Nottingham Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Northumberland, Pennsylvania.
- Location
- 58 Neitz Road, Northumberland, Pennsylvania 17857
- CMS Provider Number
- 395390
- Inspections on file
- 22
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Nottingham Village during CMS and state inspections, most recent first.
A resident at Nottingham Village experienced inadequate pain management following a fall, despite having severe injuries and a pain assessment indicating significant discomfort. The facility did not follow its pain management policy, failing to administer prescribed medication or conduct further pain assessments. Interviews confirmed these deficiencies.
The facility did not maintain hazardous area enclosures as required, with unsealed wall penetrations around three copper pipes in the Soiled Utility area on Unit 3. This deficiency was confirmed during an exit interview with the Facility Administrator.
The facility failed to maintain the required sprinkler systems, affecting multiple smoke compartments. Observations revealed an unsealed penetration in the ceiling of the Environmental Service Room, a gap around a sprinkler escutcheon at the Nurse's Station, and a missing escutcheon in the Walk-In freezer. These issues were confirmed with the Facility Administrator.
The facility failed to maintain corridor door integrity, affecting one floor. Observations revealed that a door to a resident room was not smoke tight, and another door failed to latch properly. These deficiencies were confirmed during an exit interview with the Facility Administrator.
The facility failed to maintain a smoke barrier separation wall, affecting two smoke compartments. An observation revealed that the attic level smoke barrier separation wall door was not smoke tight when closed into the frame inside the Dietary storage area. This deficiency was confirmed during an exit interview with the Facility Administrator.
The facility failed to meet NFPA 101 standards for exits, as observed in one of ten smoke compartments. The basement level lacked two acceptable means of egress, a deficiency confirmed during an interview with the Facility Administrator.
The facility failed to assess the need for, obtain consent for, and evaluate entrapment risks of bed assistive bars for two residents. Observations revealed the presence of assist bars without proper documentation or consent. The Nursing Home Administrator confirmed the lack of necessary assessments and consent for the devices.
A resident with natural teeth did not receive routine prophylactic dental services, as confirmed by interviews and clinical record reviews. Despite a dental exam noting significant plaque buildup and recommending cleanings every six months, there was no evidence of such services being provided in the past year.
The facility's main kitchen had several deficiencies in food storage and sanitation, including expired food items, improper storage conditions, and unclean equipment. Observations revealed issues such as a hole in a macaroni bag, expired rosemary and blue food coloring, and ice accumulation on food boxes in the freezer. Additionally, orange juice and other food items were not used within required timeframes, and clean items were not protected from contamination. An employee was also seen without a beard guard in a food prep area.
The facility's arbitration agreements failed to ensure a neutral and fair process for three residents, as the agreements allowed the facility to select the arbitrator unless their chosen arbitrator was unavailable. This deficiency was confirmed through a review of the agreements and interviews with the Nursing Home Administrator and DON.
A facility failed to implement transmission-based precautions for a resident with a UTI caused by an ESBL E-Coli, an MDRO. Despite the laboratory report indicating the presence of this MDRO, the facility did not initiate contact or enhanced barrier precautions as required by their policies. Observations and interviews confirmed the lack of isolation measures and the resident's dependency on staff for care without using necessary precautions.
A facility failed to offer and document the administration or refusal of an influenza vaccine for a resident during the 2024-2025 season. Despite the facility's policy requiring annual vaccination offers and documentation, there was no evidence of the vaccine being administered or declined. Interviews confirmed the absence of necessary documentation and contact with the resident's responsible party.
A resident did not receive a COVID-19 booster due to a lack of documented consent refusal from their responsible party. The facility's policy requires offering the vaccine and documenting consent or refusal, but no such documentation was found. Interviews confirmed the resident had not received any COVID vaccines since admission, and attempts to contact the responsible party were inadequately documented.
A resident with hemiparesis following a cerebral infarction was unable to reach her call bell due to its placement at the head of her bed, which was not accessible given her limited range of motion. This deficiency was observed and discussed with facility leadership.
A resident sustained a tibial plateau fracture and ligamentous knee injury, but the facility failed to investigate the cause of the injury as required by their abuse policy. Despite the resident's complaints of pain and subsequent medical findings, there was no documentation on how the injury occurred, and the DON confirmed the lack of investigation.
