resident Call Bells
Penalty
Summary
The facility failed to provide care in a manner and environment that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This deficiency was identified through interviews and clinical record reviews involving two residents. Anonymous Resident 1, who is cognitively intact, reported waiting an hour for staff to respond to a call bell and change their brief during the second shift over the past weekend, noting longer wait times when agency staff were on duty. Similarly, Resident 14, also cognitively intact and diagnosed with diabetes and hypertension, reported waiting an hour or more for staff to respond to call bells and provide necessary care such as toileting after 6:00 PM. The Nursing Home Administrator confirmed that residents should be treated with dignity and respect, including timely responses to their requests for assistance.
Failure to Provide Feeding Assistance to Resident with Dysphagia
Penalty
Summary
The facility failed to provide necessary feeding assistance to a resident with dysphagia, leading to a deficiency in care. Resident 196, who was admitted with a diagnosis of difficulty swallowing, had a care plan requiring staff assistance for eating. Despite a physician's order for a pureed diet and nectar consistency liquids, the resident was not assisted during a dinner meal, resulting in the resident coughing up a piece of shrimp. The incident report and clinical records showed no evidence of staff assistance during this meal, and interviews with the Nursing Home Administrator and Director of Nursing confirmed the lack of compliance with the care plan.
Failure to Provide Bedtime Snack for Diabetic Resident
Penalty
Summary
The facility failed to provide a nourishing evening snack to a resident, identified as Resident 14, who was part of a sample of 14 residents. The facility's Nourishment and Supplement Policy, last reviewed on August 21, 2023, mandates the availability of snacks and supplements between meals. Resident 14, who has diabetes and hypertension, expressed during an interview on May 31, 2024, that a bedtime snack would help manage his blood sugar levels and prevent hunger between supper and breakfast. Despite requesting a bedtime snack over the past four to five days, there was no documented evidence in the clinical records that such a snack was provided. This was confirmed by the director of nursing during an interview on the same day.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that six residents were free from physical abuse perpetrated by other residents, resulting in serious harm and injury to one resident. The incidents involved residents with severe cognitive impairments and behavioral disturbances, including dementia, anxiety, and psychosis. The facility's abuse prohibition policy, dated August 30, 2023, was reviewed, and it was found that the facility did not tolerate abuse, neglect, mistreatment, or exploitation of residents. However, the facility failed to implement sufficient supervisory measures to monitor residents with known aggressive behaviors, leading to multiple instances of resident-to-resident physical abuse. One significant incident involved Resident 203, who was pushed by Resident 225, resulting in a fractured leg and hip. Resident 203, who had severe cognitive impairment and dementia, was standing in the doorway of a lounge when Resident 225, also severely cognitively impaired, pushed her, causing her to fall. The fall led to an acute fracture of the left proximal femur and a nondisplaced fracture of the left hip, requiring surgical repair. Prior to the incident, Resident 203 was independent in transferring and ambulating but became totally dependent on staff for mobility needs post-surgery. Other incidents included Resident 212 being hit by Resident 3, Resident 178 being punched by Resident 212, Resident 93 being hit by Resident 188, and Resident 487 being physically assaulted by Resident 221. In each case, the facility failed to effectively monitor and supervise residents with known aggressive behaviors, resulting in physical abuse and psychosocial harm to the victims. The facility's failure to protect these residents from abuse and to implement adequate supervisory measures was confirmed through interviews with the Nursing Home Administrator and Director of Nursing.
Facility Fails to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, leading to potential contamination and microbial growth. During an initial tour of the kitchen, several unsanitary conditions were observed, including soiled garbage cans, dust accumulation on hood vents and ice machine filters, and visibly soiled plastic pitchers. Additionally, there was a build-up of dirt on the floor of the dry storage room and the stainless-steel table in the dishroom. A black substance was found on the lid of a chemical sanitizer container, and the floor basin in the janitor closet was heavily soiled with debris in the drain. These observations were confirmed by the foodservice director and Registered Dietitian (RD) present during the tour. Further inspection of the white building's kitchen area revealed improper storage of margarine, which was not kept refrigerated as required by the manufacturer. Additionally, a section of the wall above the floor basin in the janitor closet was missing. In the resident food pantry on the third floor of the Blue building, several food items were found without proper labeling or dating, and there was a red substance spilled inside the refrigerator. These observations were confirmed by a licensed practical nurse and the Nursing Home Administrator, who acknowledged that the food in the resident pantry should be labeled and dated, and the dietary department should be maintained in a sanitary manner.
