Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nursing And Rehabilitation At The Mansion during CMS and state inspections, most recent first.
The facility failed to prepare and store food in a safe and sanitary manner in the main kitchen. Surveyors observed dust on the stove hood and a heating/cooling unit with a blackish buildup on its vents in the dry goods area. During tray line service, staff were plating lunch trays and placing them in carts while food temperature documentation was not current; an employee stated breakfast temps had not been measured and lunch temps had not yet been recorded.
Arbitration agreements for two residents did not ensure a neutral and fair arbitration process. The agreements stated that if the resident or responsible party and the facility could not agree on a neutral arbitrator within 30 days, the arbitration services company used by the facility would serve as the neutral arbitrator. An employee who reviewed the arbitration process confirmed the wording in the agreements, and the issue was discussed with the NHA and DON.
A resident’s active physician orders did not match the resident’s POLST/end-of-life wishes regarding artificial hydration and nutrition by tube. The chart showed the resident’s family reviewed and signed a POLST stating no tube hydration or nutrition, but the active orders directed staff to trial tube nutrition and/or hydration until the discrepancy was identified during survey review.
A facility binder in the main lobby contained full survey letters and a complaint deficiency letter with a CMS-2567 that identified a resident by name and specific identifier. This left the resident's personal and medical information exposed in a public area, and the DON and NHA were informed of the finding.
The facility failed to ensure MDS assessments accurately reflected the status of two residents. One resident had documented bilateral shoulder OA, pain, decreased UE strength, and limited ROM with dependence for upper-body ADLs, yet multiple MDSs coded no UE ROM impairment. Another resident had missing and broken teeth observed and reported dental concerns, but the admission and significant change MDSs coded no dental concerns; the RNAC confirmed the coding errors.
The facility failed to invite a cognitively intact resident to care plan meetings, with no documentation showing the resident was invited. The facility also failed to update another resident’s care plan to reflect current DNR status, even though the physician order, EHR banner, and POLST all indicated DNR while the care plan still listed Full Code and CPR interventions.
A resident receiving hemodialysis had a left arm fistula that was not functioning and a tunneled catheter in the right upper chest for treatments. Although the care plan and bedside sign restricted use of the left arm, staff obtained BP from the right arm and did not have evidence of clarifying the resident’s bilateral limb restrictions with the physician or dialysis provider before the surveyor’s questioning.
A resident receiving morphine sulfate had an incomplete controlled drug accountability record, with multiple doses lacking required nurse signatures and discrepancies in the recorded remaining quantity. The MAR and accountability sheet did not consistently match, and the DON later confirmed that 1.5 ml of morphine was unaccounted for. The destruction entry for the remaining medication also did not specify how the medication was destroyed.
Failure to implement EBP for a resident with a tunneled right central venous catheter used for dialysis. The resident had a central line in the right upper chest and staff reported using mask and gloves when touching the site, but no gown was used. Observations of the room and doorway showed no EBP signage or PPE setup, and the care plan did not include EBP interventions.
A resident with chronic respiratory issues experienced a significant drop in oxygen saturation, and the facility failed to notify the physician of this change. Despite attempts to adjust oxygen delivery, the resident's condition worsened, leading to CPR initiation. The facility did not document a comprehensive respiratory assessment or consult the physician, resulting in a deficiency.
The facility failed to administer physician-ordered supplemental oxygen correctly for three residents. One resident received oxygen at a higher rate than prescribed, another had oxygen administered at higher rates despite adequate saturation levels, and a third lacked continuous oxygen due to equipment issues. Staff confirmed these deficiencies.
A facility failed to ensure LPNs had the necessary competencies for administering IV therapy via a PICC line. A resident admitted for IV antibiotic therapy was cared for by LPNs without documented specialized training, as required by facility policy and state regulations. Observations and interviews revealed that multiple LPNs, including those without IV certification, were involved in the resident's care, leading to a deficiency finding.
The facility did not ensure that attending physicians responded to pharmacy recommendations for three residents. A resident's physician did not address a recommendation for dose reduction of Buspirone and Venlafaxine, and another resident's AIMS evaluation was not completed as recommended. Additionally, a third resident's physician did not act on a recommendation for dose reduction of psychoactive medications.
The facility failed to store food properly and maintain kitchen equipment in a sanitary manner, leading to potential food contamination. Observations revealed unsecured and expired food items in the freezer and refrigerator, and open bags in dry storage without dates. The kitchen equipment and environment were unsanitary, with grease buildup on the oven, debris under the sink, and dirty areas where clean dishes and meal trays were stored.
The facility failed to assist two residents with activities of daily living. One resident, dependent on a mechanical lift for transfers, remained in bed due to unavailable slings. Another resident, requiring moderate assistance for bathing, had not received a shower since a documented date, with no further attempts made despite protocol. These deficiencies were confirmed by staff interviews.
The facility failed to adhere to care plans and physician orders for several residents, including not applying a splint for a resident with contractures, delaying the initiation of a care plan for a resident with a PICC line, and not following skin protection measures for a resident with a neurostimulator. Staff were unaware of necessary interventions, and care plans lacked critical details.