The facility inaccurately assessed two residents' conditions in their MDS. One resident with hemiparesis was incorrectly noted as having no upper extremity impairment, and another resident's discharge status was wrongly recorded as to a hospital instead of home. These errors were confirmed by the DON.
A facility failed to document and plan for a resident's cardiac pacemaker use. The resident, with a history of heart disease, indicated that her pacemaker alerts the facility to fluid accumulation, affecting her Lasix medication. However, her records lacked physician orders or a care plan for the pacemaker. The facility was unaware of the device's communication method or emergency procedures, and the device was not included in her care plan.
A facility failed to implement a restorative nursing program for a resident with hemiparesis following a stroke, as recommended by therapy. Despite discharge recommendations for passive and active range of motion exercises to maintain the resident's ability for daily tasks, there was no evidence that the program was implemented. Interviews confirmed that the program was never established, and nursing staff were not educated on it.
A facility failed to prevent potential complications from a dialysis access site for a resident requiring dialysis. The resident, who receives dialysis through a fistula in the right arm, reported that staff sometimes attempted to take blood pressure readings from the restricted arm. The clinical records lacked any indication of this restriction, which was confirmed by the DON. A sign indicating the restriction was placed only after the surveyor's inquiry.
The facility failed to provide adequate nursing staff, resulting in delayed call bell responses for two residents. One resident reported staff not returning after responding to her call bell, while another resident, needing assistance for toileting, experienced a 32-minute delay in response. The facility acknowledged these findings.
The facility failed to ensure proper labeling and secure storage of medications on Station III and for a resident. An unlocked medication cart was left unattended, accessible to unauthorized individuals. Additionally, a resident self-administered improperly labeled and expired eye drops, requiring assistance to open the bottle. These issues were confirmed by staff and acknowledged by the facility's administration.
The facility did not meet the Act 52 Infection Control Plan requirements due to the absence of maintenance staff in infection control committee meetings. Attendance records from January to October 2024 showed no evidence of participation from the maintenance department. Interviews with the maintenance director and nursing home administrator confirmed this deficiency.
Failure in Pain Management for Resident
Penalty
Summary
Nottingham Village was found to be non-compliant with the pain management requirements as outlined in 42 CFR Part 483, Subpart B. The facility failed to provide adequate pain management for a resident who had been admitted with severe injuries, including a displaced bimalleolar fracture and a displaced osteochondral fracture. On January 19, 2025, the resident was found on the floor, complaining of severe pain, which was assessed as a seven out of ten. Despite the resident's complaints and nonverbal signs of pain, the facility did not implement the pain management program as per their policy, which required pain assessment every shift and updating the physician if pain was not managed effectively. The facility's documentation revealed that the resident was not administered any as-needed Tylenol on the day of the incident, despite having an order for it. Furthermore, there were no further assessments of the resident's pain after the initial assessment on the first shift. Interviews with the resident and the Director of Nursing confirmed these findings, indicating a failure to adhere to the facility's pain management policy and to address the resident's severe pain adequately.
Plan Of Correction
1. Resident # 1's Pain has been re-assessed and is reporting her pain is being managed. 2. DON / Designee will audit the month of February MAR's to identify residents reporting over 7 pain. These residents will be assessed along with input from their PCP to determine if a new pain management regimen is necessary. 3. DON will conduct education with licensed nurses on the facility's pain management policy and include pain management focus when assessing residents post injury or accident. 4. DON / designee will audit random MAR's to determine if residents reporting over 7 pain are being managed properly; weekly x 4 weeks. DON / designee will audit IR's with reported injuries to validate pain has been assessed and managed properly; weekly x 4 weeks. Results of these audits will be reported to the QAPI team. 5. Date of compliance 3/13.
Unsealed Wall Penetrations in Soiled Utility Area
Penalty
Summary
The facility failed to maintain hazardous area enclosures as required by NFPA 101 standards. During an observation on December 16, 2024, at 10:05 a.m., it was noted that the Soiled Utility area on Unit 3 had unsealed penetrations in the wall around three copper pipes. This deficiency affects one of the two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator on the same day at 12:00 p.m.
