Northern Dauphin Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Millersburg, Pennsylvania.
- Location
- 990 Medical Road, Millersburg, Pennsylvania 17061
- CMS Provider Number
- 395428
- Inspections on file
- 36
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Northern Dauphin Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to ensure proper administration and documentation of controlled substances for multiple residents, resulting in missed doses, incorrect medication administration, and inaccurate records. An LPN was found to have signed out medications at times she was not present, and several residents reported not receiving pain medication as documented. Facility leadership confirmed that documentation practices did not align with policy requirements.
A resident with a psychiatric history attacked another resident with a pen, causing multiple skin tears and penetrating wounds to the head and neck. The incident occurred after both attended a group activity, with no prior altercation observed. Staff intervened upon hearing calls for help, separated the residents, and provided immediate wound care. The facility failed to prevent abuse, resulting in actual harm.
Several residents dependent on staff for ADL support did not consistently receive scheduled showers or grooming, such as shaving, as outlined in their care plans and facility policy. Observations revealed residents with unaddressed facial hair and missed showers, with no documentation of refusals or re-approach attempts. Facility leadership confirmed that hygiene care should be provided as scheduled and refusals documented, but records did not reflect this practice.
The facility did not consistently monitor and document resident weights as ordered, nor did it notify physicians of significant weight loss in several cases. For example, a resident with diabetes and dysphagia did not have weekly weights obtained due to a missed order entry, while other residents with dementia and muscle weakness experienced significant weight loss without physician notification or proper documentation of weekly weights. These failures were confirmed by the NHA, who acknowledged lapses in expected monitoring and communication procedures.
Two residents did not receive timely dental care as required by facility policy. One resident, after oral surgery and becoming edentulous, was not fitted for dentures despite documented chewing difficulties and weight loss. Another resident with loose teeth repeatedly requested dental care and was added to the dental list multiple times, but was not seen by a dentist. These failures resulted in unmet dental needs for both residents.
The facility did not offer or document education on the most recent COVID-19 vaccine for several residents, with some only having received a previous season's vaccine and one lacking any record of being offered or receiving a COVID-19 vaccine. The Infection Preventionist/Assistant DON confirmed the lapse, and the Administrator was informed but provided no further details.
Three residents experienced failures in receiving timely and appropriate care according to physician orders and their preferences. One resident waited months for an orthopedic consult despite ongoing requests, another did not have a GI consult or lab work scheduled as ordered, and a third missed multiple medication doses without physician notification or proper documentation. These deficiencies resulted from lapses in follow-up, order transcription, and adherence to medication administration policies.
The facility did not ensure that monthly medication regimen reviews by a consultant pharmacist were addressed in a timely manner by physicians for two residents with mental health diagnoses. Pharmacy recommendations regarding medication changes were either not responded to or were significantly delayed, and facility policy lacked a specified timeframe for physician response.
Surveyors found that food and beverage items in both nourishment pantries were not properly labeled with resident identifiers or date marked after opening, as required by facility policy. Staff confirmed that these items should have been labeled and dated to ensure food safety.
A resident with a history of hypokalemia and hyperlipidemia developed a sacral wound that progressed to an unstageable pressure ulcer. The prescribed wound care regimen, including cleansing and application of medical grade honey and calcium alginate, was not documented as completed on two occasions, with no explanation provided for the missing documentation.
The facility did not meet the required nurse aide staffing ratios from December 14 to December 20, 2024, across multiple shifts. The day, evening, and night shifts were consistently understaffed, with the number of NAs falling short of the mandated ratios for the resident census. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to meet the required minimum staffing levels for LPNs across multiple shifts. On several occasions, the number of LPNs on duty was below the required ratio for the number of residents present. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide the required 3.2 hours of direct nursing care per resident per day for six out of seven days reviewed. The lowest recorded was 2.14 hours. This was confirmed by the Nursing Home Administrator.
A resident with heart failure and chronic kidney disease fell in the bathroom, resulting in a facial hematoma and hospital transport. Despite a care plan requiring 15-minute checks and assistance with transfers, the resident was found alone, indicating a failure to provide adequate supervision and adhere to the care plan.
The facility failed to provide sufficient nursing staff, impacting the care of several residents, as evidenced by missed showers and staff testimonies. Residents with conditions like dementia, CKD, and hypertension did not receive scheduled showers, and staff reported feeling understaffed, particularly during the second shift. The Nursing Home Administrator was unaware of the documentation issues, indicating a need for better training.
A resident with heart failure and major depressive disorder experienced a fall, prompting a request for a UA C&S due to a history of UTIs. Despite an order issued on November 4, the test was not collected until November 22, resulting in a delayed UTI diagnosis. The Nursing Home Administrator acknowledged the test should have been obtained sooner.
A resident with neurocognitive and bipolar disorders was monitored using a video baby monitor without proper authorization or consent, breaching privacy and confidentiality. The monitor was used instead of 1:1 supervision, with no physician orders or consent from the resident's guardian. The facility also failed to inform the resident's roommate about the monitor, highlighting a systemic issue in maintaining privacy.
The facility consistently failed to meet state-mandated staffing requirements for NAs and LPNs across various shifts, as identified in multiple surveys from July 2023 to July 2024. The facility did not provide the required number of NAs per residents during day, evening, and overnight shifts, nor did it meet the required nursing care hours per resident per 24-hour period. These deficiencies indicate a pattern of insufficient staffing levels.
The facility failed to provide complete bed-hold policy notices to residents or their representatives during hospital transfers. One resident did not receive any notice, while three others received notices lacking bed reservation cost information. Interviews revealed that nursing staff were unaware of room rates, contributing to the omission.