Failure to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment on four of five resident units, specifically in the blue and white buildings. Observations revealed multiple deficiencies, including broken closet door handles, strong odors of urine and feces, missing ceiling blocks, and unattended tools and debris in resident rooms. Additionally, several rooms had personal items, food, and medical equipment improperly stored, contributing to the unclean environment. Sticky substances, food debris, and urine-filled containers were also noted in various rooms, further indicating a lack of proper sanitation and maintenance. Further observations highlighted issues such as detached heating unit vents, chipped and cracked over-the-bed table trays, stained privacy curtains, and walls with multiple gouges and staples. Bathrooms in several rooms had strong urine smells, brown spots, and dried tube feeding formula on equipment. The Director of Nursing confirmed that the facility is expected to be maintained daily to provide a clean and sanitary environment for the residents, which was evidently not upheld in these instances.
Failure to Provide Accessible Grievance Information and Forms
Penalty
Summary
The facility failed to make information and forms accessible regarding the grievance/complaint process and the residents' rights to file a grievance anonymously in prominent locations on four of seven floors. Specifically, the Blue Building's first, second, and third-floor nursing units, as well as the [NAME] Building Lobby, lacked postings indicating the location of grievance forms, the process of filing a grievance, the expected resolution time, the identification of the facility's grievance official, and how to contact the grievance official. Additionally, there were no concern/grievance forms or black boxes available for residents to file grievances anonymously in these areas. During an interview, the Nursing Home Administrator acknowledged the facility's failure to post the necessary grievance process procedural information and the absence of grievance forms and boxes on the first and third floors. This deficiency was observed during a survey conducted on April 19, 2024, and was found to be in violation of 28 Pa. Code 201.18(e)(1) Management and 28 Pa. Code 201.29 (a)(c) Resident rights.
Failure to Administer and Maintain Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for six residents. Resident 59's oxygen concentrator was observed running at 1.5 L/min instead of the prescribed 4 L/min, and the nasal cannula was not in use and improperly stored. Additionally, the oxygen tubing and humidification bottle were not dated, and the tubing was not stored in a bag when not in use. Similar issues were observed on a subsequent day, with the nasal cannula found on the floor and no bag available for storage. There was no documented evidence of the resident's refusal or removal of the prescribed supplemental oxygen. Resident 26 had a physician order for oxygen at 2 L/min via nasal cannula as needed, but the oxygen concentrator was turned on at 2 L/min even when the resident was not receiving oxygen therapy. The oxygen tubing and nebulizer equipment were not dated and were improperly stored. Resident 124 was observed receiving humidified oxygen therapy at 2 L/min, but the oxygen tubing was not dated. Resident 8, who had a physician's order for continuous oxygen therapy at 4 L/min, was observed with undated oxygen tubing and humidification bottle. Resident 64, with a physician order for oxygen at 3 L/min, was observed with undated oxygen tubing and humidification bottle. On another occasion, the nasal cannula was found on the floor, and the tubing was not stored in a bag when not in use. Resident 48, who had a physician order for oxygen at 2 L/min as needed, was observed with undated oxygen tubing and an empty oxygen cylinder tank. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the physician's orders for supplemental oxygen were not followed, and the oxygen equipment was not kept clean or properly stored.