Plan Of Correction
1. The penetration areas around the copper pipes were resolved with the application of a silicone caulk-filler. 2. Corrective action occurred on 12/16/24. 3. Administrator / Designee will educate maintenance staff on K321 and regarding hazardous area wall penetration issues. 4. Maintenance staff will conduct random inspections of other potential hazardous areas to determine that no other penetration issues are identified. Inspections to be done weekly x4 weeks and results submitted to the QA Committee.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the required sprinkler systems in three specific locations, affecting four out of ten smoke compartments. During an observation on December 16, 2024, it was noted that the Environmental Service Room in Unit 3 had an unsealed penetration in the ceiling. Additionally, the Nurse's Station in Unit 3 had an unsealed gap around a sprinkler escutcheon. Furthermore, the Walk-In freezer in the Dietary area was missing an escutcheon. These deficiencies were confirmed during an exit interview with the Facility Administrator on the same day.
Plan Of Correction
1. Unsealed penetration in the ceiling of Environmental Service Room was adjusted and corrected. Sprinkler Escutcheon at station 3 nurses station causing the gap was adjusted and is back into place. Missing escutcheon for walk-in freezer has been ordered. 2. Issue in the Environmental Service Room and Nursing station 3 noted above were corrected on 12/16/24. The missing escutcheon for sprinkler head in walk-in freezer is scheduled to be replaced on 12/27/24. 3. Administrator / Designee will educate maintenance staff regarding K353 maintenance of required sprinkler systems. 4. Maintenance Staff will conduct random inspections of other smoke compartments containing sprinkler heads to identify other similar issues. Inspections will be done weekly x 4 weeks and results reported to QA committee.
Deficiency in Corridor Door Integrity
Penalty
Summary
The facility failed to maintain the integrity of two corridor openings, which affected one of the two floors. During an observation conducted on December 16, 2024, it was noted that the door to Resident Room 125 on Unit 1 was not smoke tight when latched into the frame. This indicates that the door did not meet the required standards for resisting the passage of smoke, which is a critical safety feature in long-term care facilities. Additionally, the door to Resident Room 120 on the same unit failed to latch into the frame when tested. This deficiency was confirmed during an exit interview with the Facility Administrator on the same day. The failure of these doors to function properly compromises the safety measures intended to protect residents from smoke in the event of a fire, as they do not provide the necessary barrier to prevent smoke from entering the corridor.
Plan Of Correction
1. Resident Room Doors 125 & 120 had adjustments made to the frames to eliminate the gap and ensure smoke tight closure. 2. Corrective action was completed on 12/16/24. 3. Administrator / Designee will educate maintenance staff on K363 regarding corridor doors and maintaining sufficient smoke tight closure. 4. Maintenance Staff will conduct random inspections of resident room doors to identify other potential closure issues. Inspections will be conducted weekly x 4 weeks and results will be submitted to the QA committee.
Smoke Barrier Separation Wall Deficiency
Penalty
Summary
The facility failed to maintain a smoke barrier separation wall, which affected two out of ten smoke compartments. During an observation on December 16, 2024, at 11:12 a.m., it was noted that the attic level smoke barrier separation wall door was not smoke tight when closed into the frame, specifically inside the Dietary storage area. This deficiency was confirmed during an exit interview with the Facility Administrator on the same day at 12:00 p.m.
Plan Of Correction
1. A door latch mechanism will be installed on the attic door to correct the gap and wall separation. 2. The door latch will be installed on 12/27/24. 3. Administrator / Designee will educate maintenance staff on K374 regarding smoke barrier wall separation deficiencies. 4. Maintenance staff will conduct random inspections of other similar areas to identify other potential issues. Inspections will be conducted weekly x4 weeks and results will be reported to the QA committee.
Deficiency in Required Exits for Smoke Compartment
Penalty
Summary
The facility was found to be non-compliant with the National Fire Protection Association (NFPA) 101 standards regarding the number of exits required for each story and smoke compartment. Specifically, the deficiency was identified in one of the ten smoke compartments within the facility. During an observation conducted on December 16, 2024, at 10:00 a.m., it was noted that the basement level of the facility did not have two acceptable means of egress as required. This finding was confirmed during an exit interview with the Facility Administrator on the same day at 12:00 p.m.
