Muncy Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncy, Pennsylvania.
- Location
- 215 East Water Street, Muncy, Pennsylvania 17756
- CMS Provider Number
- 395571
- Inspections on file
- 26
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Muncy Place during CMS and state inspections, most recent first.
Surveyors observed multiple instances of improper food storage, including undated and expired food items, damaged and leaking milk cartons, and unsanitary conditions in both the main kitchen and a kitchenette. Additional issues included debris accumulation, unclean equipment, and improperly labeled resident food items. Facility leadership was made aware of these findings.
Two residents were not provided dignified dining assistance, as staff stood while feeding them, left them unattended to serve others, and delayed feeding, resulting in one resident falling asleep before being assisted. These practices were observed and confirmed by facility leadership.
A resident received both scheduled and PRN doses of Alprazolam, with orders allowing for a daily total exceeding the recommended maximum dose. The facility did not identify or address the resident's consistent use of PRN medication at a specific time, nor did it ensure timely physician review of the medication regimen, resulting in a failure to individualize care and prevent unnecessary psychotropic medication use.
A resident receiving Eliquis, an anticoagulant, had no care plan addressing their anticoagulant use or related risks such as bleeding and bruising, despite documentation in clinical records and MDS assessments. This omission was confirmed by interviews with facility leadership.
A resident with hypertension received Metoprolol despite physician orders to hold the medication for low systolic blood pressure, with no documented rationale for these actions. Nursing shift reports indicated the medication was held, but the MAR did not reflect this, resulting in inaccurate documentation and failure to follow prescribed care parameters.
A resident with limited ROM and arthritic changes did not consistently receive a physician-ordered hand splint as directed in her care plan. Observations showed the splint was often not in use, staff were unclear on the schedule, and documentation was incomplete, resulting in inconsistent contracture prevention interventions.
A resident with a recently placed PEG tube for esophageal dysmotility did not receive appropriate G-tube feeding and care. A nurse administered water and nutrition by pushing the syringe plunger instead of using the gravity method, failed to verify tube placement or check for residuals as ordered, and did not perform proper hand hygiene between tasks. The facility lacked a policy for verifying tube placement and did not follow its own competency process for G-tube care.
Staff failed to follow infection control protocols by not performing hand hygiene between glove changes during wound and gastrostomy tube care for two residents, and housekeeping staff did not wear a gown as required when cleaning the room of a resident on contact precautions for a multi-drug resistant urinary tract infection. These actions were not consistent with facility policy or accepted standards of practice.
Two residents experienced falls resulting in injury, including a fracture, after staff failed to follow required care plan interventions such as activating bed alarms and providing two-person assistance for bed mobility. In both cases, staff did not implement established safety measures, leading to substantiated findings of neglect.
The facility failed to maintain the range of motion (ROM) for seven residents, as staff did not complete or document prescribed ROM exercises. Care plans included various ROM exercises, but documentation showed multiple instances of non-completion across shifts. One resident expressed a desire to walk but reported not receiving recent therapy, highlighting the facility's failure to provide necessary restorative services.
A facility failed to ensure accurate MDS assessments for a resident, as an MDS assessment incorrectly indicated the use of a urinary catheter without supporting documentation. An interview with the Administrator confirmed the resident did not utilize a urinary catheter.
A facility failed to maintain optimal communication for a resident with a history of CVA, who had unclear speech and was usually understood. The resident's care plan identified communication problems, but the recommended AAC device was not available as it was taken home by the resident's sister. Despite the resident's reported frustration, no follow-up or alternative devices were provided to aid communication.
A resident's dental appointment was canceled because the facility did not stop her blood thinners as recommended, delaying necessary dental care. The resident, who had dental caries and a large cavity requiring extraction, experienced discomfort due to a broken tooth. The facility confirmed the next appointment was scheduled for a later date.
A facility failed to implement Enhanced Barrier Precautions for a resident with a tracheostomy, as a respiratory therapist did not wear a gown during high-contact care activities, despite the requirement to do so. The resident was on Enhanced Barrier Precautions due to colonization with multi-drug resistant organisms, and the incident was reported to the Nursing Home Administrator and DON.