The facility failed to involve two residents in their care planning process and did not update a care plan to reflect the use of plastic utensils for a resident with feeding difficulties. Despite diagnoses such as COPD and muscle weakness, the residents were not invited to their care plan meetings, and documentation was lacking. The oversight was confirmed through staff interviews, revealing a gap in the facility's process.
Two residents with pressure ulcers did not receive necessary care and treatment. One resident's wound care was not performed according to policy, and a dietary recommendation for increased protein was not followed. Another resident did not receive recommended nutritional supplements for malnutrition and wound healing. Facility staff confirmed the process for addressing dietary recommendations was inadequate.
A resident with hypertension and chronic respiratory failure fell from their bed while receiving assistance from one nurse aide. Despite an updated care plan requiring two-person assistance for bed mobility, the resident continued to receive help from only one person on several occasions. The Nursing Home Administrator acknowledged this discrepancy.
The facility failed to meet professional standards for food storage and equipment use, with undated food items found in the kitchen and nourishment areas, and soiled equipment including a refrigerator and ice machine. Staff interviews confirmed expectations for proper labeling and cleaning were not met.
Two residents experienced deficiencies in care due to failures in medication administration and documentation. One resident did not have blood pressure measured before receiving Metoprolol, despite physician orders, due to a transcription error. Another resident did not receive necessary lab tests and pain management due to incorrect order entry and lack of pain level parameters for medication administration.
A facility failed to assess a resident's ability to self-administer medication, as required by its policy. The resident had a physician's order to self-administer Voltaren gel for arthritis pain, but no assessment was documented. Interviews revealed the resident did not wish to self-administer, and the medications were removed from the bedside. The Regional Director of Clinical Services confirmed the lack of assessment and inappropriate medication storage.
A facility failed to ensure care according to professional standards for a resident with bipolar disorder and PTSD. Despite a psychiatry consult recommending a valproic acid level test for safe Depakote dosing, there was no documentation of the physician's review or an order for the test. The resident was hospitalized when the test was initially ordered, but hospital records did not show it was conducted.
Two residents with limited mobility did not receive prescribed mobility aids, such as hand splints and gerisleeves, as observed during multiple checks. Despite physician orders and care plans, staff inaccurately documented the application of these aids. The DON expected adherence to orders and accurate documentation.
The facility failed to monitor the nutritional status of two residents, leading to significant weight loss. One resident with dementia and diabetes was not weighed as required, while another with dementia and dysphagia experienced a 10% weight loss over six months without physician notification. Despite nutrition interventions, communication lapses contributed to these deficiencies.
The facility failed to provide proper respiratory care for two residents. One resident used oxygen for several days without a physician's order or dated tubing, and another resident's care plan to change and label oxygen tubing weekly was not followed. The DON confirmed the need for orders and proper dating of tubing.
A facility failed to maintain infection control practices by not posting a required precaution sign for a resident on contact precautions due to nasal MRSA. Despite a physician's order and care plan intervention, observations revealed the absence of signage on the resident's door. The DON confirmed the expectation for such signage, indicating a lapse in policy adherence.
The facility failed to provide appropriate care for several residents, including one with a specific order to avoid blood pressure measurements in a particular arm due to a graft, which was ignored multiple times. Additionally, four residents requiring two-person assist with mechanical lifts were often transferred with only one-person assist, contrary to their care plans. These actions indicate a significant deficiency in following prescribed care interventions.
Failure to Administer and Document Controlled Substances per Professional Standards
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for six of eight residents reviewed, specifically regarding the administration and documentation of controlled substances. Facility policy required medications to be administered safely, timely, and as prescribed, with proper documentation on the Medication Administration Record (MAR) and controlled substance records. However, multiple discrepancies were identified, including missed doses, administration of incorrect medications, and inaccurate or missing documentation. For example, one resident with chronic pain and osteoarthritis did not receive a scheduled dose of oxycodone and was instead given loratadine, an over-the-counter allergy medication, which was confirmed by pill identification and resident report. The MAR and controlled substance records showed signatures for medication administration at times when the responsible nurse was not present in the facility, and the nurse's own statement did not address the missed dose. Other residents with diagnoses such as COPD, diabetes, anxiety, and depression also experienced inconsistencies in the administration and documentation of their prescribed oxycodone. In several cases, the controlled substance records indicated that medication was dispensed and signed out by an LPN at times when she was not on duty, or the MAR did not reflect that the medication was given. Some residents reported not receiving pain medication despite records indicating otherwise, and in some instances, documentation was completed before or long after the medication was reportedly administered. Interviews with residents corroborated these discrepancies, with several stating they did not receive medication as documented or only took medication at specific times contrary to the records. The facility's own leadership acknowledged that controlled substances should be documented immediately after administration, not an hour or more later, and that every administration should be recorded. The investigation revealed a pattern of improper medication handling, including failure to follow policy for controlled substances, inaccurate recordkeeping, and administration errors. These failures were substantiated through policy review, clinical record review, facility investigation, and interviews with residents and staff.
Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in actual harm. A resident with a history of paranoid schizophrenia and anxiety disorder entered another resident's room and attacked her with a pen, causing multiple skin tears and penetrating wounds to the back of the head and neck. Staff responded to the incident after hearing yelling and separated the residents, finding the pen tip lodged in one of the wounds. The injured resident, who had hemiplegia and hemiparesis following a stroke, hypertension, and GERD, reported that the attacker followed her into her room, ignored her request to leave, and began the assault. Prior to the incident, both residents had attended a smoking club activity together, but staff and the residents themselves reported no interaction or altercation during the activity. Witness statements from staff confirmed that the attack was unprovoked and occurred shortly after the smoking club. Staff observed the aggressor holding the back of the victim's wheelchair and striking her in the head and neck with a pen. Immediate assessment and wound care were provided to the injured resident, who declined hospital transfer but received a tetanus shot the following day. Interviews with facility leadership indicated they were unaware of any prior issues between the two residents. The incident was reported and investigated, but the deficiency was cited due to the facility's failure to ensure residents were free from abuse, as required by policy. The event resulted in actual physical harm to the resident who was attacked.