Failure to Assess and Obtain Consent for Bed Assistive Devices
Penalty
Summary
The facility failed to obtain consent for, assess the need for, and assess entrapment risks from bed assistive bars for two residents. For Resident 19, observations revealed the presence of assist bars mounted bilaterally at the head of her bed. However, the facility could not provide documentation of an assessment for the need of the assistive device, an assessment of potential entrapment risks, or consent obtained prior to the installation of the device. It was only after the surveyor's questioning that a new physician's order and relevant assessments and consent forms were completed. Similarly, for Resident 108, observations showed the presence of assist bars, but the facility lacked documentation of an assessment for the need of the assistive device, an assessment of potential risks, or consent obtained prior to the installation. The Nursing Home Administrator confirmed that Resident 108 was unable to use the assist bars, and there was no documentation to support their use. The deficiency was identified through observation, clinical record review, and staff interviews.
Plan Of Correction
1. Resident # 19 has been assessed for need, consented on the risk and benefits, and an entrapment inspection completed for her bed positioning device. Resident #108 no longer has bed positioning devices. 2. DON/designee will conduct a sweep to determine if other residents using siderails or positioning devices have a current assessment of need, risk and benefits consent, and a completed entrapment inspection on record. 3. Licensed Nurses and Rehab Staff will be educated on CFR Code 483.25(n) and the Center's policy regarding bedrail use in a skilled nursing facility. 4. DON/designee will conduct weekly sweeps to validate residents using bedrails or bed positioning devices have documented evidence of assessment of need, risk and benefit consent, and current entrapment risk inspection. Audit will be conducted weekly x 4 weeks, and then monthly x 3 months. Results of the audits will be submitted to the QAPI team. 5. Date of Compliance 1/30/2024
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine prophylactic dental services for a resident, identified as Resident 62, who was reviewed for dental concerns. An interview with Resident 62 revealed that he had natural teeth but had never received a cleaning from a dental hygienist or professional, and he was responsible for brushing his own teeth. An interview with the Director of Nursing confirmed the absence of evidence showing that a hygienist or dental professional had provided preventative cleaning for Resident 62 in the past year. A progress note from the facility's consulting dental provider, dated September 17, 2024, indicated an annual exam by the dentist, revealing heavy soft plaque and food debris buildup, light hard calculus deposits, moderate gingival inflammation, and a moderate risk for caries. The recommended treatment plan was for preventative cleanings every six months, but there was no clinical record evidence that these cleanings were provided in the past year.
Plan Of Correction
1. Resident 62 to have dental cleaning by dental professional. 2. DON/Designee will audit current residents who resided in the Center during the past 12 months to identify those who may have not received a dental cleaning. 3. DON/Designee will educate nursing staff on 483.55(b). 4. DON/Designee will conduct random audits weekly X 4 weeks and then monthly X 3 months to validate residents have received or have been offered dental cleaning in prior 12 months. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food items and maintain equipment in a safe and sanitary manner in the main kitchen. During an initial tour, several issues were observed, including a bag of elbow macaroni with a hole and no open or use-by date, and a temperature control unit with a significant accumulation of a black substance on the vents. An open container of whole rosemary had an expired use date, and an open container of blue food coloring had an unreadable use-by sticker. In the walk-in freezer, cardboard boxes containing food items were found under circulation fans with a large accumulation of ice. The walk-in cooler contained orange juice containers that were not used within the required 10 days of thawing, as well as low-fat cottage cheese and cubed cheese with expired use-by dates. Further observations revealed several clear containers of pudding, a thawed box of hot dogs, and a container of hot dog chili sauce with expired use-by dates. A large bag of shredded lettuce and baked lima beans also had expired use-by dates. Clean items stored on wire racks were not protected from mop splash during floor cleaning. A green plastic tray in the sink next to the dishwasher had a build-up of a black substance, and temperature control units and machines had visible dust and black build-up. Additionally, an employee was observed without a beard guard while working in a food prep area. These findings were reviewed with the dietary manager and administrative staff.
