Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Myerstown Nursing And Rehab Llc during CMS and state inspections, most recent first.
Failure to report alleged abuse to the State Survey Agency: Facility documentation showed that one resident kissed another resident without consent, and when a third resident intervened, he was threatened with violence. The DON confirmed no report had been filed with the State Survey Agency, despite the facility being aware of the allegations.
Failure to Monitor and Document Behavioral Symptoms: A resident with dementia with agitation and Alzheimer’s disease had physician-ordered monitoring for agitated behaviors and non-pharmacological interventions, but staff did not consistently document his behaviors or interventions. The resident had a history of choking his wife, later misidentified and attempted to kiss a female resident, and entered another resident’s room where he allegedly kissed or attempted to kiss one resident and threatened the other. He was also observed unsupervised, walking the halls and interacting with other residents, and the DON confirmed the care plan and MD orders were not implemented for behavioral health management.
Improper food storage and unsanitary dietary conditions: Surveyors found insects in the dry storage area, food shipment boxes and produce stored on the floor, expired and undated food items in coolers, food debris and spills on floors, uncovered food in tray line coolers, and debris on the dish machine. The Dietary Director confirmed items should have been dated, expired items removed, and the last food delivery had occurred earlier that week.
Unsafe and Unclean Conditions on Third Floor: The facility failed to maintain a safe, clean, and comfortable environment on the Third Floor. Surveyors observed dirty dried splatter and trash in all four hallways, sticky and odorous handrails, trash and a sticky substance in resident rooms, an overflowing trash can with dirty laundry under a sink, loose sink trim, a metal heater panel on the shower room floor, a white substance on a shower thermometer, and an orange substance on the bottom of a medication room refrigerator.
Failure to follow physician orders was identified for two residents. One resident with respiratory failure and CHF received metoprolol despite SBP being below the ordered hold parameter, and the medication was also withheld once when the ordered parameters were met. Another resident with DM2, heart disease, and chronic constipation had constipation-related orders for MiraLax, prune juice, and Magnesium Hydroxide, but the record lacked documentation showing the orders were carried out during periods without BM.
Failure to assess and treat a resident's pressure ulcer. A resident with severe malnutrition and dementia was dependent for ADLs and at risk for pressure ulcers. Facility policy required weekly wound evaluations, but there was no documented evidence that the resident's left heel wound was assessed weekly, and the TAR showed the ordered wound treatment was not completed on one day shift. The DON confirmed the missing documentation and missed treatment.
A resident with arthritis of the left knee, difficulty walking, and a history of falls required assistance with transfers and had a care plan directing staff to place fall mats on both sides of the bed. However, repeated observations found the resident in bed without the floor mats in place, and the DON confirmed the mats should have been there.
Failure to maintain ordered oxygen equipment for two residents. One resident with respiratory failure and CHF was observed with a cannula under the chin, connected to an empty O2 tank, and later with undated tubing not connected to the running concentrator. Another resident with DM2 and heart disease had undated tubing and a concentrator filter covered with a white substance. The DON confirmed the equipment had not been maintained per policy and MD orders.
A resident with ESRD and dependence on renal dialysis had an order for dialysis 3 days per week, but staff did not document or provide the dialysis center with the resident’s vital signs, condition, or treatments on any of 25 dialysis treatment days reviewed. Facility policy required nursing staff to report the resident’s condition and treatment provisions to the dialysis provider each dialysis day, and the DON confirmed there was no evidence of this communication.
Improper Meal Texture Served to Resident on Mechanical Soft Diet: A resident with dx including lung cancer and dysphagia had a physician order and ST discharge summary indicating a mechanical soft ground texture diet. During lunch observation, the resident was served chicken tenders and fries cut into about one-inch pieces with creamy coleslaw instead of the ordered mechanical soft meal, and the Dietary Director stated the resident should not have received those chopped food items and coleslaw.
Failure to provide ordered ice cream with lunch. A resident with lung cancer, COPD, and moderate protein-calorie malnutrition was identified as nutritionally at risk, and the care plan and nutrition assessment included serving ice cream with lunch. During observation, the resident’s meal tray was present, but the ice cream was not provided despite being listed on the tray card, and the resident stated he did not receive it. The Administrator stated dietary staff did not follow the resident’s food preferences identified on the meal ticket.
Failure to use required barrier precautions during wound care was cited after an RN changed a resident’s sacral pressure injury dressing without wearing a gown, despite facility policy requiring gloves and a gown for high-contact care when a resident has a wound. The resident had quadriplegia, reduced mobility, needed help with personal care, and had a stage 3 sacral pressure injury with orders for daily wound cleansing, Triad paste, and a bordered gauze dressing.
Failure to post current nurse staffing information. During multiple facility tours, no staffing information was posted, and later the lobby posting was dated two days earlier. The Administrator confirmed that incorrect staffing data was posted.