Failure to Provide Adequate Personal Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain adequate personal grooming and hygiene for residents who were dependent on staff for assistance with activities of daily living (ADLs). Facility policy required that appropriate care and services, including hygiene such as bathing, grooming, and shaving, be provided in accordance with the resident's plan of care and preferences. However, multiple residents who required assistance did not consistently receive showers as scheduled, and there was a lack of documentation regarding refusals or alternative interventions. One resident with hemiplegia, contracture, and visual impairment reported a preference for showers and being shaved, but was observed with facial hair on multiple occasions and received bed baths instead of showers on several scheduled days, with no documentation of refusal. Another resident with muscle weakness and a need for personal care assistance was observed with significant facial hair and had not received a shower since a specified date, with no clear documentation of refusal or re-approach. A third resident with depression and hypertension reported not always receiving scheduled showers and instead receiving bed baths, with no documentation of refusals for the missed showers. A fourth resident, also requiring assistance with personal care, was observed with facial hair and had a care plan intervention for grooming, but there was no evidence that scheduled grooming was consistently provided. Interviews with facility leadership confirmed that personal hygiene care, including shaving, should be offered on shower days and as preferred by the resident, and that refusals should be documented with re-approach attempts. The clinical records and nurse aide documentation failed to show that these protocols were followed, resulting in unmet hygiene and grooming needs for the affected residents.
Failure to Monitor and Report Significant Weight Loss in Multiple Residents
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of residents' nutritional status, specifically regarding the monitoring of weights as ordered by physicians and timely notification of significant weight loss to physicians. Facility policy required residents to be weighed at intervals established by the interdisciplinary team, with significant weight changes to be evaluated and communicated to the physician and multidisciplinary team. However, for four residents, there were lapses in following these protocols, including missed weekly weight measurements and lack of physician notification after significant weight loss. One resident with multiple diagnoses, including diabetes, schizophrenia, and dysphagia, had an order for weekly weights due to prior weight loss, but these weights were not obtained or documented because the order was not entered into the electronic record. Another resident with dementia and dysphagia experienced a significant weight loss over a month, but there was no documentation that the physician was notified, and recommended weekly weights were not consistently obtained due to a transcription error. Additionally, a reweigh measure was missed in the dietitian's assessment because it was not properly recorded in the electronic health record. A third resident with dementia and muscle weakness had a significant weight loss, but again, there was no documentation of physician notification or evidence that weekly weights were obtained as ordered. The fourth resident, with bipolar disorder and dementia, experienced substantial weight loss over several months, but the clinical record did not show that the physician was notified of these changes. In all cases, interviews with the Nursing Home Administrator confirmed the lack of documentation and acknowledged that the expected procedures for monitoring and communication were not followed.
Failure to Provide Timely Dental Services to Residents
Penalty
Summary
The facility failed to assist residents in obtaining both routine and emergency dental care, as required by policy, for two residents. One resident, with a history of diabetes, schizophrenia, intellectual disabilities, and dysphagia, underwent oral surgery to remove several teeth and became edentulous. Despite being care planned for denture fitting and experiencing documented difficulty chewing and weight loss, the resident did not receive dentures in a timely manner. The delay was attributed to the lack of a consult for new dentures following surgery, and the timeframe from surgery to denture provision was considered excessive by facility staff. Another resident, diagnosed with depression and hypertension, reported having two loose top front teeth and repeatedly requested dental care. Although the care plan and physician orders indicated the need for a dental consult, and nursing notes documented ongoing requests to add the resident to the dental list, there was no evidence that the resident had been seen by a dentist. The resident continued to be added to the dental list over several months without receiving the necessary dental evaluation or treatment.
Failure to Offer and Document Current COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered the most current COVID-19 vaccinations as required. Facility policy and CDC guidance both require that residents be encouraged to stay up-to-date with COVID-19 vaccines, be provided with education about the vaccine, and have their vaccination status properly documented. Clinical record reviews for four residents showed that either the most recent COVID-19 vaccine (2024-2025) was not offered or there was no documentation of education or offer of the vaccine. Specifically, three residents had only received the Fall 2023 vaccine, and one resident had no documentation of ever being offered or receiving any COVID-19 vaccine. Further review of the clinical records for these residents did not reveal any evidence that they were educated on or offered the most recent COVID-19 vaccine. During an interview, the Infection Preventionist/Assistant DON confirmed the accuracy of the vaccination dates and was unable to explain why the most recent vaccines had not been offered. The Nursing Home Administrator was also made aware of the issue but did not provide additional information.
