Northampton County-gracedale
Inspection history, citations, penalties and survey trends for this long-term care facility in Nazareth, Pennsylvania.
- Location
- Gracedale Avenue, Nazareth, Pennsylvania 18064
- CMS Provider Number
- 395476
- Inspections on file
- 30
- Latest survey
- October 17, 2025
- Citations (last 12 mo.)
- 8 (3 serious)
Citation history
Health deficiencies cited at Northampton County-gracedale during CMS and state inspections, most recent first.
The facility did not implement adequate interventions for residents with known aggressive and wandering behaviors, leading to one resident being physically assaulted and injured after entering another's room, and another resident experiencing sexual abuse. The lack of monitoring and preventive measures resulted in actual harm and distress to the affected residents.
A resident with significant cognitive and physical impairments was allowed to leave AMA without a documented capacity assessment or timely provider notification. The resident left in a wheelchair, without medications, a confirmed destination, or social support, and staff did not notify the provider until two days later. This failure to follow policy and ensure resident safety resulted in Immediate Jeopardy.
A resident with dementia and a history of wandering, who was identified as high risk for elopement, was left unsupervised when assigned 1:1 staff failed to remain with them as required by care plan and physician order. The resident used a door code to exit the building undetected, and staff had not received required elopement prevention training. The facility also failed to change door codes after discovering the resident had obtained them, and did not immediately respond to the resident's alert bracelet alarm, resulting in the resident's unwitnessed elopement.
A resident with dementia and a history of wandering, identified as an elopement risk, was left without required 1:1 supervision after the assigned staff member left and was not replaced. This lapse in supervision resulted in the resident eloping from the facility. Facility records also showed that required nurse aide ratios and direct care hours were not met on the day of the incident.
The NHA and DON failed to ensure effective management and supervision, resulting in two residents eloping—one after removing a roam alert bracelet and another despite a physician's order for 1:1 supervision. Required staff education on elopement prevention was not completed as indicated in the Immediate Jeopardy action plan, affecting 29 residents at risk for elopement. Documentation did not show that assigned staff received necessary training prior to their shifts.
Two residents with dementia and complex needs did not have comprehensive care plans addressing their identified risks and barriers. One resident with memory impairment and wandering behavior had no documented interventions for elopement risk or use of an alert device, while another Spanish-speaking resident with communication difficulties lacked care plan interventions to address language barriers.
A resident with dementia and a history of wandering was able to repeatedly remove his alert bracelet and elope from the facility due to the lack of a stronger tamper-resistant band, absence of 1:1 observation, and failure to update the care plan as required by facility policy. The resident was eventually found by police off facility grounds, and staff confirmed that necessary interventions were not implemented.
Three residents were subjected to physical and mental abuse by an LPN, who was observed hitting a resident, inserting fingers and wash cloths into the resident's mouth, and restricting the movement of two other residents. One resident sustained physical injuries requiring ER evaluation, while the others experienced significant distress. Staff failed to intervene promptly, and the incident was only addressed after a resident called 911.
A resident with severe protein calorie malnutrition, bipolar disorder, and dementia was inaccurately documented on the MDS as receiving an antipsychotic medication, despite no clinical record or orders supporting this. The inaccuracy was confirmed by the Administrator.
A resident with diabetes and a stage 4 sacral pressure ulcer did not receive physician-ordered wound care treatments as documented in the treatment administration record, with multiple dates showing missing documentation. The DON confirmed the lack of evidence that the required wound care was completed as ordered.
A resident with cognitive impairment and multiple medical conditions did not receive ordered podiatry care for mycotic toenails. Despite a physician's order and the weekly availability of a podiatrist, the resident was not scheduled for a podiatry visit, and observation showed the toenails remained discolored, thick, long, and jagged.
Two residents with limited ROM did not receive prescribed restorative nursing programs as ordered. One resident with upper limb paralysis and cognitive impairment did not receive active or passive ROM exercises despite therapy and physician orders. Another resident with lower extremity weakness was not offered passive ROM exercises on most days, and staff documentation confirmed the deficiency.
A medication cart on one nursing unit was observed to be unlocked and unattended in a common area, contrary to facility policy requiring secure storage of drugs and biologicals. The cart was accessible to anyone nearby during multiple observation periods.
Food items in two nourishment rooms were found improperly stored without required labeling or dating, and an LPN was observed distributing meal trays without changing gloves or performing hand hygiene after touching various surfaces, in violation of facility policies.