Failure to provide required transfer notifications: A resident was transferred to the hospital after a change in condition, but there was no documented evidence that the resident’s RP or legal representative received written notice of the transfer and reason for the move. In addition, written discharge or transfer notices were not sent to the Office of the State LTC Ombudsman for four other residents who were transferred to the hospital after changes in condition.
Failure to follow a physician order for daily weights for a resident with CHF and DM. The care plan called for weights at the same time each day and recording them, but the weight record had no documented evidence that weights were obtained on multiple days. The DON confirmed the missing documentation.
Failure to document and complete ordered heel wound care for a resident with CHF and DM. The resident had pressure ulcers to both heels, and the physician ordered skin prep to one heel every shift, a dry dressing to the other heel daily, and a weekly skin check. The record showed no documented evidence that the ordered treatments were completed or that the weekly skin check and wound evaluation were done, and the DON confirmed the missing documentation.
Failure to change a resident’s PICC dressing as ordered. A resident with osteomyelitis had a PICC line with an order for the transparent dressing to be changed on admission and weekly, but the dressing was observed clean, dry, and intact and the resident stated it had not yet been changed. The TAR showed no documentation that the dressing was changed as ordered, and the DON confirmed the lack of documented evidence.
Two residents who were dependent on staff for toileting and incontinence care did not receive timely, dignified assistance. One resident with cervical disc disorder and cervicalgia activated the call bell multiple times for incontinence care; staff walked past the room, turned off the call light without assisting, and made a dismissive remark before the resident finally received help more than an hour after the initial request. Another resident with CHF and diabetes was observed in bed with the call bell placed out of reach in a bedside table drawer and repeatedly yelled out for help with urination, personal items, water, and food, while staff did not respond and the call bell remained inaccessible.
A resident with cervical disc disorder with myelopathy, cervicalgia, and a documented self-care deficit was dependent on staff for toileting and required prompt response to call bells per the care plan. The resident requested incontinence care using the call bell, which remained unanswered for an extended period while staff walked by, turned off the call light without providing care, and, in one instance, an NA refused to provide care and left the room. The resident had to reactivate the call bell multiple times and did not receive the requested incontinence care for over an hour after the initial request.
Surveyors found that the call bell system in multiple rooms on three units illuminated in the hallway but did not produce an audible alarm when activated. A resident with chronic pain and dysphagia, dependent on staff for toileting and dressing and care planned for fall risk with a call light intervention, reported his call bell had not worked properly for two days, which was confirmed on observation. Another resident with diabetes and insomnia, also care planned for fall risk with a call light intervention, reported that his call bell worked only sporadically. Staff and the Administrator acknowledged that the call bells had been lighting but not sounding since the previous day.
The facility failed to notify two residents or their responsible parties of physician-ordered changes in treatment and medications. For one resident with CHF and dementia, new orders for sacral wound care with triad paste and right heel wound care with calcium alginate were implemented without documented notification to the resident or representative. For another resident with dementia, new orders for Mucinex for a productive cough and hydrocortisone cream for a rash were also not accompanied by documented notification. The Administrator confirmed there was no documentation that these residents or their responsible parties were informed of the changes.
Surveyors found that a resident remained in the same hospital gown from the prior day because no clean gowns were available on the unit, and a NA confirmed the absence of gowns on hallway linen carts. Observations on all three nursing units showed linen carts and clean linen rooms with no or very few gowns, sheets, towels, and wash cloths, along with dirty floors, debris, and opened bags of clean linens placed directly on the floor. On one unit, multiple full, odorous bins of soiled linens were left in the hallway outside the clean utility room, and later checks the same day showed that these linen supplies had not been replenished.
A resident with multiple serious diagnoses, including kidney failure, COPD, respiratory failure, metabolic encephalopathy, and a UTI, was admitted and had an order for 0.25 ml of morphine solution (20 mg/ml) every four hours. The MAR showed that the resident did not receive the ordered morphine for two days because the medication was not available from the pharmacy. The DON confirmed that the resident did not receive the morphine as ordered until two days after admission, resulting in a cited deficiency in pharmacy and nursing services.
Surveyors observed damaged windowsills, chair rails, and walls in multiple rooms and the dining area, along with debris and a black substance on floors in several rooms and an elevator, indicating a failure to maintain a safe, clean, and comfortable environment.
The facility did not employ a full-time qualified dietitian or a qualified dietary services manager, as confirmed by both the dietary manager and the Administrator during staff interviews.
Surveyors found that food items in two nursing unit pantries were not labeled with resident names or dates, and refrigerators and freezers contained opened and undated items, as well as visible food debris and hair. The Administrator confirmed that staff were responsible for labeling and dating resident food, but this was not done according to facility policy.
A resident with significant mobility limitations and a history of amputation waited 29 minutes for staff to respond to their call bell after requesting assistance to the bathroom, despite facility policy requiring a response within 20 minutes. The delay caused the resident to miss an activity.