Failure to Provide Resident-Directed Care and Timely Implementation of Physician Orders
Penalty
Summary
The facility failed to provide resident-directed care and services in accordance with professional standards of practice and consistent with physician orders for three residents. For one resident with depression and hypertension, there was a significant delay in scheduling an orthopedic consult for bilateral knee flexion contractures. Despite the resident's ongoing requests and a physician order to schedule a second opinion, the appointment was not scheduled for five months. Documentation showed that the referral was sent, but follow-up was not conducted in a timely manner, resulting in the resident waiting an extended period for the consult. Another resident with dementia, lack of coordination, and muscle weakness had a physician order for a gastroenterology (GI) consult that was not scheduled for several months. Additionally, laboratory orders for CBC, CMP, and urinalysis were not completed as ordered, with documentation indicating that some orders were not properly transcribed or scheduled. There was also a failure to implement and document blood pressure monitoring every shift as ordered by the nurse practitioner, with no blood pressure readings recorded for an extended period despite an active order. A third resident with hyperlipidemia and hypertension did not receive medications as ordered, including Ambien, Patiromer Sorbitex Calcium, and Fondaparinux Sodium, on specific dates. The Medication Administration Record (MAR) was left blank or coded as held, and there was no evidence that the physician was notified of the missed doses. Interviews and documentation revealed that medications were either not available, not located, or not administered as scheduled, and staff did not follow facility policy regarding documentation and physician notification for missed or delayed doses.
Failure to Ensure Timely Physician Response to Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were completed by a consultant pharmacist and that recommendations were addressed by the attending physician or prescriber in a timely manner for two of five residents reviewed. Facility policy did not specify a required timeframe for physician response to pharmacy recommendations. For one resident with diagnoses including major depressive disorder, anxiety, and intellectual disabilities, pharmacy recommendations to discontinue as-needed ondansetron and to add amlodipine were documented, but there was no evidence of physician response or action taken on these recommendations. The resident's orders continued to include ondansetron and did not include amlodipine, and the facility was unable to provide proof of physician response. For another resident with major depressive disorder and anxiety, a pharmacy recommendation for a gradual dose reduction of mirtazapine was made during a medication regimen review, but the physician did not address this recommendation until more than two months later, after being prompted for a response. Staff interviews confirmed the expectation that physicians should review and respond to medication regimen reviews in a timely manner, but this did not occur for the residents in question.
Failure to Properly Label and Date Food and Beverages in Nourishment Pantries
Penalty
Summary
Surveyors identified that the facility failed to store and serve food and beverages in accordance with professional standards for food safety in both nourishment pantries. During observations, it was found that several food and beverage items, including containers of moderately thick water and prune juice, were open, partially used, and not date marked as required. Additionally, multiple food items such as boxes and metal containers with holiday decorations, a box of smoked sausages, and ice cream cones were found without resident identifiers or date markings. Facility policy requires all foods to be labeled, dated, and consumed by their safe use-by dates, and for food and beverages from outside sources to be labeled with the resident's name, room number, and date. Interviews with the Food Service Director and the Nursing Home Administrator confirmed that the observed items should have been date marked and labeled with resident identifiers, in accordance with facility policy. The failure to properly label and date mark these items was acknowledged by staff during the survey, and the deficiency was cited under 28 Pa code 211.6(f) - Dietary Services.
Failure to Consistently Document and Administer Ordered Pressure Ulcer Treatment
Penalty
Summary
A resident with diagnoses including hypokalemia and hyperlipidemia developed incontinence associated dermatitis (IAD) on the sacrum, which was later identified as an unstageable pressure ulcer. The wound clinic provided a treatment plan that included daily cleansing with soap and water, patting dry, and applying medical grade honey, calcium alginate, and bordered gauze. A physician's order for this treatment was documented in the Medication Administration Record (MAR) with specific instructions for daily and as-needed application. Review of the resident's MAR revealed that the required wound care treatment was not documented as completed on two separate dates, as the corresponding boxes were left blank. During an interview, the Nursing Home Administrator was unable to explain the lack of documentation for these dates and stated that staff are expected to document after completing treatments. The failure to ensure consistent documentation and administration of ordered wound care treatments led to the deficiency.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for nurse aides (NAs) across multiple shifts from December 14 to December 20, 2024. Specifically, the facility did not provide the mandated number of NAs per resident during the day, evening, and night shifts. On December 14, the evening shift had 165 residents but only 13.67 NAs, falling short of the required 15.0 NAs. Similar deficiencies were noted on December 15, with both day and evening shifts understaffed, and on December 16, where the evening shift again did not meet the required staffing ratio. The issue persisted throughout the week, with the evening and night shifts on December 17, the evening shift on December 18, and the evening shift on December 19 all failing to meet the required NA-to-resident ratios. On December 20, all three shifts were understaffed, with the day shift having 13.33 NAs for 164 residents, the evening shift having 6.33 NAs, and the night shift having 6.57 NAs, all below the required ratios. The Nursing Home Administrator confirmed the facility's failure to meet staffing requirements during an electronic communication on December 24, 2024.
Plan Of Correction
1. CNA ratio noted to be deficient cannot be corrected as this is a past event. 2. CNA schedules will be monitored daily to ensure scheduled staff meet projected ratio requirement by the Scheduler and DON/Designee. 3. Re-education to Scheduler and Nursing Administrative Staff regarding the required ratio to be completed. Facility is increasing its presence with advertising on social media in regard to promoting/advertising open positions and vetting applicants; Agency rate has been increased and shift bonus being offered. HR attends job fairs as they are available. Tuition reimbursement and referral bonus are all in place as incentive for recruiting and committal purposes. 4. Ratio will be audited by DON/designee daily x4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results provided to QAPI. Date of compliance 02/04/2025.
LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) across multiple shifts from December 14 to December 20, 2024. Specifically, on December 14, the day shift had 165 residents with only 4.75 LPNs, falling short of the required 6.60 LPNs. The evening shift on the same day had 5.28 LPNs instead of the required 5.50 for 165 residents, and the night shift had 3.03 LPNs instead of 4.13. Similar deficiencies were noted on December 15, 17, 19, and 20, with the night shifts consistently understaffed. On December 19, the night shift had 166 residents with 4.09 LPNs, not meeting the required 4.15. On December 20, the evening shift had 4.81 LPNs for 164 residents, below the required 4.17, and the night shift had 3.31 LPNs instead of 4.10. The Nursing Home Administrator confirmed the facility's failure to meet staffing requirements during an electronic communication on December 24, 2024.