Insufficient Staff Competency and Skills
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skills to meet the behavioral health needs of residents, as evidenced by incidents involving three residents. Resident 213, who was admitted with dementia and severe cognitive impairment, exhibited multiple behavioral symptoms, including physical and verbal aggression and wandering into other residents' rooms. Despite these behaviors being documented, the facility did not address the underlying issues, leading to an incident where Resident 213 was punched by another resident after intruding into their room. The facility's investigation did not address Resident 213's wandering behavior adequately. Resident 214, diagnosed with latent syphilis, displayed consistent behaviors of attempting to get onto the elevator. On multiple occasions, the resident managed to get onto the elevator, triggering alarms, but staff were not immediately available to assist. Observations revealed that staff did not employ any interventions to occupy, divert, or distract the resident during these incidents. An interview with a CNA confirmed that individualized diversional activities were not attempted for residents with behaviors, and those displaying disruptive behaviors were removed from group activities and monitored in the hallway. Resident 188, admitted with bipolar disorder and Lewy body dementia, exhibited severe cognitive impairment and aggressive behaviors. An incident occurred where Resident 188 hit another resident and then struck a nurse aide who attempted to intervene. The nurse aide was the only staff member present in the dining room at the time, as other staff were occupied elsewhere. The facility was unable to provide evidence that they employed sufficient staff with the necessary competencies and skills to ensure resident safety and well-being, as confirmed by the Nursing Home Administrator.
Failure to Implement Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized plans to manage dementia-related behavioral symptoms for four residents, leading to deficiencies in promoting resident safety and well-being. Resident 213, who was severely cognitively impaired, exhibited consistent wandering behaviors, including entering other residents' rooms uninvited. Despite increased supervision, the interventions were not effective, and the care plan was not individualized or revised in a timely manner. This resulted in an incident where Resident 213 was physically abused by another resident due to the wandering behavior. Resident 138, also severely cognitively impaired, had a care plan that included interventions for wandering and aggressive behaviors. However, these interventions were not consistently implemented. The resident experienced an unwitnessed fall and self-injurious behavior, and there was no evidence that the care plan's interventions were followed to manage these behaviors. Observations revealed that the resident was often left without diversional activities, contrary to the care plan's requirements. Resident 221, diagnosed with dementia and other behavioral disturbances, displayed verbal aggression and physical altercations with a roommate. The care plan was not updated to include specific interventions to manage these behaviors. Similarly, Resident 225 exhibited intrusive wandering behaviors, and the care plan did not include individualized interventions to address these behaviors. Despite multiple incidents of wandering and unsuccessful redirection attempts, the facility failed to revise the care plan to manage the resident's dementia-related behaviors effectively.
Inadequate Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the specific resources necessary to care for its resident population competently. The assessment provided, last reviewed on January 9, 2024, did not accurately reflect the current resident population, which included 73 residents with Alzheimer's disease/dementia and 54 residents with a mental disorder, intellectual disability, or related condition. Additionally, there were seven incidents of resident-to-resident abuse between January 1, 2024, and April 19, 2024. The facility assessment did not include comprehensive data and corresponding resources to address the behavioral health and dementia care needs of the residents, compromising resident safety and their freedom from physical abuse.
Failure to Accommodate Resident Preferences
Penalty
Summary
The facility failed to incorporate preferred resident schedules into the residents' daily routines and to allow residents to make choices about aspects of their life that were important to them. Resident 19, who has hemiplegia and COPD, expressed a desire to go outside for fresh air, which was noted as somewhat important in his MDS assessment. However, staff interviews revealed that residents, including Resident 19, often complained about not being able to go outside, and there was no established schedule for outdoor activities for non-smoking residents. The Director of Life Enrichment Services confirmed the lack of a structured schedule for outdoor breaks for these residents. Resident 26, diagnosed with COPD and major depressive disorder, preferred to shower in the morning but faced a conflict with her smoking schedule. She was unable to wash her hair during her shower because she was not allowed to go outside with wet hair, and staff could not accommodate her by allowing her to shower after her smoke break. The Nursing Home Administrator confirmed the fixed smoking times and the requirement for staff supervision during showers, which did not align with Resident 26's preferences. Resident 64, who has depressive episodes and reduced mobility, was cognitively intact and expressed frustration over the scheduling conflict between her preferred activities and smoking breaks. She mentioned that the 2:00 PM activities, which she enjoyed, often coincided with her smoking break, and staff suggested she split her time between the two, which was not feasible for activities like BINGO. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to reasonably accommodate the residents' preferred schedules and choices.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's care plan, reviewed on April 19, 2024, did not identify PTSD symptoms, triggers, or specific interventions to minimize triggers and prevent re-traumatization. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility did not provide culturally competent, trauma-informed care in accordance with professional standards of practice, considering the resident's experiences and preferences.