A resident with a known peanut allergy and moderate cognitive impairment was served a peanut butter bar for dessert, despite documentation of the allergy and care plan instructions to offer alternate food items. The DON confirmed the error after the resident identified the allergy when interviewed.
A resident with multiple medical conditions did not receive simethicone as ordered by the physician because the medication was not available from the pharmacy. The resident experienced severe gas pain over several days, and documentation confirmed the medication was not administered as prescribed. The DON verified the medication was unavailable and not given.
A resident with serious health conditions did not receive care according to physician's orders, including daily weight monitoring and medication administration. The facility failed to notify the physician of a significant weight change and did not administer several medications as prescribed, nor did they follow procedures for changing administration tubing and replacing antimicrobial caps.
A facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter. Observations showed the catheter drainage bag hanging off the bed, uncovered, and touching the floor, contrary to facility policy. The resident, who required extensive assistance and was at increased risk for infection, had chronic obstructive pulmonary disease and congestive heart failure. The Nursing Home Administrator confirmed the catheter bag should not be uncovered and on the floor.
Failure to Report Alleged Abuse to the State Survey Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey Agency for two residents after an incident involving Resident 8. Facility documentation showed that on July 16, 2026, Resident 8 entered the room shared by Resident 2 and Resident 1 and kissed Resident 2 without her consent. Resident 2 had diagnoses including chronic kidney disease, heart disease, type 2 diabetes, and dementia. Resident 1 had diagnoses including type 2 diabetes, heart disease, spinal damage, and PTSD. Facility documentation also showed that when Resident 1 intervened, Resident 8 threatened Resident 1 with violence. The facility was aware of the alleged abuse involving Residents 1, 2, and 8 on July 16, 2026, but there was no evidence that the incident had been reported to the State Survey Agency as of July 28, 2026. In an interview on July 27, 2026, the DON confirmed that no report had been filed with the State Survey Agency.
Failure to Monitor and Document Behavioral Symptoms
Penalty
Summary
The facility failed to implement physician-ordered monitoring and documentation of agitated behaviors and non-pharmacological interventions for a resident with dementia with agitation, Alzheimer’s disease, and a history of colon and prostate cancer. The resident’s MDS showed cognitive impairment, and a physician’s order dated February 18, 2026 directed staff to monitor and document agitated behaviors and attempted interventions every day and on every shift. The care plan also included interventions to engage the resident in structured activities and to observe, document, and report behavioral changes to the physician. Facility documentation showed that after the resident was admitted following an incident in which he choked his wife at home, he later misidentified a female resident as his wife, attempted to kiss her, and followed her until staff intervened, which led to his move to another floor. On July 16, 2026, he entered the room of two residents without invitation, allegedly kissed or attempted to kiss one resident without consent, and threatened the other resident with bodily harm when objected to. Review of documentation from June 27, 2026 through July 27, 2026 showed no evidence that his behavior was monitored and documented for 22 of 30 days, including July 16, 2026. During observation on July 27, 2026, he was seen unsupervised interacting with other residents, walking the halls independently, and sitting alone at a window, and the DON confirmed that the physician’s orders and care plan were not implemented for behavioral health management.
Improper food storage and unsanitary dietary conditions
Penalty
Summary
The facility failed to properly store food and maintain sanitary conditions in the dietary department. During a tour of the dietary department, surveyors observed insects flying around the dry storage food area, food shipment boxes and produce stored directly on the floor, an opened box of brownie mix and juice cartons not stocked in the food storage area, and a box of pancake mix with a use-by date of July 6, 2025. In the same area, there was a granular white substance with a shoe print in it on the floor and dried white splatter across from the sugar packet shelves. In cooler 2, surveyors found food debris on the floor, including onion skins, mashed peas, a crushed margarine cup, a dried brown celery stalk, and an apple. They also observed a cut onion labeled use-by June 21, 2026, opened and undated shredded carrots, yogurt past its use-by date, mushy undated shredded carrots and cabbage, an opened bag of salad mix with brown lettuce and mushy carrots dated June 6, 2026, and a pan of peeled potatoes in water with a very strong odor. In cooler 3, there was black dried liquid on the floor, crushed coffee creamers, opened gallons of milk with use-by dates of July 10, 2026 and July 8, 2026, milk crates directly on the floor, and two areas of a solid brown thick substance coming from the ceiling above a running fan. In the walk-in freezer, boxes of frozen food were on the floor, green peas were on the floor, the freezer fan was covered with thick ice, and there was a large accumulation of ice below it. Additional observations included a dried white substance and dried brown liquid at the coffee station, an uncovered garbage can with an insect flying around it, uncovered and dated food items in tray line coolers, and brown crumbled debris on top of the dish machine. The Dietary Director confirmed the items should have been dated, expired items should have been removed, and the last food delivery was on July 10, 2026.