The facility failed to implement physician's orders for a resident with acute cystitis, Alzheimer's disease, and chronic kidney disease. The resident was observed without the prescribed Darco Flat, roam alert bracelet, or chair alarm on multiple occasions.
The facility failed to provide adequate catheter care for a resident with an indwelling urinary catheter, as staff repeatedly positioned the catheter drainage bag above the bladder level and allowed it to touch the floor, contrary to facility policy.
Failure to Prevent Resident-to-Resident Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents from abuse, resulting in physical and sexual harm to two residents. One resident with a history of mood disorder, anxiety, alcohol-induced dementia, and psychosis was known to be verbally and physically aggressive, often refusing care and exhibiting behavioral disturbances. Despite these ongoing behaviors and documented refusal to allow others into his room, there was no evidence that interventions were implemented to prevent other residents from entering his room. This lack of intervention led to an incident where another resident, who had cognitive communication deficits, dementia, and a tendency to wander, entered the aggressive resident's room and sustained multiple injuries, including skin tears, bruising, and a fractured coccyx, after being assaulted. Additionally, another resident with a history of wandering and confusion entered the room of a resident without cognitive impairment and engaged in inappropriate sexual contact. The affected resident reported the incident, expressing agitation and anxiety, and requested medication for anxiety. Documentation showed that there were no interventions implemented to increase monitoring of the resident with wandering behaviors to prevent such incidents. The report highlights that the facility did not follow its own abuse prevention and resident-to-resident altercation policies, which required monitoring for aggressive behaviors and implementing care plan changes to prevent further incidents. The failure to provide adequate supervision and interventions for residents with known behavioral issues directly resulted in physical and sexual abuse, causing actual harm to at least one resident.
Failure to Notify Provider and Assess Capacity During AMA Discharge
Penalty
Summary
The facility failed to ensure timely notification of a provider when a resident left the facility against medical advice (AMA), and did not confirm the resident's capacity to make such a decision. The facility's policy required prompt notification of the resident's physician or provider if a resident or representative requested discharge AMA. However, documentation showed that the provider was not notified until two days after the resident had left the facility. There was also no evidence that a capacity evaluation was performed prior to the resident's discharge, despite the resident having a history of altered mental status, cognitive deficits, and a recent stroke. The resident in question had multiple diagnoses, including problems related to living alone, altered mental status, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and a below-the-knee amputation. The care plan indicated performance deficits in activities of daily living, limited mobility, impaired cognitive function, and short-term memory loss. The resident's physician had documented that decision-making capacity needed to be re-evaluated before discharge, as the resident seemed unable to understand the potential problems after leaving the facility, such as not having a home or transportation. Despite this, there was no documentation of a capacity assessment being completed, and staff allowed the resident to sign out AMA without confirming capacity or ensuring a safe discharge plan. Staff interviews confirmed that no capacity evaluation was performed, and the provider was not notified at the time of discharge. The resident left the facility in a wheelchair, without medications, a confirmed destination, or social support. Facility documentation showed that the AMA discharge form was signed by the resident and nursing supervisors, but there was no evidence of timely provider notification or interventions to ensure the resident's safety. This series of actions and omissions resulted in an Immediate Jeopardy situation.
Removal Plan
- The facility policy, Discharging a Resident Without a Physician's Approval, was updated and compliance with the updated policy will be implemented. The updates included that when a resident desires to leave AMA, staff will reference the resident's capacity in the medical record for consideration with management of the discharge and any AMA discharge will now require an incident report that will prompt staff to contact the provider.
- Physicians will be notified of AMA discharges immediately. The incident reports are audited by the risk management nurse. Compliance with the policy will be audited through High Risk Event and Quality Assurance and Performance Improvement (QAPI) meetings.
- Nursing staff onsite were re-educated on the updated policy, and notification to the Pennsylvania Department of Health and the local Area Agency on Aging at the time of an AMA discharge. The remainder of nursing staff will be educated.
- A new physician's order set was implemented to clearly communicate to the interdisciplinary team when a resident lacks capacity, has capacity, or if capacity is to be determined. Resident capacity will be documented with the order set. Nursing supervisors will audit new admissions for implementation of the order set.
- The interdisciplinary team will be educated on the new order set, and to document resident capacity based only on physician documentation. Compliance will be reviewed at QAPI meetings.