A resident with a pressure ulcer did not receive the correct treatment as prescribed by the physician. An LPN administered a mixture of Medihoney and Zinc Oxide 20 percent paste instead of the prescribed 40 percent concentration. The facility had the correct treatment available, but it was not used, and the deficiency was communicated to the Nursing Home Administrator.
A facility failed to ensure proper accountability and security of controlled substances on a nursing unit. An LPN did not verify the controlled substance count during medication administration for two residents, leaving the medication cart unlocked and unattended. Discrepancies in medication counts were noted, and the facility's policy lacked specific instructions for reconciling counts at the time of administration. Interviews revealed expectations for nurses to sign for medications at the time of administration, but the policy did not direct staff to reconcile counts.
A facility failed to maintain complete clinical documentation for a resident who required weekly weight monitoring due to weight loss. Although weights were recorded by hand, they were not transcribed into the electronic health record as required, resulting in an incomplete record.
The facility failed to implement enhanced barrier precautions for two residents, one with a pressure ulcer and another with a PICC line. Staff did not use gowns during high-contact activities, despite the presence of signs and policies requiring such precautions. The deficiencies were confirmed by staff and management during a survey.
Food Temperature Monitoring and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare and store food items in a safe and sanitary manner in the main kitchen. During observation of the kitchen, there was an accumulation of dust on the stainless-steel hood over the stove, and the dry goods storage area contained a white heating/cooling unit near the ceiling with a build-up of a blackish substance on its vents. During observation of the tray line, staff were plating the lunchtime meal and placing trays into delivery carts, and seven entrees were already prepared on trays in the meal carts. When documentation of lunch food temperatures was requested, the binder provided contained temperature records for breakfast, lunch, and dinner, but the last recorded temperatures were dated the previous day. An employee stated that breakfast temperatures had not been measured and lunch temperatures had not yet been written down, and the employee then stopped plating meals to begin taking food temperatures.
Arbitration Agreements Did Not Ensure a Neutral Arbitrator
Penalty
Summary
The facility's arbitration agreements failed to ensure a neutral and fair arbitration process for two residents with signed agreements, Residents 13 and 50. Review of Addendum XIII: Arbitration Agreement for Resident 13, signed by the resident's responsible party, showed language stating that if the parties could not agree on a neutral arbitrator after 30 days, the arbitration services company used by the facility would serve as the neutral arbitrator under its Rules of Procedure. This wording allowed the facility to select the arbitrator if the resident or responsible party and the facility could not agree on a neutral arbitration service within the specified time. A similar Addendum XIII: Arbitration Agreement for Resident 50, signed by an X, contained the same language giving the facility's utilized arbitration services company the role of neutral arbitrator if no agreement was reached within 30 days. Employee 4, identified by the Nursing Home Administrator as the staff member who reviews the arbitration agreement process with residents, confirmed this wording during interview. The Nursing Home Administrator and the Director of Nursing were also interviewed regarding these concerns, and the report cited 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(b)(2), and 28 Pa. Code 201.29(a)(j).
Advance Directive Orders Did Not Match Resident Wishes
Penalty
Summary
The facility failed to ensure that active physician orders reflected Resident 11’s end-of-life wishes regarding artificial hydration and nutrition by tube. Clinical record review showed social services documentation that the interdisciplinary team met with the resident’s two sons and reviewed a POLST form stating that artificial hydration and nutrition by tube were not to be used. The physical chart also contained a POLST signed by the resident’s son/responsible party indicating the resident was not to receive hydration or nutrition by tube. However, the resident’s active physician orders dated August 12, 2025, instructed staff to trial nutrition and/or hydration via tube, creating a discrepancy between the POLST and the active orders. The discrepancy was reviewed with the Nursing Home Administrator and the DON, and a revised physician order dated December 17, 2025 later stated the resident was not to have nutrition or hydration via tube.
Resident Information Left in Public Survey Binder
Penalty
Summary
The facility failed to ensure a resident's right to privacy of personal and medical information in the main lobby area. During observation of the lobby, a binder labeled Department of Health Survey Results was found containing recent survey results and plans of correction. Review of the binder showed that the facility had placed full health survey letters and complaint deficiency letters into it, including a complaint deficiency letter and associated CMS-2567 from a complaint investigation completed on December 27, 2024. That letter identified Resident 74 by name and specific resident identifier, and the facility did not keep that resident's personal and medical information confidential.
Inaccurate MDS Assessments for ROM and Dental Status
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected residents’ status for two residents. One resident had documented primary osteoarthritis of both shoulders, pain in both shoulders, decreased bilateral upper extremity strength, limited range of motion in both arms and shoulders, and dependence on staff for upper body ADLs, including inability to don or doff a shirt without assistance. During interview and observation, the resident stated he had bilateral arm and shoulder ROM limitations from arthritis and was not participating in exercise programs or therapy related to ROM exercises, and he was observed able to raise his arms only to midway between his waist and head. Despite these findings and OT documentation describing decreased ROM, strength, endurance, and increased pain/resistiveness, multiple MDS assessments recorded no functional impairment or limitation with ROM of the bilateral upper extremities. A second resident stated that her teeth had broken over several years from medications used most of her life and that she had missing and broken teeth; observation confirmed missing teeth. She also stated she would be interested in receiving professional dental services in the facility. However, the admission MDS and a significant change MDS both assessed her as having no dental concerns, including no obvious broken teeth or cavities. During interview, the RN assessment coordinator confirmed that the dental coding on the MDS assessments was incorrect.