Unsafe and Unclean Conditions on Third Floor
Penalty
Summary
The facility failed to ensure that a safe, clean, and comfortable environment was maintained on one nursing unit, the Third Floor. Observations from July 13, 2026, through July 15, 2026, found dirty dried splatter and trash on the floors throughout four of four hallways, and the handrails in four of four hallways were sticky and had an unpleasant odor. In resident rooms [ROOM NUMBER], there was trash and a sticky substance on the floors, and the trash can was overflowing with dirty laundry piled beneath the sink. In room [ROOM NUMBER], the plastic trim on the front of the sink was on the floor. In the shower room, a metal panel from the heater was on the floor and a white substance was on the thermometer hanging in the shower stall. In the medication storage room, an orange substance was on the bottom of the refrigerator.
Failure to Follow Physician Orders for Medication and Constipation Care
Penalty
Summary
The facility failed to ensure physicians' orders were implemented for two residents. One resident had diagnoses including acute and chronic respiratory failure and congestive heart failure. A physician ordered metoprolol twice daily with instructions not to administer it if systolic blood pressure was below 110 mm/Hg or if heart rate was less than 60 bpm. Review of the MAR for July 2026 showed the medication was administered seven times when the resident's systolic blood pressure was below 110 mm/Hg, and it was withheld once when systolic blood pressure was above 110 mm/Hg and heart rate was above 60 bpm. Another resident had diagnoses including type 2 diabetes, heart disease, and chronic constipation. Physician orders directed staff to give MiraLax as needed for constipation, prune juice on the second day without a bowel movement, and Magnesium Hydroxide Suspension on the third day with a small or no bowel movement. Review of the clinical record showed no evidence that the resident had no bowel movements during two separate date ranges in June 2026, and there was no documentation supporting implementation of the constipation-related orders. The DON confirmed in interview that the residents' physician's orders were not followed.
Failure to Assess and Treat a Resident's Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one sampled resident with a pressure ulcer. Facility policy required weekly skin evaluations to be documented in the electronic medical record and, when skin impairments were present, the wound location, characteristics, and wound status were to be evaluated and documented. Resident 7 was admitted with severe malnutrition and dementia, was cognitively impaired, dependent on staff for activities of daily living, and identified as at risk for pressure ulcers on the MDS assessment. The care plan noted the resident was at risk for skin breakdown and had a pressure ulcer on the right hip. A physician's order dated June 29, 2026 directed staff to cleanse the resident's left heel with normal saline, apply betadine to the base of the wound, and leave it open to air twice daily and as needed for deep tissue injury. There was no documented evidence that the left heel wound was assessed weekly during the week of July 6, 2026. The TAR for July 2026 also showed no evidence that the ordered wound treatment was completed on the day shift on July 13, 2026. The DON confirmed on July 15, 2026 that there was no documented evidence that the left heel pressure ulcer was assessed weekly or that the treatment to the left foot was completed on the noted dates.
Failure to Maintain Ordered Fall Mats
Penalty
Summary
The facility failed to implement safety interventions for one resident with a history of falls. Resident 34 had diagnoses including arthritis of the left knee and difficulty walking, and the MDS indicated the resident required assistance for transfers from one surface to another. The care plan documented a history of falls and directed staff to place fall mats on both sides of the bed. However, observations on July 12, 2026, and July 14, 2026, showed the resident in bed without the floor mats in place on either side of the bed. During interview, the DON confirmed that the floor mats should have been in place.
Failure to Maintain Ordered Oxygen Equipment
Penalty
Summary
Adequate respiratory care was not provided for two residents who had physician-ordered oxygen therapy and equipment maintenance requirements. Facility policy required oxygen equipment, including nasal cannulas, humidifiers, and tubing, to be changed weekly and dated when changed. Resident 1 had diagnoses including acute and chronic respiratory failure and congestive heart failure, and a physician ordered oxygen by nasal cannula every day on all three shifts, with tubing and the humidification bottle changed, the oxygen filter cleaned, and the tubing dated every Saturday night. On observation, Resident 1 was seen with the cannula beneath his chin and connected to an empty oxygen tank, and later was seen wearing a nasal cannula with undated tubing that was not connected to the running oxygen concentrator. The resident stated he was not aware of when the tubing was replaced. Resident 74 had diagnoses including type 2 diabetes, heart disease, and chronic constipation, and a physician ordered oxygen at night for shortness of breath, with tubing and the humidification bottle changed, the oxygen filter cleaned, and the tubing dated every Sunday night. On observation, Resident 74's oxygen tubing was not dated and the filter on the concentrator was covered with a white substance. The resident stated he did not know when the tubing was last replaced and was sure it had been more than two weeks. The DON confirmed that the resident's oxygen equipment had not been maintained per policy and physician's orders.