Failure to Provide Adequate Supervision and Elopement Prevention
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident who was identified as being at high risk for elopement. The resident, who had diagnoses including dementia, insomnia, wandering, restlessness, and agitation, was assessed as having memory impairment and was able to ambulate independently. The care plan and physician orders required 1:1 supervision and the use of a roam alert bracelet due to the resident's history and ongoing behaviors such as exit-seeking, attempting to use elevators, and previously eloping from another facility. Despite these interventions, there were multiple documented incidents where the resident was found attempting to access elevators, standing by exit points, and even obtaining and hiding door codes, yet the facility did not consistently implement or evaluate the recommended 1:1 supervision in a timely manner. On the day of the incident, the assigned 1:1 staff member left their post and was not replaced, leaving the resident unsupervised in violation of the care plan and physician's order. During this period without supervision, the resident was able to use a previously obtained door code to exit the facility through a stairwell door, as later confirmed by camera footage. The facility also failed to change the door codes after discovering the resident had obtained them, and did not provide required elopement prevention training to the staff assigned to the resident at the time of the incident. Additionally, the facility did not immediately initiate a search when the resident's alert bracelet alarmed, and there was no evidence that staff on the unit had received the necessary training as outlined in the facility's Immediate Jeopardy action plan. Further review revealed that 29 residents on the same unit were assessed as being at risk for elopement, yet there was no documentation that staff had received the required education on elopement prevention prior to their shifts. The facility's failure to provide adequate supervision, implement timely interventions, and ensure staff were properly trained directly resulted in the resident's unwitnessed elopement from the building, which was only discovered after the resident could not be located and was later found offsite by police.
Removal Plan
- Resident 2's room was changed to a secure unit.
- The facility changed all the door and elevator codes.
- The facility updated the 1:1 policy to include that staff is never to walk away from the assigned resident until another staff member takes their place.
- The facility educated all staff regarding the new 1:1 policy and not sharing door codes.
- The facility educated staff that a search should occur immediately if a door alarm is sounding.
- The facility instructed staff not to utilize fire alarm doors for everyday use to decrease alarm fatigue.
- The facility will continue to assess residents' risk of elopement upon admission, quarterly, and with events.
- The Nursing Home Administrator will update the pre-admission review of elopement risk to ensure the facility can safely manage a resident at risk of elopement.
- Monthly department head meetings will be held for the leadership team to discuss elopement events.
- Staff members observed to be giving out door and elevator codes to visitors or residents will receive disciplinary action.
Failure to Provide Required 1:1 Supervision and Adequate Staffing
Penalty
Summary
The facility failed to provide sufficient and competent staff to implement a resident's care plan interventions. Clinical record review showed that a resident with dementia, insomnia, wandering, restlessness, and agitation was assessed as having memory impairment and was able to walk without assistance. The resident was identified as an elopement risk, and the care plan included 1:1 observation as an intervention. On September 17, 2025, a physician ordered 1:1 supervision for this resident. However, facility documentation revealed that the staff member assigned to provide 1:1 supervision left the assignment at 8:00 p.m. on September 20, 2025, and was not replaced, leaving the resident without required supervision. As a result, the resident eloped from the facility later that night. Additionally, staffing documentation indicated that the facility did not meet the state-required nurse aide ratios and minimum direct care hours per resident on that day.
Failure to Prevent Resident Elopement and Ensure Staff Training
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure adequate interventions and supervision were provided to prevent the elopement of two residents. One resident was able to self-remove a roam alert bracelet and exit the facility, resulting in an Immediate Jeopardy situation. The facility's action plan required that all nurses receive education on elopement prevention before their next shift and that all staff be educated by a specified date. However, documentation showed that this education was not completed as required. A second resident, who had a physician's order for one-to-one supervision due to exit-seeking behavior, also eloped after being left unsupervised by the staff assigned to provide this supervision. There was no documented evidence that the nurse aide assigned to supervise the resident or the LPN overseeing the aide had received the necessary elopement training prior to their shifts, as required by the facility's Immediate Jeopardy action plan. Additionally, 29 residents on one unit were identified as being at risk for elopement, but the required staff education was not completed for that unit. The NHA and DON failed to fulfill their responsibilities to ensure compliance with federal and state regulations, contributing to these Immediate Jeopardy situations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the specific needs of two residents as identified in their comprehensive assessments. For one resident with vascular dementia, syncope, and a history of stroke, clinical records showed memory impairment and wandering behavior, with an elopement risk assessment indicating the use of an alert bracelet. However, there was no documented evidence that the care plan included interventions to monitor elopement risk, wandering, or the use of the alert device. For another resident with dementia, insomnia, wandering, restlessness, and agitation, who primarily spoke Spanish and rarely understood English, the MDS Care Area Assessment summary indicated that communication should be addressed in the care plan. Despite this, there was no documentation of interventions to address the resident's communication barrier in the care plan.