Plan Of Correction
1. No residents were affected by deficient practice. Expired food items have been discarded; surfaces found to have dust and debris have been cleaned; other issues found have been resolved. Employee # 7 counselled for failing to wear beard guard. 2. Administrator / designee will conduct a kitchen inspection to determine if other expired food items exist; storage of items on bottom shelves have lining protection; equipment, vents, and other surfaces are free from dust / stains / debris; staff are wearing proper hair restraining devices. 3. Administrator / designee will conduct training with all Dietary personnel on CFR 483.60 (i)(1)(2) and the Center's Policy regarding Food Procurement / Storage / Sanitation. 4. Administrator / designee will monitor for compliance by conducting routine kitchen audit inspections at least weekly x 4 weeks and then monthly x 3 months. Results of the inspections will be submitted to the QAPI team. 5. Date of Compliance 1/30/2024.
Deficient Arbitration Agreement Process
Penalty
Summary
The facility's arbitration agreements were found to be deficient in ensuring a neutral and fair arbitration process for three residents who had signed these agreements. The agreements stipulated that the arbitration would be administered by an arbitrator services company designated by the facility. If this company was unable or unwilling to serve, the facility would then select an alternative arbitration service. This process did not guarantee that both parties would mutually agree upon a neutral arbitrator unless the facility's chosen arbitrator was unavailable. The deficiency was identified during a review of the arbitration agreements signed by three residents and confirmed through interviews with the Nursing Home Administrator and the Director of Nursing. The facility's current arbitration agreements did not provide for mutual selection of a neutral arbitrator, which was confirmed by the Nursing Home Administrator. This failure to ensure a neutral arbitration process was in violation of resident rights and management responsibilities as outlined in the relevant state codes.
Plan Of Correction
1. Residents #19, 62 and 68 have been offered a new arbitration agreement which meets compliance. 2. Administrator / Designee will conduct a sweep of all current in-house residents to identify who has a signed arbitration agreement not meeting the required language. 3. Administrator / designee will contact NV legal representatives to seek assistance in reconstructing an Arbitration Agreement that meets regulatory requirement. A regulatory compliant arbitration agreement will be re-offered to all current residents/ patient reps. 4. Administrator / designee will conduct random audits of new admissions, weekly x4 weeks and then monthly x 3 months. Results of the audits will be submitted to the QAPI team. 5. Date of Compliance 1/30/2025
Failure to Implement Transmission-Based Precautions for MDRO
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident who was readmitted from the hospital with a urinary tract infection (UTI) caused by an extended-spectrum beta-lactamases (ESBL) E-Coli, a multiple drug-resistant organism (MDRO). Despite the laboratory report indicating the presence of this MDRO, the facility did not initiate contact or enhanced barrier precautions as required by their policies. The resident's care plan did not include these precautions, and there was no evidence of isolation measures being implemented upon the resident's readmission or after the final laboratory report. Observations and interviews revealed that the resident was incontinent of bowel and bladder and dependent on staff for care, which included the use of incontinence briefs. However, staff did not use isolation gowns or post signs indicating the need for enhanced barrier or contact precautions. The Director of Nursing confirmed the lack of evidence for implementing these precautions, and a nurse aide confirmed the resident's incontinence and dependency on staff for care without using the necessary precautions.
Plan Of Correction
1. Resident 103 has no current active infection, contact precautions not needed. Resident 103 does not have targeted MDRO and elimination is contained and covered as described by QSO-24-08-NH, so no enhanced barrier precautions are needed. Policy "enhanced barrier precautions" to be updated to make sure reflect proper QSO guidance on enhanced barrier precautions. 2. There are no other residents to protect in a similar situation. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80(a)(1)(2)(4)(e)(f) and QSO-24-08-NH. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that residents are on the appropriate precautions. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to offer and administer an influenza immunization to one of the five residents reviewed for immunizations, specifically Resident 3. According to the facility's policy, residents without medical contraindications should be offered the influenza vaccine annually between October 1st and October 31st. However, a review of Resident 3's clinical records revealed no evidence of receiving the influenza vaccine for the 2024-2025 season, despite having received it in previous years. The facility's policy also requires documentation of vaccine education and informed consent or refusal, which was missing in Resident 3's records. During interviews, Employee 8, a registered nurse and infection control prevention coordinator, confirmed the absence of documentation regarding the administration or declination of the vaccine for Resident 3. The facility could not produce an informed consent for the 2024-2025 influenza vaccine, nor evidence of any contact with Resident 3's responsible party to obtain consent or refusal. This lack of documentation and failure to follow the facility's vaccination policy led to the identified deficiency.