Failure to Communicate Resident Condition and Treatments for Dialysis
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for one resident receiving dialysis. Resident 2 had diagnoses of end-stage renal disease and dependence on renal dialysis, and had a physician’s order to receive dialysis three days per week. Facility policy required nursing staff to provide the dialysis provider with a report on the resident’s condition and treatment provisions each dialysis treatment day and as needed. However, clinical record review and review of the pre-dialysis communication forms showed no evidence that staff obtained and/or provided the resident’s vital signs, recorded the resident’s condition, or documented treatments provided on the day of dialysis for 25 of 25 dialysis occasions from May 6, 2026 through July 14, 2026. The DON confirmed that there was no evidence the facility communicated the resident’s condition or treatments to the dialysis center on each dialysis treatment day.
Improper Meal Texture Served to Resident on Mechanical Soft Diet
Penalty
Summary
The facility failed to serve food in the form prescribed to meet the needs of one resident with a mechanical soft diet order. The resident had diagnoses including malignant neoplasm of the upper lobe of the right bronchus or lung and dysphagia. A physician order dated August 23, 2025, directed staff to provide a mechanical soft texture diet, and a Speech Therapy Discharge summary indicated the resident still needed the mechanical soft ground texture diet. The care plan also noted the resident had no teeth, did not use dentures, and was at risk for nutritional problems due to a gradual down trend in weights. During lunch observation on July 13, 2026, the resident was served chicken tenders and French fries cut into about one-inch pieces with creamy coleslaw, while the meal ticket indicated a mechanical soft diet. The facility’s weekly menu for the mechanical soft diet listed ground chicken tenders, mashed potatoes, and broccoli for that lunch meal. In interview, the Dietary Director stated staff were to follow the lunch menu for the mechanical soft diet and that the resident should not have received the chopped food items and coleslaw.
Failure to Provide Ordered Ice Cream With Lunch
Penalty
Summary
Food that accommodated resident preferences was not provided for Resident 8. The resident had diagnoses including malignant neoplasm of the upper lobe/bronchus or lung, COPD, and moderate protein-calorie malnutrition. The MDS indicated the resident was alert and oriented and required set-up assistance only with activities of daily living. The care plan identified nutritional risk due to a gradual down trend in weight, with an intervention for staff to provide and serve the diet as ordered. A Nutrition Risk Assessment completed on May 10, 2026, noted the resident was at nutritional risk due to current disease state and included an intervention to serve ice cream with lunch. During observation on July 15, 2026, at 12:45 p.m., the resident was seated next to his bed with his lunch tray on the tray table stand. The tray contained the main entree, side dish, fruit, vegetable, and a drink, and staff had served the meal. The tray card indicated the resident was to receive ice cream at lunch, but the resident stated he did not get it and said he was supposed to and would like to have it. The Administrator stated in interview that the dietary department did not follow Resident 8's food preferences identified on the meal ticket.
Failure to Use Required Barrier Precautions During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to follow the facility’s infection prevention policy during wound care for one sampled resident. The facility policy stated that enhanced barrier precautions applied when a resident had a wound and that gloves and a gown were to be worn before high-contact care activities, including wound care. Resident 11 had diagnoses including quadriplegia, reduced mobility, and need for assistance with personal care, and had a stage three pressure injury on the sacrum. A physician’s order directed daily and as-needed cleansing with normal saline, application of Triad paste, and coverage with a bordered gauze dressing. During observation of wound care, the RN changed the sacral dressing without wearing a gown during the high-contact care. The Infection Preventionist later confirmed that the nurse should have worn a gown during the dressing change.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information. During a tour on July 12, 2026 at 9:15 a.m., no staffing information was posted. During another tour on July 13, 2026 at 9:15 a.m., no staffing information was posted. On July 15, 2026 at 11:50 a.m., staffing information was posted in the lobby, but it was dated July 13, 2026. At that time, the Administrator confirmed that incorrect staffing data was posted on July 15, 2026.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to notify a resident’s representative in writing of a transfer to the hospital and the reasons for the move for one resident who was transferred out of the facility after a change in condition. Clinical record review showed that the resident was sent to the hospital on June 19, 2026, and there was no documented evidence that the resident’s responsible party or legal representative received written information about the transfer. The facility also failed to provide copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for four residents who were transferred to the hospital after changes in condition. Clinical record review showed transfers for one resident on April 23, 2026, another on May 22, 2026, one resident with transfers on March 4, 2026 and April 21, 2026, and another on May 4, 2026, with no documented evidence that the required notices were sent. In interviews on July 14, 2026, and July 15, 2026, the Administrator confirmed there was no documented evidence that the transfer notification was sent to the resident’s representative and that the written discharge or transfer notices were not sent to the Ombudsman.
Failure to Follow Daily Weight Order
Penalty
Summary
The facility failed to follow a physician order for one resident who was admitted with diagnoses including congestive heart failure and diabetes. On April 23, 2026, the physician ordered staff to weigh the resident daily, and the care plan also identified the resident as at risk for a nutritional problem with an intervention to weigh the resident at the same time of day and record the weight. Review of the weight record showed no documented evidence that weights were obtained per the physician order on April 23, 25, 27, and 28, 2026. During an interview on June 18, 2026, at 12:05 p.m., the DON confirmed there was no documented evidence that the resident's weights were obtained per the physician order.