Failure to Discontinue Medication as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for Resident 103. Resident 103, who was admitted with diagnoses of unspecified psychosis and dementia with agitation, had a physician order for risperidone 0.25 mg to be given in the evening. This order was later changed on March 14, 2024, to discontinue risperidone and start Asenapine transdermal patch 3.8 mg/24 hours at bedtime. Despite the availability of the Asenapine patch on March 15, 2024, and its administration as ordered, nursing staff continued to administer risperidone 0.25 mg to Resident 103 from March 15, 2024, through March 26, 2024, resulting in 12 additional doses of risperidone being given after it was supposed to be discontinued. During an interview on April 19, 2024, the Director of Nursing and Nursing Home Administrator confirmed that the nursing staff did not follow the physician's orders, leading to a significant medication error. This error was identified through a review of the clinical records and staff interviews, which revealed that the nursing staff failed to accurately administer medications as per the physician's updated orders, thereby compromising the resident's care.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility's administration failed to effectively use its resources to promote resident safety by not implementing established procedures to prevent physical abuse of six residents. The facility's policy on abuse, dated August 30, 2023, states that abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone will not be tolerated. Despite this policy, a review of facility reports and clinical records between January 1, 2024, and April 19, 2024, revealed that the facility failed to protect six residents from physical abuse perpetrated by other residents. The job descriptions for the Administrator and the Director of Nursing (DON) indicate that they are responsible for ensuring the health and safety of residents and adherence to regulatory guidelines. However, the deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Freedom from Abuse, Neglect, and Exploitation (F600) 483.12(a)(1) revealed that both the Administrator and the DON failed to fulfill their essential job duties. This failure resulted in the cited deficiency, indicating a lack of effective oversight and implementation of procedures to prevent resident abuse.
Untimely Response to Resident Requests
Penalty
Summary
The facility failed to provide care in a manner and environment that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This was reported by 15 out of 33 interviewed residents. The deficiency was identified through a review of clinical records, facility-provided documentation, grievances lodged with the facility, minutes from Resident Council meetings, and resident and staff interviews. Residents expressed concerns that staff did not answer their requests for assistance via the nurse call bell system in a timely manner, leading to extended wait times for care and assistance, including instances where residents were left soaked in urine or in pain while waiting for help. The Resident Council meeting minutes from January 23, 2024, and multiple grievances filed in January and February 2024, highlighted the issue of untimely responses to call bells. During random interviews conducted on March 20, 2024, residents from various units reported waiting times ranging from 20 minutes to over an hour for staff to respond to their call bells. Specific instances included residents waiting for assistance with incontinence care, pain management, and basic needs like getting water. The residents indicated that these delays occurred across different shifts, with some residents experiencing daily delays. Interviews with individual residents provided detailed accounts of their experiences. For example, Resident 141 reported waiting over an hour for assistance and being reprimanded by staff for needing a change of bed linens due to incontinence. Resident 6 mentioned waiting 20-30 minutes multiple times a week, particularly during the day shift at lunchtime. Resident 163 expressed frustration over waiting for pain medication, sometimes for up to an hour. The Nursing Home Administrator acknowledged the expectation for residents to be treated with dignity and respect but could not explain the widespread reports of untimely staff responses, which negatively affected the residents' quality of life in the facility.
Failure to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas on four of five nursing units. Observations revealed multiple instances of unclean and worn furniture in various resident areas. Specifically, a dried brown fecal-like substance with a foul odor was found on a seat cushion in the resident lounge area on the third floor of the Blue Building. Additionally, soiled areas from unknown substances were observed on seat cushions in the resident dining and sitting areas on the second floor of the Blue Building and the first and second floors of the [NAME] Building. Worn and torn furniture exposing underlying cushions was also noted in these areas. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed the observations and acknowledged that the facility's environment should be kept in good repair and maintained in a clean and homelike manner. The DON specifically confirmed the presence of the brown fecal-like substance on the chair cushion and stated that maintenance staff would be informed to clean it immediately.
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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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