Plan Of Correction
1. Resident 3 family contacted to see if they receive consent if they want the influenza vaccine. 2. Infection Control Preventionist (IP) /designee to do audit to make sure that all consents for influenza for current residents have either been received back or contact to determine administration. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80(d)(1)(2). 4. Infection Control Preventionist (IP)/Designee will do an audit weekly x4 and monthly x3 to make sure new residents have determination of influenza vaccine. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Document COVID-19 Vaccine Consent for Resident
Penalty
Summary
The facility failed to offer and administer a COVID-19 immunization booster to a resident, identified as Resident 3, who was reviewed for immunizations. The facility's policy requires that each resident be offered the COVID-19 vaccine unless medically contraindicated or already immunized, with proper documentation of consent or refusal. Resident 3 was admitted to the facility in May 2022, and her immunization history showed she did not receive a COVID booster in October 2023 because her responsible party refused consent. However, the facility could not provide documentation of this refusal. Interviews with Employee 8, a registered nurse and infection control staff, confirmed that Resident 3 did not receive any COVID vaccines since her admission, and there was no documentation of consent refusal in her medical record. Despite attempts to contact Resident 3's responsible party for consent, the facility failed to document these efforts adequately. The deficiency was discussed with the Director of Nursing and the Nursing Home Administrator, highlighting the lack of documentation and failure to offer the vaccine as per the facility's policy.
Plan Of Correction
1. Resident 3 family contacted to see if they receive consent if they want the COVID-19 vaccine. 2. Infection Control Preventionist (IP) /designee to do audit to make sure that all consents for COVID-19 vaccine for current residents have either been received back or contact to determine administration. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80 (d)(3)(i)-(vii) COVID-19 Immunization. 4. Infection Control Preventionist (IP) /Designee will do an audit weekly x4 and monthly x3 to make sure new residents have determination of COVID-19 vaccine. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Accommodate Resident's Call Bell Accessibility
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 108, regarding the accessibility of a call bell. Resident 108 was admitted with a diagnosis of hemiparesis following a cerebral infarction, affecting her right dominant side and limiting her range of motion. During interviews and observations conducted on December 3 and 4, 2024, it was noted that Resident 108 was unable to reach her call bell, which was attached to the top of the assist bar rail at the head of her bed. This issue was discussed with the Nursing Home Administrator and Director of Nursing on December 5, 2024. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services, indicating a failure to reasonably accommodate the resident's needs and preferences.
Plan Of Correction
1. Resident 108 call bell corrected, care plan that she prefers it on the side of affected limb. 2. DON/Designee to do a sweep of residents to make sure call bells accessible to resident. 3. DON/Designee will educate nursing staff about call bell accessibility, policy and on 483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. 4. DON/Designee will do a random audit weekly x4 and monthly x3 to ensure call bell placement. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Investigate Resident's Injury
Penalty
Summary
The facility failed to implement its abuse policy regarding the investigation of an unknown injury for a resident. The policy, last reviewed on July 18, 2024, requires the use of an incident reporting system to report, investigate, and track all unusual incidents, including those of unknown origin. However, the facility did not complete an investigation into the cause of a resident's injury, which was necessary to rule out the potential for abuse and neglect. The resident, identified as Resident 28, complained of right leg pain, which was initially treated with Tylenol but proved ineffective. Subsequent medical evaluation revealed a tibial plateau fracture and ligamentous knee injury. Despite these findings, there was no documented evidence in the resident's clinical record indicating how the injury occurred. An interview with the Director of Nursing confirmed that the facility did not conduct an investigation into the injury, as required by their policy.