Failure to Document and Complete Ordered Heel Wound Care
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient for one resident with pressure ulcers to both heels. The resident was admitted with diagnoses including congestive heart failure and diabetes. The admission nursing evaluation documented pressure ulcers to the right and left heels, and on April 23, 2026, the physician ordered skin prep to the left heel every shift and a dry dressing to the right heel daily. On April 30, 2026, the physician also ordered a weekly skin check and completion of the Weekly Skin Check Form. Facility policy stated that weekly skin evaluations would be completed and documented, wound location and characteristics would be documented, and wound status would be evaluated on the Wound Evaluation Flow Sheet. Review of the clinical record showed no documented evidence that the ordered treatments were completed to the left or right heel from April 23 to May 4, 2026. There was also no documented evidence that the resident's wound was evaluated or that the Weekly Skin Check Form was completed on April 30, 2026. The DON confirmed in interview that there was no documented evidence that the treatments to the resident's left and right heels were completed per physician order.
Failure to Change PICC Dressing as Ordered
Penalty
Summary
The facility failed to implement appropriate measures for the care and management of a PICC line for one resident with osteomyelitis. The resident was admitted with a PICC line, and the care plan directed staff to change the dressing as ordered by the physician. On May 28, 2026, the physician ordered the transparent dressing to be changed on admission and then weekly. During an observation on June 18, 2026, the resident’s PICC dressing was clean, dry, and intact, and the resident stated it had not yet been changed. Review of the Treatment Administration Records showed no documented evidence that the dressing was changed on June 10 or June 17, 2026. The DON confirmed there was no documented evidence that the dressing was changed as ordered.
Failure to Provide Timely, Dignified Assistance With Toileting and Call Bell Access
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with toileting and incontinence care in a manner that maintained resident dignity for two dependent residents. One resident had cervical disc disorder with myelopathy, cervicalgia, no cognitive impairment, and was care planned as dependent on staff for toileting with a need for prompt response to all requests for assistance. During an interview, this resident requested incontinence care and activated the call bell at 9:48 a.m. The call light remained on until 10:02 a.m., during which time a nurse aide walked past the room without assisting. At 10:02 a.m., a staff member turned off the call light and left the room without providing care. The resident reactivated the call bell at 10:11 a.m.; at 10:12 a.m., a nurse aide entered, stated, “What is it now?” turned off the call bell, and again did not provide assistance. The resident activated the call bell a third time at 10:41 a.m. and did not receive toileting assistance until 11:00 a.m., more than one hour after the initial request. The second resident had diagnoses including congestive heart failure and diabetes and was assessed as dependent on staff for toileting, with a care plan intervention for staff to keep the call bell within reach and answer promptly. Observation showed this resident in bed with the call bell placed in the bedside table drawer, out of reach. The resident subsequently yelled out that she was urinating and needed help, identifying her room number, and stated that she had to go to the bathroom and might need to again. Later, she stated she did not have her things and could not get to them, and she continued to yell out for assistance with the bathroom, water, and food. Throughout these observations, the call bell remained out of reach and staff did not respond to her verbal requests for assistance.
Failure to Provide Timely Incontinence Care and Assistance With ADLs
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living, specifically incontinence care, to a resident who was unable to perform these tasks independently. The resident had diagnoses including cervical disc disorder with myelopathy and cervicalgia, had no cognitive impairment per the MDS, and was dependent on staff for toileting. The resident’s care plan identified a risk for falls, directed staff to encourage use of the call bell for assistance, required prompt response to all requests for assistance, and documented a self-care deficit requiring staff assistance with ADLs. On the morning of April 3, 2026, the resident requested incontinence care and activated the call bell at 9:48 a.m. The call light remained on until 10:02 a.m., during which time NA 1 walked past the room without assisting. At 10:02 a.m., a staff member turned off the call light and left the room without providing care. At 10:11 a.m., the resident reactivated the call bell; at 10:12 a.m., NA 1 entered, asked, “What is it now?”, turned off the call bell, refused to provide care, and walked away. The resident activated the call bell again at 10:41 a.m. and did not receive incontinence care until 11:00 a.m., more than one hour after the initial request, contrary to the care plan requirement for prompt response and assistance with ADLs.