Plan Of Correction
1. LPN ratio noted to be deficient cannot be corrected as this is a past event. 2. LPN schedules will be monitored daily to ensure scheduled staff meet projected ratio requirement by the Scheduler and DON/Designee. 3. Re-education to Scheduler and Nursing Administrative Staff regarding the required ratio to be completed. Facility is increasing its presence with advertising on social media in regard to promoting/advertising open positions and vetting applicants; Agency rate has been increased and shift bonus being offered. HR attends job fairs as they are available. Tuition reimbursement and referral bonus are all in place as incentive for recruiting and committal purposes. 4. Ratio will be audited by DON/designee daily x4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results provided to QAPI. Date of compliance 02/04/2025.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for six out of seven days reviewed. Specifically, on December 14, 15, 16, 17, 19, and 20, 2024, the facility provided less than the required hours, with the lowest being 2.14 hours on December 10. This deficiency was confirmed during an electronic communication with the Nursing Home Administrator on December 24, 2024, at 9:00 AM, where it was acknowledged that the facility did not meet the staffing requirements.
Plan Of Correction
1. Minimum required 3.20 hours of direct patient care noted to be deficient cannot be corrected as this is a past event. 2. PPD will be calculated in advance and updated daily based on census to ensure facility is meeting PPD requirement by the Scheduler and DON/Designee. 3. Re-education to Scheduler and Nursing Administrative Staff regarding the required PPD to be completed. Facility is increasing its presence with advertising on social media in regards to promoting/advertising open positions and vetting applicants; Agency rate has been increased and shift bonus being offered. HR attends job fairs as they are available. Tuition reimbursement and referral bonus are all in place as incentive for recruiting and committal purposes. 4. PPD will be audited by DON/designee daily x4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results provided to QAPI. Date of compliance 02/04/2025.
Failure to Prevent Accident Hazards for a Resident
Penalty
Summary
The facility failed to prevent accident hazards for one of the residents, identified as Resident 2, who had a history of heart failure and chronic kidney disease. On November 1, 2024, Resident 2 was found lying face down in the bathroom by a nurse aide after a fall, which resulted in a hematoma to the face and required hospital transport. The incident occurred despite the resident's care plan, which included interventions such as 15-minute checks and assistance with transfers and ambulation to prevent falls. The care plan for Resident 2 also specified that the resident required staff participation for toilet use and assistance with a rolling walker and two-person support for transfers. However, the clinical record indicated that Resident 2 needed varying levels of assistance for toilet use, ranging from limited to total staff dependence. During an interview, the Nursing Home Administrator stated that staff should have stayed with Resident 2 in the bathroom until assistance was no longer needed, highlighting a failure to adhere to the care plan and provide adequate supervision.
Plan Of Correction
1. This event is unable to be corrected as it is a past event. 2. Audit of residents on frequent monitoring for falls to ensure supervision in bathroom is care planned. Audit of ADL and Fall Care Plans completed to ensure level of assistance with ADLs is current and reflected on Kardex. 3. Education provided to nursing staff that residents on frequent monitoring for falls to be supervised while in bathroom. Education being provided to nursing, therapy and MDS staff to ensure understanding of updating care plans when issue has been resolved. 4. Daily audit Monday - Friday of fall investigation(s) completed x4 weeks; then 3x per week for 2 weeks; then monthly x2 months to ensure ADL assistance was provided per care plan by DON or designee, results to QAPI. Date of compliance 01/14/2025.
Insufficient Nursing Staff Leads to Missed Care
Penalty
Summary
The facility was found to have insufficient nursing staff to provide necessary personal care and related services, impacting the well-being of seven residents. Interviews with nursing aides revealed that they often felt understaffed, particularly during the second shift, which affected their ability to provide adequate care, including scheduled showers for residents. This staffing issue was corroborated by resident interviews, where concerns were raised about the lack of staff to provide adequate care. Clinical record reviews for the affected residents showed that scheduled shower tasks were not completed as planned. For instance, Resident 5, diagnosed with dementia and depression, did not receive a shower on a scheduled day, as indicated by the 'not applicable' marking in their records. Similar patterns were observed for other residents, such as Resident 6, who missed showers on multiple occasions, and Resident 7, who did not receive a shower on a scheduled day. These lapses in care were consistent across several residents, all of whom had specific medical conditions requiring regular attention. The Nursing Home Administrator was unaware of why staff marked 'not applicable' instead of 'refused' for missed showers, indicating a lack of clarity or training in documentation practices. The administrator acknowledged the issue and mentioned plans to educate staff on proper documentation. However, the report focuses on the deficiency in staffing and its direct impact on resident care, as evidenced by the missed showers and staff and resident testimonies.
Plan Of Correction
1. This event cannot be corrected as it is a past event. 2. Unit Managers have assumed responsibility of providing CNA's at the start of each shift their shower assignment and the nurse assigned to the hallway must ensure showers were provided and documented appropriately; calculation of shift CNA deployment will be completed daily for accuracy by the DON/Designee. 3. Nursing education provided on the responsibilities of meeting the highest practicable residents' physical, mental and psychosocial needs; education provided to Nursing Administration regarding monitoring appropriate CNA deployment on each shift. Education provided to On-Call Manager, RN Supervisor and Scheduler to review steps to be taken when call offs; Utilization of a new external recruiting group for hiring purposes, increased agency rates, tuition reimbursement, referral bonus and incentive bonus' offered all designed to assist the facility in meeting the needs of the residents. 4. 10 random shower audits on off shifts completed weekly x4 weeks, then monthly x2. CNA deployment will be audited by DON/designee daily x4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results provided to QAPI. Date of compliance 01/14/2025.