Failure to Prevent Elopement Due to Inadequate Supervision and Policy Noncompliance
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent an elopement for a resident identified as being at risk. The resident, who had diagnoses including vascular dementia, syncope, and cerebral infarction, was independently ambulatory and had documented memory impairment. Despite being assessed as a wanderer at risk for elopement, the resident was able to repeatedly remove his alert bracelet, which was intended to prevent unauthorized exits. Facility policy required that residents capable of removing their alert bracelets be issued a stronger, tamper-resistant band and, if still able to remove it, be placed on one-to-one observation. However, after the resident removed his alert bracelet on multiple occasions, there was no documented evidence that a stronger band was provided or that one-to-one observation was implemented as required by policy. Additionally, there was no documentation that the resident's care plan was updated to include interventions addressing his elopement risk, wandering behavior, or alert bracelet use. On one occasion, the resident was found off the unit and returned, but later the same day, he was able to leave the facility undetected and was found by police walking along a road a mile away. Staff interviews confirmed the lack of appropriate interventions and care plan updates, and the failure to follow facility policy led to an Immediate Jeopardy situation.
Removal Plan
- Resident 1's room was changed to a secure unit, and a new alert bracelet was placed on the resident. The resident's care plan was updated to include risk for elopement. Resident 1 was placed on 1:1 observation.
- The facility conducted an immediate audit of all residents with alert bracelets to ensure they were intact and with the appropriate band.
- The facility conducted an audit to ensure all residents with an alert bracelet had an appropriate care plan in place.
- The facility created a log to monitor each alert bracelet and band to ensure the correct band is in place, and that the policy regarding stronger bands is being followed.
- The receptionists will review the binder of at risk residents at the start of their shifts for changes and initial a log.
- The facility will update the template for 1:1 orders in the electronic health record.
- The facility educated all staff in the facility on the facility's procedure for alert bracelets, stronger bands, and resident care plans. All staff that were available were immediately educated. Other staff will be re-educated prior to the start of their next shift.
- Weekly audits of alert bracelets, bands, logs, and care plans will be completed and the results discussed at QAPI (Quality assurance, performance improvement) committee.
- Signs are posted with instructions to not share door codes and to be aware of residents who may try to exit.
Failure to Prevent Resident Abuse by LPN
Penalty
Summary
The facility failed to protect three residents from physical and/or mental abuse, as evidenced by an incident involving an LPN and three residents. According to facility documentation and staff and resident statements, the LPN was observed in a resident's room wearing full PPE, tapping one resident on the chest and back, and inserting her fingers into the resident's mouth. Blood-stained wash cloths were found on the floor, and two other residents in the room were shouting for help. One nurse aide reported that the LPN prevented her from entering the room and did not report the incident immediately. Resident interviews revealed that the LPN instructed them to put on PPE gowns, restricted their movement, and physically abused one resident by hitting and forcing wash cloths and towels into her mouth. One resident called 911 for help. As a result of the incident, the abused resident was transferred to the emergency room and was found to have petechial hemorrhages on the hard palate, periorbital edema, swollen lips, and difficulty closing her mouth. Nursing documentation noted that the resident expressed fear for her life. The other two residents also reported being frightened and subjected to inappropriate actions by the LPN, such as being sprinkled with water and being prevented from leaving the room. The facility's failure to intervene promptly and ensure the residents' safety resulted in actual physical harm to one resident and mental distress to all three involved.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. Clinical record review showed that the resident had diagnoses of severe protein calorie malnutrition, bipolar disorder, and dementia. The resident's MDS assessment indicated the use of an antipsychotic medication, but a review of the clinical record revealed no orders for or evidence that the resident received such medication. This inaccuracy was confirmed by the Administrator during an interview.
Failure to Document and Administer Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide physician-ordered wound care treatments for one of five sampled residents with pressure ulcers. Clinical record review showed that a resident with diabetes mellitus and hidradenitis suppurativa had a stage 4 pressure sore on the sacrum. The physician had ordered wound care involving cleansing with wound cleanser, application of a collagen sheet, filling with silver alginate, and covering with an Optifoam gentle dressing every shift. However, the treatment administration record for March 2025 lacked documentation that these treatments were completed on six specific dates. The Director of Nursing confirmed there was no documented evidence that the wound treatments were performed as ordered on those dates.