Plan Of Correction
1. Resident 28 has a completed Incident Report and investigation summary regarding the unknown Fracture. 2. DON/Designee will audit the past 30 Incident / Accident reports to determine if other injuries of unknown origin have been investigated properly. 3. DON/Designee will educate nursing Staff on making sure that incidents of unknown origin are resolved and abuse has been ruled out, and abuse prohibition policy. 4. DON/Designee will do a random audit weekly x4 and monthly x3 of Incident Reports to validate complete investigation including to rule out abuse for injuries of unknown origin. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to ensure accurate assessments of residents' conditions, as evidenced by discrepancies in the Minimum Data Set (MDS) assessments for two residents. Resident 108, admitted with hemiparesis following a cerebral infarction, was incorrectly assessed as having no impairment in her upper extremities, despite her own report of limited range of motion on her right side. This error was confirmed by the Director of Nursing. Similarly, Resident 112's MDS inaccurately recorded his discharge status as being to a hospital, while nursing documentation indicated he was discharged to his home. This discrepancy was also confirmed by the Director of Nursing.
Plan Of Correction
1. MDS for Resident 108 has been modified to reflect impairment. Resident 112 MDS modified to reflect correct discharge placement. 2. DON / Designee will audit recent MDS completed in the past 30 days to identify other potential inaccuracies. 3. DON/Designee will educate RNACs on 483.20(g) Accuracy of Assessments. 4. DON/Designee will do a random audit weekly x4 and monthly x3 to accuracy of MDS assessments. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Document and Plan for Cardiac Pacemaker Use
Penalty
Summary
The facility failed to ensure quality of care for a resident with a cardiac pacemaker. The resident, who has a history of heart disease and heart failure, indicated that her pacemaker device alerts the facility when fluid accumulation is detected in her body, prompting adjustments to her Lasix medication. However, a review of her clinical records revealed no physician orders or care plan addressing the presence and management of the pacemaker. The resident's diagnoses included acute on chronic heart failure and paroxysmal atrial fibrillation, and her admission records noted a history of heart ablation and an AICD. During an interview with the Director of Nursing and the Nursing Home Administrator, it was confirmed that the facility was unaware of how the pacemaker device communicates with the monitoring company or the necessary emergency procedures to ensure its continued functioning during utility interruptions. The device was not included in the resident's plan of care, indicating a lack of comprehensive documentation and planning for the resident's cardiac needs.
Plan Of Correction
1. Resident 68 care plan, orders were updated to reflect the pacemaker being present. 2. There are no other current residents in the Center with a pacemaker who would be affected by the deficient practice. 3. Nursing staff will be educated on 483.25 and making sure that resident with cardiac medical devices are care planned and ordered. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that any residents with pacemakers have orders and care plans as appropriate. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Implement Restorative Nursing Program for Resident with Limited ROM
Penalty
Summary
The facility failed to implement a restorative nursing program for a resident with limited range of motion, as recommended by therapy. Resident 108, who was admitted with hemiparesis following a cerebral infarction affecting her right side, was not provided with the necessary passive and active range of motion exercises. These exercises were recommended by physical therapy to maintain her ability for clothing management and daily hygiene tasks. Despite the therapy discharge documentation noting that staff were trained to perform these exercises, there was no evidence in the clinical record that the program was implemented. An interview with the resident confirmed that she no longer received physical therapy, and an interview with the physical therapist revealed that a range of motion program was never established for her. Additionally, nursing staff were not educated on the program. These findings were confirmed with the Director of Nursing, indicating a lapse in the facility's responsibility to provide appropriate care to maintain or improve the resident's range of motion.
Plan Of Correction
1. Resident 108 to be re-evaluated by therapy to make sure appropriate for RNP program to the lower extremities. 2. DON/Designee will audit the past 30 days of therapy discharges to an RNP to identify if other residents been affected. 3. DON/Designee will educate Therapy on 483.25(c) (3), and policy named Restorative Policy. 4. Rehabilitation supervisor/Designee will do an audit weekly x4 and monthly x3 to assure that RNP programs were communicated with nursing staff to implement. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Implement Dialysis Access Site Care
Penalty
Summary
The facility failed to implement appropriate care to prevent potential complications from a dialysis access site for a resident requiring dialysis services. The resident, who undergoes dialysis treatment three times a week through a fistula located over his right bicep, reported that staff occasionally attempted to take blood pressure readings from his right arm, despite his instructions to use his leg. There were no indicators in the resident's room or clinical records to restrict the use of his right arm for blood pressure assessments or blood draws. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the right arm limb restriction was not included in the resident's plan of care until after the surveyor's inquiry. This oversight posed a risk of potential damage to the resident's dialysis fistula. A subsequent observation revealed that a sign was placed above the resident's bed to indicate the restriction, but this was only after the issue was raised by the surveyor.