Failure to Obtain Timely Laboratory Services
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident diagnosed with heart failure and major depressive disorder. The resident experienced a fall on November 1, 2024, and a urine sample was requested due to a history of urinary tract infections (UTIs). An interdisciplinary team reviewed the fall incident on November 4, 2024, and a new order was issued to obtain a urine analysis and culture sensitivity test (UA C&S) to rule out infection as a cause of the fall and increased behavior. Despite the order, the UA C&S was not collected until November 22, 2024, after a physician/nurse practitioner noted on November 21, 2024, that the test was needed due to dysuria. The delay in obtaining the urine sample resulted in a positive UTI diagnosis. During an interview, the Nursing Home Administrator expressed that the UA C&S should have been obtained earlier. This deficiency highlights the facility's failure to provide timely laboratory services as required.
Plan Of Correction
1. This event is unable to be corrected as it is a past event. U/A was obtained. 2. Nursing notes audited for past 14 days to ensure any lab requests had timely follow up from physician and orders entered into PCC for collection. 3. Re-education provided to licensed staff on antibiotic stewardship and s/s of UTI. Education provided to nursing staff to ensure orders requested have been addressed by MD and orders entered as indicated. Education provided to physicians on the importance of providing follow up to nursing request(s). 4. Audit daily Monday-Friday of progress notes for lab requests and if order obtained by MD and entered into PCC for collection x2 weeks; then 3x per week for 2 weeks; then monthly x2 months by DON or designee. Results to QAPI. Date of compliance 01/14/2025.
Unauthorized Video Monitoring Breaches Resident Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident by placing a video baby monitor in the resident's room without proper authorization or consent. The resident, who was admitted with frontotemporal neurocognitive disorder and bipolar disorder, was supposed to be under 1:1 monitoring. However, instead of providing direct supervision, the facility used a baby monitor to observe the resident, with the camera placed in the resident's room and the monitor kept at the nurse's desk or on the medication cart. This action was taken without any physician orders for video monitoring or 1:1 supervision, and without obtaining written consent from the resident's guardian. Additionally, the facility did not inform the resident's roommate or their representative about the presence of the video monitor in the shared room. Interviews with multiple employees revealed a lack of awareness regarding the authorization for 1:1 monitoring and the use of the video monitor. The Nursing Home Administrator confirmed the use of the baby monitor for the resident when they were in their room, indicating a systemic issue in maintaining resident privacy and confidentiality as required by federal and state laws.
Facility Fails to Meet Staffing Requirements
Penalty
Summary
The facility was found to be non-compliant with state-mandated minimum staffing requirements for nursing staff, as outlined in the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations. The deficiencies were identified through multiple surveys conducted between July 2023 and July 2024. The facility consistently failed to provide the required number of nurse aides (NAs) and licensed practical nurses (LPNs) across various shifts, including day, evening, and overnight shifts. These failures were documented on numerous occasions, indicating a pattern of insufficient staffing levels. Specifically, the facility did not meet the minimum requirement of one NA per 12 residents during the day and evening shifts, and one NA per 20 residents overnight, as mandated from July 1, 2023. Additionally, the facility failed to provide the required number of LPNs per residents during different shifts, with specific shortfalls noted in the surveys. The facility also did not meet the required total number of nursing care hours per resident per 24-hour period, which was set at a minimum of 2.87 hours from July 1, 2023, and increased to 3.2 hours from July 1, 2024. These deficiencies were observed over several survey periods, with specific dates and instances of non-compliance detailed in the report. The repeated failure to meet staffing requirements suggests systemic issues in maintaining adequate staffing levels to ensure proper care for residents. The report does not provide details on any corrective actions taken by the facility to address these deficiencies.
Failure to Provide Complete Bed-Hold Policy Notices
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to residents or their representatives at the time of hospital transfer, as required. This deficiency was identified for one resident who did not receive any notice and for three other residents whose notices did not include the required information about bed reservation costs. Specifically, Resident 9 was transferred to the hospital without receiving the bed-hold notice, while Residents 3, 4, and 136 received notices that omitted the cost of reserving their beds. The clinical records of the affected residents revealed various medical conditions, including hypertension, anxiety disorder, atrial fibrillation, intellectual disability, aphasia, epilepsy, end-stage renal disease, and others. Interviews with the Nursing Home Administrator and other staff indicated that the nursing staff was responsible for generating the bed-hold notices but were not aware of room rates, which contributed to the omission of cost information. The Business Office Manager was identified as the point of contact for questions regarding room rates, but there was no confirmation that all residents or their representatives were informed about the bed-hold reserve payments.
Failure to Involve Residents in Care Planning and Update Care Plans
Penalty
Summary
The facility failed to ensure residents' rights to participate in the care planning process and did not review and revise the care plans for two residents. Resident 10, diagnosed with left hand contracture, COPD, and muscle weakness, was not invited to her care plan meetings, as confirmed by her interview and the absence of documentation in her clinical record. Although her representative was invited to one meeting via letter, there was no evidence that the resident herself was invited to any meetings. Similarly, Resident 125, with diagnoses including muscle weakness, feeding difficulties, and COPD, was also not invited to his care plan meetings. His clinical record lacked documentation of invitations, and while his representative was invited to one meeting, the resident was not directly informed. Additionally, the facility did not update Resident 125's care plan to reflect the use of plastic utensils for meals, which was necessary due to his poor fine motor skills. This oversight was noted despite the presence of physician orders and therapy progress reports indicating the need for plastic utensils to aid in self-feeding. Interviews with the Nursing Home Administrator and other staff confirmed the lack of documentation and communication regarding the residents' participation in care plan meetings, highlighting a gap in the facility's process for involving residents in their care planning.