Failure to Provide Ordered Foot Care and Podiatry Services
Penalty
Summary
A deficiency was identified when a resident with diagnoses including encephalopathy and ischemic cardiomyopathy, who was dependent on staff for care and had mild cognitive impairment, did not receive appropriate foot care as ordered. The resident had a physician's order for nursing staff to schedule a podiatry clinic visit for mycotic toenails, but there was no documented evidence that this was done. Observation revealed the resident's toenails were discolored, thick, long, and jagged, and the Director of Nursing confirmed the resident was not scheduled with the podiatrist despite the podiatrist being available weekly at the facility. This failure to provide the ordered foot care and schedule the resident for podiatry services resulted in the resident not receiving necessary treatment for their mycotic toenails.
Failure to Implement Restorative Nursing Programs for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to implement prescribed restorative nursing programs (RNP) to maintain or improve range of motion (ROM) for two residents with limited mobility. One resident with monoplegia, muscle weakness, and lack of coordination had an occupational therapy recommendation and physician's order for active assisted and passive ROM exercises for the upper extremities. Despite these orders, there was no evidence that staff provided the required RNP, as confirmed by the Director of Nursing and the Program Director of Rehabilitation. The resident was dependent on staff for activities of daily living and had cognitive impairment, with a noted limitation in upper extremity ROM. Another resident with diagnoses including atrial fibrillation and cauda equina syndrome was care planned for passive ROM exercises to the lower extremities. The resident reported that staff did not perform the exercises and that he would not refuse them if offered. Review of the RNP task flowsheet showed that the resident was not offered restorative ROM on 19 out of 30 days. The Director of Nursing confirmed the lack of documented evidence that the RNP was provided as required.
Unlocked and Unattended Medication Cart in Common Area
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were securely stored on one of twelve nursing units. According to the facility's policy, all compartments containing drugs and biologicals, including medication carts, must be locked when not in use and should not be left unattended if unlocked. However, observations on Tower 5 revealed that a medication cart was left unlocked and unattended in a common area, making it accessible to anyone in the vicinity during two separate observation periods on the same day.
Food Storage and Meal Distribution Lapses
Penalty
Summary
The facility failed to store food in a sanitary manner on two nursing units, Northwest 1 and Northwest 2. During observations, multiple food items in the nourishment room refrigerators and cabinets were found without proper labeling or dating, including packages of strawberries, blueberries, shrimp, crawfish tail meat, pepperoni, chili sauce, and bulk containers of cookies. Some items were labeled with use-by dates, but several perishable items lacked both resident names and dates, contrary to facility policy which requires perishable foods to be labeled with the resident's name, the item, and a use-by date. Staff confirmed that the nourishment rooms were intended for resident use only. Additionally, the facility failed to distribute resident meal trays in a sanitary manner on the Northeast 1 unit. An LPN was observed serving food while wearing the same gloves after touching door knobs, keypads, and her jacket, without changing gloves or performing hand hygiene between tasks. This practice was inconsistent with the facility's policy on standard precautions, which requires staff to change gloves and wash hands between resident contacts and tasks.
Failure to Implement Physician's Orders
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for one of the 37 sampled residents. Resident 5, who had diagnoses including acute cystitis without hematuria, Alzheimer's disease, and chronic kidney disease, was observed without the prescribed Darco Flat, roam alert bracelet, or chair alarm on multiple occasions. Specifically, on April 30, 2024, and May 1, 2024, Resident 5 was seen in his wheelchair in the dining room area without these prescribed items in place, despite the physician's order dated April 23, 2024.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to ensure adequate catheter care for a resident with an indwelling urinary catheter. The facility's policy required that the urinary drainage bag be positioned lower than the bladder at all times to prevent backflow and that the catheter tubing and drainage bag be kept off the floor. However, observations revealed multiple instances where these guidelines were not followed. On one occasion, the resident was seen in a wheelchair with the catheter drainage bag hanging on the armrest, above the level of the bladder. On another occasion, the catheter was observed on the mattress while the resident was in bed, and later, the catheter bag was placed directly on the floor. Additionally, a registered nurse and a nurse aide were observed placing the catheter bag on the resident's lap and wheelchair armrest, respectively, both of which were above the bladder level. The resident involved had diagnoses including acute cystitis without hematuria, Alzheimer's disease, chronic kidney disease, and urine retention. The physician had ordered a Foley catheter for the resident every shift. Despite this, the facility staff failed to maintain the proper positioning of the catheter drainage bag, as evidenced by multiple observations over two days. These actions were in direct violation of the facility's urinary catheter care policy and contributed to the deficiency noted in the report.
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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