Food Storage and Kitchen Sanitation Deficiencies Identified
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and did not maintain the kitchen and kitchenette environments in a sanitary condition. During an observation of the main kitchen, surveyors found a walk-in cooler containing a bag of lunch meat with no dates, asiago and provolone cheeses past their use-by dates, an opened bag of lettuce past its use-by date, a container labeled 'vegetable fresh prep' past its use-by date, cooked bacon past its use-by date, chicken salad and feta cheese both past their use-by dates. Another walk-in cooler contained a damaged, leaking milk carton contaminating adjacent cartons and the surrounding area. In the dry storage area, a hospitality cart held a snack bag of expired pretzels, and a storage rack with adaptive equipment had multiple clear plastic cups with handles that had a build-up of moisture, with staff unable to state how long the cups had been wet. In the dishwashing area, a black plastic corner floor shelf holding housekeeping items had an accumulation of debris underneath, including food items, a single-use butter container, and a drinking straw. The corner of the dishwashing room where a fan was attached had significant dried splash stains on the walls and ceiling, and the fan itself had a build-up of dust on its protective cover and blades. The floor near a drain under the ice machine contained various debris, including a plastic cup and a broken piece of a red plate. Additionally, in the second floor kitchenette, the resident refrigerator contained a sandwich with no dates or label. These findings were reviewed with facility leadership.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to ensure resident dignity during dining for two residents. Observations showed that a nurse aide stood between the two residents while feeding them their lunch meals and intermittently left the table to serve other residents, leaving the residents unattended. Another nurse aide later finished feeding both residents while also standing between them. On a separate occasion, a different nurse aide fed one of the residents while standing for 30 minutes and then left the dining area with the resident, with no staff observed attempting to feed the other resident until much later, at which point the resident was asleep. These actions and inactions were confirmed during an interview with the Administrator and the Director of Nursing.
Failure to Review and Individualize Psychotropic Medication Regimen
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary psychotropic medication. Clinical record review revealed that a resident had active physician orders for Alprazolam, including a PRN (as needed) dose of 1 mg every eight hours with a 180-day stop date, and a scheduled dose of 0.5 mg three times daily. If administered as ordered, the resident could have received up to 4.5 mg of Alprazolam per day, exceeding the usual maximum adult dose of 4 mg per day. Review of the medication administration records showed that the PRN dose was administered on multiple occasions, but never more than once per day, and not daily. The pattern of administration indicated that the PRN dose was consistently given between 10:00 AM and 12:00 PM on most occasions. Despite this pattern, the facility did not identify or address the resident's consistent need for the PRN antianxiety medication at a specific time of day in the care plan. Additionally, there was insufficient evidence that the resident required a dose exceeding the recommended daily maximum, or that the 180-day stop date met the regulatory requirement for physician review at 14 days. Interviews with facility leadership confirmed these findings, and the care plan lacked individualized interventions based on the resident's medication use pattern.
Failure to Develop Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of anticoagulant medication for one resident. Clinical record review showed that the resident had an active physician's order for Eliquis, an anticoagulant, and both annual and quarterly MDS assessments documented the resident's use of this medication. However, the resident's care plans did not include any information regarding anticoagulant use, nor did they address associated risks such as bleeding and bruising or outline measures for prevention of potential complications. These findings were confirmed through interviews with the DON, Nursing Home Administrator, Assistant DON, and Assistant Nursing Home Administrator.
Failure to Follow Physician-Ordered Medication Parameters and Inaccurate Documentation
Penalty
Summary
The facility failed to provide care in accordance with physician-ordered medication parameters for a resident diagnosed with hypertension. The resident had a physician order for Metoprolol Tartrate 25 mg to be administered every eight hours via gastrostomy tube, with specific instructions to hold the medication if the pulse was less than 60 or if the systolic blood pressure (SBP) was less than 100. Clinical record review revealed that the medication was administered on multiple occasions when the resident's SBP was below the ordered threshold, specifically on several dates in May, June, and July 2025. There was no documentation providing a rationale for administering the medication outside of the specified parameters. Additionally, while the facility provided nursing shift report sheets indicating that the medication doses were held on the dates in question, the resident's Medication Administration Record (MAR) did not reflect that the doses were actually held. This discrepancy between the shift report sheets and the MAR documentation was confirmed during a meeting with the Nursing Home Administrator and Director of Nursing. The lack of accurate documentation and adherence to physician orders constituted a failure to provide the highest practicable care as required.