Failure to Maintain Functioning Call Bell System on All Units
Penalty
Summary
Surveyors identified that the facility failed to provide a properly working call bell system in resident bathrooms and bathing areas on all three units. On multiple observations on March 19, 2026, call bells in rooms 103, 105, 203, and 316 illuminated in the corridor but produced no audible sound when activated. Staff interviews, including with a nurse and another employee, confirmed that the call bells were lighting up in the hallway but not sounding when used. The Administrator also confirmed that the call bell system had not been functioning properly and that this issue, with lights working but no audible alarm, had been occurring since the prior day. Clinical record review showed that one resident had chronic pain and dysphagia, was alert and oriented, and was dependent on staff for toileting and dressing. This resident’s care plan identified a risk for falls and included an intervention for staff to ensure the call light was within reach and to encourage its use; the resident reported that his call bell had not worked properly for two days, and observation confirmed there was no sound when the call bell was activated. Another resident with diabetes and insomnia, who was also alert and oriented and care planned as at risk for falls with the same call light intervention, reported that his call bell sporadically did not work properly. These findings demonstrated that the malfunctioning call system affected multiple rooms and residents whose care plans relied on a functioning call bell for fall-risk interventions.
Failure to Notify Residents/Responsible Parties of Physician-Ordered Treatment Changes
Penalty
Summary
The facility failed to notify residents or their responsible parties of physician-ordered changes in treatment for two of five sampled residents, as required. For one resident with diagnoses including congestive heart failure and dementia, the clinical record showed that on February 1, 2026, the resident complained of sacral pain and the physician ordered application of triad paste, and on February 4, 2026, the physician ordered application of calcium alginate to a right heel wound; there was no documented evidence that the resident or responsible party was notified of these new treatment orders. For another resident with dementia, the clinical record showed that on February 6, 2026, the physician ordered Mucinex for five days for a productive cough and hydrocortisone cream twice daily for a rash, with no documented evidence that the resident or responsible party was notified of these medication and treatment changes. In an interview on February 24, 2026, at 1:04 p.m., the Administrator confirmed there was no documented evidence that the residents or their responsible parties were notified of these physician-ordered changes, constituting a failure to immediately inform the resident, physician, and family of changes affecting the resident, in violation of 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Inadequate Linen Supply and Unclean Linen Areas Across All Nursing Units
Penalty
Summary
Surveyors identified a failure to maintain a safe, clean, comfortable, and homelike environment related to linen availability and cleanliness across all three nursing units and for one sampled resident. On the second floor, a resident reported remaining in the same hospital gown as the previous day due to a lack of clean gowns on the unit. At the same time, a nurse aide confirmed that there were no hospital gowns available on the hallway linen carts. Observation of the second floor linen carts showed no clean resident gowns, and the clean linen room on that unit contained only two clean gowns and no sheets, with the floor noted to be dirty and littered with debris, plastic cups, and dirt. Additional observations on the third and first floor units showed similar deficiencies in linen supply and environmental cleanliness. On the third floor, the linen cart had few gowns, sheets, and towels, and the clean linen room contained few clean gowns and sheets, with debris on the floor and two opened bags of clean linens placed directly on the floor. On the first floor, the clean linen room had no sheets, few clean gowns, and no wash cloths, and three full, odorous bins of soiled linens were located in the hallway outside the clean utility room. Follow-up observation later the same day confirmed that the linen carts and clean linen rooms on these units had not been replenished and remained sparse or empty.
Failure to Provide Ordered Morphine Due to Pharmacy Unavailability
Penalty
Summary
Surveyors identified that the facility failed to ensure a prescribed medication was available from the pharmacy for administration as ordered by the physician for one of three sampled residents. The resident was admitted on a specified date with diagnoses including kidney failure, COPD, respiratory failure, metabolic encephalopathy, and a urinary tract infection. On the day of admission, at 12:06 p.m., the physician ordered 0.25 ml of a morphine solution (20 mg/ml) to be administered every four hours. According to the Medication Administration Record, the resident did not receive any doses of the ordered morphine on two consecutive days because the medication was not available from the pharmacy. In an interview conducted on a later date at 10:45 a.m., the Director of Nursing confirmed that the resident did not receive the morphine as ordered until another specified date at 12:00 a.m. This failure to provide the ordered medication was cited under 28 Pa. Code 211.9(d) related to pharmacy services and 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Environmental Deficiencies Noted in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment on one of its nursing units. During observations conducted on two separate days, surveyors noted multiple instances of physical damage and cleanliness issues. Specifically, the top left edge of the windowsills was found to be damaged in several resident rooms and in the dining room. Additional damage was observed to the chair rail under the television and to a wall beneath a wooden shelf in the dining room. Furthermore, debris and a black substance were present on the floors of several resident rooms and in an elevator. These findings indicate that the facility did not ensure the environment was properly maintained as required.
Failure to Employ Qualified Dietary Services Manager or Full-Time Dietitian
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. During an interview, the dietary manager confirmed that there was no qualified dietary manager employed. Additionally, the Administrator verified that the facility did not have a full-time dietitian or a qualified dietary manager in place. These findings were based on staff interviews and a review of facility staffing, with no evidence provided to show compliance with the requirement for appropriate dietary service management.