Plan Of Correction
1. Resident 62 care plan updated, special instructions updated, and order placed not to use right arm for BP, veni-punctures. 2. Currently there are no other dialysis patients in the Center that could be potentially affected by the same deficient practice. 3. DON/Designee will educate nursing staff on 483.25(1), and policy Dialysis. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that all new dialysis residents have appropriate orders and care plans for affected limbs related to fistulas. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Delayed Call Bell Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically in responding to call bells in a timely manner. Resident 19 reported that when she rings her call bell, staff would come in and say they would return, but they never did. This indicates a lack of follow-through in addressing her needs. Additionally, Resident 52, who was assessed as cognitively intact and requiring extensive assistance for toileting, experienced a significant delay in response to her call bell. On December 3, 2024, Resident 52's call bell was not answered for 32 minutes, and when a nurse aide finally entered her room, the aide left immediately without providing the necessary assistance. Resident 52, who has a diagnosis of irritable bowel syndrome and had not had a bowel movement for three days, required a bedpan to move her bowels. Despite this urgent need, the nurse aide prioritized collecting breakfast trays over attending to Resident 52's call for help. The call bell was answered a second time only after 35 minutes from the initial call. The facility's administration acknowledged these findings, which highlight the deficiency in nursing services as per the relevant state codes.
Plan Of Correction
1. Resident 52 call bell answered at the time of need, Resident 19 made sure all needs are met. 2. DON/Designee will do a random audit of residents to make sure that call bells are being answered timely to see if any other residents affected. 3. DON/Designee will educate nursing staff on 483.35(a), and policy named call bells. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure call bells are being answered timely and all needs have been met of the resident. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications and biologicals on one of its nursing units, Station III, and for a specific resident, Resident 29. During an observation, a medication cart was found unlocked and unattended in a busy area of the nursing station, making it accessible to non-licensed staff, visitors, and other residents. This situation persisted for several minutes until it was confirmed by a licensed practical nurse. Such inattention to securing medications poses a risk of unauthorized access and potential misuse. Additionally, during a medication administration observation, a licensed practical nurse allowed Resident 29 to self-administer eye drops that were improperly labeled and stored. The eye drops were kept in a zippered pouch with other personal items, had a label that was rubbing off, and were not marked with the resident's name or administration details. The eye drops were also expired, and the resident required assistance to open the bottle. The nurse only realized the eye drops were expired after being informed by the surveyor. These findings were acknowledged by the facility's Administrator and Director of Nursing.
Plan Of Correction
1. Medication cart was locked at the time of the finding. Resident 29 eye drops (expired) were discarded and obtained new. 2. There are no other residents to protect in a similar situation. 3. DON/Designee will educate nursing staff on labeling and storage of drugs and biologicals. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that medication carts are locked, and medications are appropriately stored. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Infection Control Committee Lacks Required Maintenance Staff Participation
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. The plan mandates the inclusion of a representative from various departments, including medical staff, administration, laboratory, nursing, pharmacy, physical plant, patient safety, infection control, and the community. However, upon review of the infection control committee meeting attendance records from January to October 2024, it was found that there was no evidence of participation from a physical plant representative, specifically maintenance staff. Interviews conducted with the maintenance director and the nursing home administrator confirmed the absence of maintenance department representation in the infection control committee meetings. The maintenance director acknowledged that he had not attended any meetings and confirmed the lack of attendance from his department upon reviewing the attendance signatures. This deficiency was further corroborated by the nursing home administrator and the director of nursing, who confirmed the absence of required members at the meetings as per the available documentation.
Plan Of Correction
1. No residents were affected by the deficient practice. 2. There are no other residents to protect in a similar situation. 3. The IDT / ABX Stewardship and Infection Control Committee will be educated on the ACT 52 requirement specifically regarding required member participation. 4. Administrator / designee will audit the 4th quarter ABX Stewardship / Infection Control Committee to validate attendance by all required members per the ACT 52 Standard. 5. Date of Compliance 1/30/2025.
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.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
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.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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