Failure to Consistently Implement Physician-Ordered Hand Splint for ROM
Penalty
Summary
Facility staff failed to implement physician-ordered interventions for a resident with limited range of motion (ROM) in her hands. The resident had an active physician's order and a care plan directing staff to ensure she wore a left palm guard with digit separators for four hours in the morning and four hours in the evening, with skin checks every two hours. Multiple observations over several days showed the resident was not wearing the splint as ordered, and her hands were contracted, with her using her knuckles or fists to grasp objects. Documentation revealed inconsistent application and documentation of the splint, with some staff unaware of the correct schedule for its use. Interviews with nurse aides and the resident's husband confirmed inconsistent use of the splint, with staff unsure of the schedule and some unaware of the intervention altogether. The care instructions available to staff were vague, and documentation of the intervention was incomplete, with no staff initialing the application of the splint on certain shifts. The deficiency was discussed with facility leadership, confirming the lack of consistent implementation of the physician's order and care plan for contracture prevention.
Failure to Follow Protocols for G-Tube Feeding and Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident receiving enteral nutrition via a gastrostomy tube (G-tube). The surveyor found that the facility could not provide a policy or protocol for verifying G-tube placement during the onsite survey, and the only available policy addressed medication administration, not feeding. Clinical records showed that the resident had a recent PEG tube placement due to esophageal dysmotility and had physician orders for tube feeding, including checking tube placement and residuals three times daily. However, during observation, a registered nurse administered water and liquid nutrition by pushing the plunger of a syringe rather than allowing the fluids to flow by gravity, as required by the facility's competency process. The nurse did not verify tube placement or check for residuals before administering the feeding and was unaware of the correct insertion depth for the resident's G-tube. Additionally, the nurse failed to perform proper hand hygiene after removing soiled gloves and before donning new gloves while providing G-tube care. The nurse confirmed during an interview that she did not use the gravity method, did not check tube placement, and did not assess for residuals prior to feeding. The facility's documentation of staff competency indicated that the gravity method should be used, and the procedural steps did not include using a plunger for the entire process. These actions and omissions resulted in a failure to follow physician orders and facility protocols for safe G-tube feeding and care.
Failure to Implement Infection Control Practices and Contact Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices as required by policy and regulation. Specifically, staff did not perform hand hygiene when changing gloves during wound care and gastrostomy tube care for two residents. During wound care for a resident with open areas on both arms, a registered nurse repeatedly removed soiled gloves and donned new gloves without performing hand hygiene, despite handling dressings and cleansing wounds. Similarly, during gastrostomy tube feeding and site care for another resident, the same nurse failed to perform hand hygiene between glove changes after handling feeding equipment and before cleansing the tube insertion site. Additionally, the facility did not ensure that contact precautions were followed for a resident on contact isolation due to a urinary tract infection with multi-drug resistant organisms. Observation revealed that housekeeping staff entered and cleaned the resident's room without wearing a gown, as required by the posted isolation sign and facility policy. The staff member also left the room wearing gloves and re-entered without donning a gown, indicating a lack of adherence to contact precaution protocols. The deficiencies were confirmed through staff interviews, clinical record reviews, and direct observation. Facility policies required hand hygiene before donning and after removing gloves, as well as the use of gowns and gloves for contact precautions. However, these protocols were not followed during the observed care and cleaning activities, resulting in non-compliance with infection prevention and control standards.
Failure to Implement Fall Prevention Interventions Results in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not implementing required interventions to prevent falls for two residents. In the first case, a resident who required a bed alarm as a safety precaution was found on the floor with multiple injuries, including a laceration above the left eye and contusions to the face. Documentation revealed that the bed alarm was not activated at the time of the fall, despite being present on the bed. The nurse aide responsible for the resident did not check to ensure the alarm was functioning after placing the resident in bed, which was a direct violation of the resident's care plan and the facility's policy on fall prevention. In the second case, another resident assessed as dependent for bed mobility and requiring the assistance of two staff members was receiving care when she rolled out of bed and sustained a right distal femoral fracture. Staff statements indicated that only one nurse aide was present at the bedside while the other was in the bathroom gathering supplies, resulting in the resident being left without the required level of assistance. The care plan for this resident specifically required two staff for bed mobility, and this was not followed at the time of the incident. The facility's policies defined neglect as the failure to provide necessary goods and services to avoid physical harm, including the absence of reasonable accommodations for individual needs. In both incidents, the staff did not follow established care plans and safety interventions, leading to substantiated findings of neglect. There was no evidence in the report that the Director of Nursing or Nursing Home Administrator was notified immediately following the incidents, nor that all employees received in-service training after the substantiated neglect events.