Failure to Provide Adequate Pressure Ulcer Care and Nutritional Support
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for two residents. For one resident with multiple sclerosis and quadriplegia, a stage 3 pressure ulcer was identified, and the prescribed wound care was not performed according to facility policy. During a dressing change, an employee did not follow the correct procedure of removing gloves, washing hands, and applying new gloves between removing the old dressing and cleansing the wound. Additionally, a dietary recommendation for increased protein intake to aid in wound healing was not followed through with a physician's order. Another resident, who was admitted with severe protein-calorie malnutrition, dementia, a stage 2 pressure ulcer, and a deep tissue injury, did not receive the recommended nutritional supplements. The dietician had recommended obtaining a physician's order for Vitamin C, Zinc, and a multivitamin to address the resident's nutritional needs and support wound healing. However, there was no evidence that these recommendations were communicated to or acted upon by the resident's physician. Interviews with facility staff, including the Nursing Home Administrator and Director of Nursing, confirmed that the facility's process for addressing dietary recommendations was inadequate. The dietician's recommendations were supposed to be emailed to nursing staff for follow-up with the physician, but this process failed, resulting in the residents not receiving the necessary care and treatment for their pressure ulcers.
Failure to Provide Adequate Bed Mobility Assistance
Penalty
Summary
The facility failed to provide adequate interventions to prevent accidents for a resident with diagnoses of hypertension and chronic respiratory failure. The resident experienced a fall from their bed while receiving bathing assistance from one nurse aide. Following the fall, the resident's care plan was updated to require assistance from two staff members for bed mobility. However, the resident continued to receive bed mobility assistance from only one person on multiple occasions in June and July 2024. This inconsistency in following the care plan was acknowledged by the Nursing Home Administrator during an interview.
Deficiencies in Food Storage and Equipment Utilization
Penalty
Summary
The facility failed to adhere to professional standards for food storage and equipment utilization in the main kitchen, nourishment areas, and a medication storage area. Observations revealed multiple instances of undated food items, including bags of cut ziti, hamburger buns, sliced bread, cookies, oatmeal cream pies, instant vanilla pudding, and fudge brownie mix in the dry storage area. Additionally, the reach-in refrigerator was heavily soiled with a dead housefly present. Open food items such as bread, peanut butter, instant mashed potatoes, and various spices were not dated with an open date. The ice machine in the main kitchen had a fuzzy grey substance surrounding the vent and a black substance inside. The walk-in freezer contained undated meat items, and the second-floor nourishment area lacked an air gap between the floor drain and the ice machine drain. Further deficiencies were noted in the labeling and dating of food from outside sources. The second-floor nourishment area refrigerator contained undated items such as soup, a deli sandwich, fruit, a meat and cheese platter, and a prepared meal. The first-floor nourishment area refrigerator had undated cheese slices and an open container of thickened apple juice without an open date. The second-floor medication room nourishment refrigerator also contained undated food items from outside sources. Interviews with staff, including a Dietary Aide, Registered Nurse, and Dietary Manager, confirmed the facility's expectations for proper labeling, dating, and cleaning of food items and equipment, which were not met according to the observations.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for two residents. For Resident 10, who had diagnoses including atrial fibrillation and COPD, there was a failure to implement a pharmacy recommendation to measure blood pressure before administering Metoprolol. Despite a recommendation signed by the physician, blood pressure measurements were not documented, and the medication was administered even when the resident's systolic blood pressure was below the prescribed threshold. This issue was attributed to a transcription error that did not prompt nursing staff to take the necessary blood pressure measurements. Resident 136, who had multiple diagnoses including urinary retention and mild cognitive impairment, experienced a failure in obtaining necessary lab tests and pain management. After a urology appointment, the resident was supposed to have blood work and a urine test, which were not completed due to incorrect order entry into the electronic health record. Additionally, upon returning from the hospital, the resident did not receive the prescribed pain medication, Tramadol, and there was a lack of pain level parameters for administering acetaminophen and oxycodone, leading to inadequate pain management. Interviews with facility staff, including the Regional Director of Clinical Services and the Director of Nursing, revealed expectations that physician orders should be entered correctly and followed. The Nursing Home Administrator acknowledged that pain level parameters should have been included in the medication orders. These deficiencies highlight lapses in medication administration and documentation, as well as in the execution of physician orders, impacting the quality of care provided to the residents.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to determine the clinical appropriateness of a resident's right to self-administer medications. The facility's policy requires an interdisciplinary team to assess a resident's mental and physical abilities to ensure it is safe for them to self-administer medications. However, for one resident, this assessment was not conducted. The resident had a physician's order to self-administer Voltaren gel for arthritis pain, but there was no documented assessment in the clinical record to support this decision. During interviews with facility staff, it was revealed that the resident did not wish to self-administer the medication, and the medications were subsequently removed from the resident's bedside. The Regional Director of Clinical Services confirmed that no self-administration assessment had been completed, and the medications should not have been left at the bedside. This oversight indicates a failure to adhere to the facility's policy regarding self-administration of medications.