Failure to Store Resident Food in a Sanitary and Labeled Manner
Penalty
Summary
The facility failed to store food in a sanitary manner on both Health Care 1 and Health Care 2 nursing units. According to facility policy, nursing staff are required to label and date resident food items that require refrigeration. However, observations revealed multiple instances of noncompliance. In Health Care 1, the resident pantry refrigerator contained an opened container of ice cream, two cans of soda, an opened bottle of soda, two opened jars of salsa, and a piece of candy, none of which were labeled with a resident name or date. Additionally, the refrigerator shelves had visible food debris, a strand of hair, and a piece of plastic tape with accumulated dust. In Health Care 2, the refrigerator contained a container of chopped fresh fruit, a bag of cherries, an uncovered dish of wilted sliced tomatoes, and a container of oat milk, all undated. Opened bottles of apple cider vinegar, salad dressing, and oat milk were also present without dates or resident names. The refrigerator shelves and bottom area were found to have sticky food debris and a hair strand. The freezer contained items such as a spicy breaded chicken sandwich and ice cream products, none labeled with a resident name. During an interview, the Administrator confirmed that the refrigerators are designated for resident food only and that items are to be labeled with the resident name and dated by staff, as per facility policy. The observations and staff interview demonstrate that the facility did not adhere to its own policies regarding the labeling, dating, and sanitary storage of resident food items, resulting in a deficiency under the cited regulations.
Delayed Response to Call Bell for Resident Requiring Extensive Assistance
Penalty
Summary
A resident with a right leg above the knee amputation, reduced mobility, and chronic pain syndrome, who was able to communicate needs and required extensive assistance with activities of daily living, was observed to have their call bell activated for 29 minutes without response from staff. The resident had a care plan indicating a risk for falls and dependence on staff for toileting, with interventions specifying that staff should encourage use of the call bell and respond promptly to requests for assistance. On the day of the incident, the resident reported waiting for assistance to use the bathroom and expressed concern about missing an activity due to the delay. Facility policy expected call bells to be answered within 20 minutes, but staff did not respond within this timeframe.
Failure to Accommodate Food Allergy in Resident Meal Service
Penalty
Summary
A resident with a documented peanut allergy and moderate cognitive impairment was served a peanut butter bar for dessert, despite clear documentation of the allergy in the clinical record, ongoing plan of care, and admission documentation. The resident required set-up assistance for feeding and was at nutritional risk due to vision problems, with instructions in the care plan to offer alternate food items as needed. On the observed date, staff served the resident a meal that included a peanut butter bar, and the resident identified his peanut allergy when interviewed. The Director of Nursing later confirmed that the resident had received the peanut butter bar, which was not appropriate given his documented allergy.
Failure to Administer Ordered Medication Due to Unavailability
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cervical disc disorder with myelopathy, chronic pain, constipation, and muscle weakness did not receive simethicone as ordered by the physician. The physician's order, dated January 24, 2025, directed staff to administer simethicone twice daily. However, the medication was not available from the pharmacy, and nursing documentation confirmed that the resident did not receive the medication for four consecutive days. The resident reported experiencing severe gas pain during this period. The physician was notified of the unavailability, and a subsequent order was given to administer simethicone as needed, but the medication still was not administered as originally ordered. The Director of Nursing confirmed that the medication was not available and not given as prescribed.
Failure to Implement Physician's Orders and Administer Medications
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with bacteremia, congestive heart failure, and respiratory failure. The physician's order required the resident to be weighed daily, with a directive to notify the doctor if there was a weight gain of two or more pounds in one day. On one occasion, the resident's weight increased by two pounds, but there was no evidence that the staff notified the physician of this change as required. Additionally, the facility did not adhere to several medication administration orders for the resident. There were multiple instances where medications such as ampicillin, ceftriaxone sodium, florastor, heparin sodium, and normal saline were not administered as ordered. Furthermore, the staff failed to change administration tubing and replace antimicrobial caps as directed. These deficiencies were confirmed by the Director of Nursing during an interview.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter. The facility's policy required that the urinary drainage bag be positioned below the bladder level, not on the floor, and covered at all times to prevent backflow of urine. However, observations on two consecutive days revealed that the resident's catheter drainage bag was hanging off the bed, uncovered, and directly touching the floor. The resident had chronic obstructive pulmonary disease and congestive heart failure, required extensive assistance for activities of daily living, and was at increased risk for infection. The Nursing Home Administrator confirmed that the catheter bag should not be uncovered and on the floor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 249 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Myerstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stoneridge Poplar Run | 0.6 mi | ★★★★★ | 8 | 0 |
| Cedar Haven Healthcare Center | 5.6 mi | ★★★★★ | 4 | 1 |
| Lebanon Skilled Nursing And Rehabilitation Center | 7.1 mi | ★★★★★ | 15 | 0 |
| Alpine Valley Post Acute And Healthcare Center | 7.2 mi | ★★★★★ | 0 | 0 |
| Cornwall Manor | 8.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.