Failure to Maintain Residents' Range of Motion
Penalty
Summary
The facility failed to provide services to maintain the range of motion (ROM) for seven out of eight residents reviewed. The clinical records for these residents revealed that they had care plans in place for a restorative nursing program (RNP) aimed at preventing contractures and maintaining mobility. However, the documentation showed that staff did not complete or document the completion of the prescribed ROM exercises on multiple occasions across different shifts. This lack of documentation and completion of tasks was noted for various types of ROM exercises, including active assisted range of motion (AAROM), passive range of motion (PROM), and active range of motion (AROM) for different body parts such as shoulders, elbows, wrists, fingers, hips, knees, and ankles. For Resident 18, the care plan included AAROM and PROM exercises for both upper and lower extremities, but the task documentation revealed numerous dates where these exercises were not completed or documented. Similar deficiencies were found for Residents 42, 58, 59, 60, 71, and 88, with each having specific ROM exercises outlined in their care plans that were not consistently carried out or recorded. The lack of adherence to the care plans was consistent across both day and evening shifts, indicating a systemic issue in the facility's execution of restorative care. Resident 88, who was discharged from physical therapy to an RNP for ambulation and ROM, expressed a desire to walk and return home but reported not receiving recent therapy. Observations confirmed that the resident was in a wheelchair and had not been assisted with ambulation as per their care plan. The surveyor discussed these findings with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to provide necessary restorative services to maintain or improve residents' ROM and mobility.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident. A review of the resident's clinical record revealed an MDS assessment dated July 1, 2024, which incorrectly indicated that the resident had a urinary catheter. However, there was no documented evidence in the clinical record to support the use of a urinary catheter for this resident. An interview with the Administrator confirmed that the resident did not utilize a urinary catheter, highlighting the inaccuracy in the MDS assessment.
Failure to Maintain Communication for Resident with CVA
Penalty
Summary
The facility failed to provide care and services to maintain optimal communication for a resident with a history of a cerebrovascular accident (CVA). The resident, who had unclear speech and was usually understood, had a care plan that identified communication problems due to speech and language deficits related to the CVA. The care plan included interventions such as asking simple yes and no questions and allowing time for responses. However, the facility did not ensure the availability of an augmentative and alternative communication (AAC) device, which was recommended by speech therapy (ST) to aid the resident's communication. The ST discharge summary noted that the AAC device, a tablet used to assist the resident, was no longer in the resident's room as it had been taken home by the resident's sister. Despite the resident's reported frustration with communication, there was no follow-up from ST regarding the AAC device, and no alternative devices were offered or used to optimize the resident's communication. The Nursing Home Administrator confirmed that the AAC device was not being used and that no other devices were provided, leading to the deficiency in maintaining the resident's communication abilities.
Failure to Follow Up on Dental Services
Penalty
Summary
The facility failed to follow up with necessary dental services for a resident, identified as Resident 39, who was experiencing dental issues. On June 4, 2024, a dental consult revealed that Resident 39 had discomfort in her lower tooth, dental caries in two teeth, and a large cavity that required extraction. The dentist recommended scheduling a follow-up appointment, stopping blood thinners, treating the caries, and extracting the problematic tooth. The facility scheduled the follow-up appointment for August 14, 2024, but did not document any action taken to stop the resident's blood thinners as recommended. On August 14, 2024, Resident 39's dental appointment was canceled because the facility did not stop her blood thinners, as required for the procedure. This resulted in the resident having to wait until September 2024 for the next available appointment. The resident expressed discomfort due to a broken tooth that was supposed to be extracted. Interviews with the Administrator and Director of Nursing confirmed these findings, and it was noted that the next dental appointment was scheduled for September 23, 2024.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for a resident, identified as Resident 12, who was on Enhanced Barrier Precautions due to colonization with multi-drug resistant organisms. The resident had a tracheostomy and required management three times daily. According to the memo released by CMS, nursing care facilities are required to use Enhanced Barrier Precautions, including gown and glove use, for residents with chronic wounds or indwelling medical devices during high-contact resident care activities. On August 16, 2024, an observation was made of a respiratory therapist, identified as Employee 1, performing tracheostomy care for Resident 12 without wearing a gown, despite the requirement to do so for high-contact activities. The care included suctioning of the tracheostomy, cleaning around the site, and an inner cannula change. Employee 1 only wore gloves during the procedure, failing to adhere to the Enhanced Barrier Precautions. The Nursing Home Administrator and Director of Nursing were informed of these findings.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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