Failure to Follow Psychiatry Consult Recommendations
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for Resident 96, who has diagnoses of bipolar disorder and PTSD. The resident had a physician's order for Depakote, a medication used to treat bipolar disorder, but there was a lack of follow-through on a psychiatry consult recommendation for a valproic acid level test. This test is necessary to ensure safe dosing of Depakote. The consult was dated June 14, 2024, but there was no documentation that the resident's physician reviewed the recommendation or that an order for the test was made. During an interview, the Regional Director of Clinical Services acknowledged the absence of documentation showing the physician's review of the psychiatry consult. It was also noted that an order for the lab test was made in May 2024, but the resident was hospitalized at that time, and the hospital records did not indicate that the test was conducted. This oversight resulted in the failure to meet the resident's physical, mental, and psychosocial needs as per professional standards.
Failure to Provide Prescribed Mobility Aids
Penalty
Summary
The facility failed to ensure that residents with limited mobility received appropriate services and assistance to maintain or improve their mobility. Specifically, Resident 10, who has a left hand contracture, COPD, and muscle weakness, was observed multiple times without the prescribed c grip hand splint, despite physician orders and care plan interventions indicating it should be worn during AM cares. Nurse aide documentation inaccurately reflected that the splint was in place, and Resident 10 confirmed she does not wear a hand splint. The Director of Nursing (DON) acknowledged the expectation for physician orders to be followed and for staff to accurately document the application of the splint. Similarly, Resident 84, diagnosed with dementia and muscle weakness, was observed without the prescribed left resting hand splint and gerisleeves, which were ordered to be worn during AM cares. Nurse aide documentation incorrectly indicated that these devices were in place. The DON reiterated the expectation for adherence to physician orders and accurate documentation. These findings demonstrate a failure in providing necessary equipment and assistance to residents with limited mobility, as required by the facility's policies and physician directives.
Failure to Monitor Nutritional Status and Notify Physician of Weight Loss
Penalty
Summary
The facility failed to ensure proper monitoring of nutritional status for two residents, leading to significant weight loss. Resident 47, diagnosed with dementia and Type 2 Diabetes Mellitus, experienced a significant weight loss of 11.1% over 180 days, which increased to 13% over the same period. Despite an order for monthly weights, Resident 47 was not weighed in July 2024, as confirmed by the Nursing Home Administrator. This lack of monitoring indicates a failure to adhere to the facility's policy on weight assessment and intervention. Resident 81, who has dementia, dysphagia, and feeding difficulties, also experienced significant weight loss. The resident's weight dropped from 108.5 pounds in January 2024 to 97.9 pounds by July 2024, a 10% loss over six months. Although nutrition interventions were in place, the facility failed to notify the physician of this significant weight loss. Interviews with the Regional Nurse Manager and the Director of Nursing revealed an expectation for nursing staff to notify the physician, which was not met. Additionally, a weight warning note was missed in February 2024, indicating a lapse in communication and documentation.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents. Resident 57, diagnosed with peripheral vascular disease and hypertension, was observed using oxygen without a physician's order or a dated oxygen tubing. The resident had been using oxygen for four days, but the clinical record only showed a nursing note indicating supplemental oxygen was applied with positive effect. An order for oxygen was not documented until five days after the resident began using it, and there was no order to change the oxygen tubing. Similarly, Resident 397, who has hypertension and dementia, was observed using oxygen without a date on the tubing. Although there was a physician's order for oxygen, there was no order for changing the oxygen tubing. The resident's care plan included an intervention to change and label the oxygen tubing weekly, but this was not followed. The Director of Nursing confirmed that both residents should have had orders for their oxygen tubing to be changed weekly and that the tubing should be dated.
Failure to Post Precaution Sign for Resident on Contact Precautions
Penalty
Summary
The facility failed to maintain infection control practices to prevent the spread of infection for a resident reviewed for infection control. The facility's policy on Isolation - Multi Route Transmission-Based Precautions requires appropriate notification to be placed on the room entrance door and in front of the chart when a resident is placed on transmission-based precautions. Resident 17, who has diagnoses including chronic atrial fibrillation and hypertension, had a physician's order for contact precautions due to nasal MRSA, with an active date of May 24, 2024. Despite this, observations on multiple days in July 2024 revealed that no enhanced barrier precaution sign was posted on Resident 17's door. The Director of Nursing confirmed that the resident was on transmission-based precautions and expected signage to be posted, indicating a lapse in following the facility's infection control policy.
Failure to Adhere to Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for five of ten residents reviewed. Resident 5, who had a medical history of hypertension and peripheral vascular disease, had a physician's order specifying no blood pressure should be taken in the left arm due to a previous graft. Despite this, the resident's blood pressure was taken in the left arm multiple times over a period of several weeks, as documented in the clinical records. The resident reported an incident where a nurse attempted to take blood pressure from the left arm, despite the resident's protest, indicating a lack of adherence to medical orders. Residents 7, 8, 9, and 10, all of whom had specific care plans requiring a two-person assist with a mechanical lift for transfers, were documented as being transferred with only a one-person physical assist on multiple occasions. This discrepancy between the care plan and the actual care provided suggests a failure to follow the prescribed care interventions, potentially compromising the residents' safety and well-being. The clinical records for these residents showed repeated instances where the documented care did not align with the care plan requirements. The Nursing Home Administrator acknowledged the issue, attributing the discrepancies in documentation to potential errors in staff recording. However, the repeated nature of these documentation errors across multiple residents indicates a systemic issue in ensuring that care plans are accurately followed and documented. The facility's failure to adhere to physician orders and care plans for these residents represents a significant deficiency in providing appropriate treatment and care according to orders, residents' preferences, and goals.
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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