Failure to Invite Resident to Care Plan Meeting and Update Code Status Care Plan
Penalty
Summary
The facility failed to invite a cognitively intact resident to care plan meetings. Resident 9 had a BIMS score of 15 out of 15, indicating normal thinking and memory, and during an interview stated that he had never been invited to his care plan meetings. Review of the clinical record showed no documentation that Resident 9 was invited to any care plan meetings. During an interview, the DON stated that the resident’s responsible party had been receiving invitations, but no evidence could be found that Resident 9 himself was invited. The facility also failed to revise a resident’s comprehensive care plan to match current code status information. Resident 20 had a current physician’s order indicating DNR status, the EHR banner identified the resident as DNR, and the POLST signed by the responsible party also indicated DNR. However, the current care plan listed the resident’s advance directive as Full Code and included an intervention stating CPR would be performed as needed. The DON later confirmed that the care plan had not been updated.
Dialysis Access Restrictions Not Followed
Penalty
Summary
The facility failed to provide dialysis access care/services consistent with professional standards of practice and the resident’s comprehensive care plan for a resident receiving hemodialysis three times a week. The resident had a left arm fistula that was not functioning and was being revised, and the dialysis center was temporarily using a tunneled right central venous catheter in the right upper chest for treatments. The resident also had a sign above the bed instructing staff not to use the left arm for blood pressure assessments or blood draws, and the care plan included no venipuncture or blood pressures in the extremity with the shunt. Despite a physician order requiring weekly skin review and blood pressure assessment, the treatment record showed that an LPN obtained a blood pressure on the resident’s right arm. The LPN stated she used the arm opposite the fistula and later acknowledged the resident also had a central line access device in the right upper chest, but denied knowing the right arm was to be avoided. The RN confirmed that blood pressures were being obtained from the right arm despite the care plan’s instruction for no blood draws or blood pressure to the right upper extremity. Staff could not identify evidence that they had sought clarification from the physician or dialysis provider regarding the bilateral limb restrictions before the surveyor’s questioning, and the DON confirmed there was no evidence of such review.
Incomplete Controlled Medication Accounting
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of a controlled medication for a closed record resident who had been admitted to the facility and later discharged due to expiring on October 29, 2025. The resident had orders for morphine sulfate concentrate oral solution, including scheduled doses for generalized pain and PRN doses for pain/shortness of breath. Facility documentation showed a Controlled Drug Accountability Sheet was used to track the morphine, including quantity dispensed, administered, wasted, destroyed, remaining quantity, and staff signatures. Review of the accountability sheet showed multiple morphine administrations without a nurse signature in the required documentation fields, including several doses on October 21, October 22, and October 23, 2025. The sheet also showed instances where the recorded remaining quantity did not account for all doses documented as dispensed and administered, including a 0.25 ml discrepancy on October 22 and additional undocumented amounts between administrations on October 28. The last documented administration was on October 29, 2025, and the remaining 14.75 ml was documented as destroyed by two staff members, but the form did not specify how the medication was destroyed. The Director of Nursing later confirmed that a total of 1.5 ml was not documented and was unaccounted for on the Controlled Drug Accountability Sheet.
Failure to Implement Enhanced Barrier Precautions for Resident with Central Line
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection related to enhanced barrier precautions for Resident 6, who had a tunneled right central venous catheter used to complete dialysis. Resident 6 reported leaving the facility three times a week for hemodialysis, and observation during interview showed intravenous access tubing from a dressing on her right upper chest. She stated that staff who touched the right upper chest site wore a mask and gloves but did not wear a gown. The facility policy on Enhanced Barrier Precautions stated that EBPs are used to prevent the spread of MDROs and apply when a resident has a wound or indwelling medical device, including central lines. Observation of Resident 6's doorway and room on multiple occasions showed no indication that EBP were implemented. Review of the resident's plan of care for the tunneled right central venous catheter included that the contracted dialysis provider maintained the dressing and catheter care, but there was no intervention to implement EBP. Employee 2 confirmed that the facility did not implement measures for EBP, such as signage, accessible PPE, or PPE disposal containers, for Resident 6 who had a central line access site in her right upper chest.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a medical provider of a change in a resident's condition, specifically for one resident who was experiencing significant respiratory issues. The facility's policy requires prompt notification of the resident's physician and representative when there is a change in the resident's medical condition. However, in this case, the staff did not consult the physician when the resident's oxygen saturation levels dropped significantly, and they had to alter the resident's treatment by increasing the oxygen flow rate beyond the physician's order. The resident in question had a complex medical history, including chronic respiratory failure, COPD, and heart failure, and was on BiPAP therapy and supplemental oxygen. During a night shift, the resident was found to have shortness of breath while lying flat, and their oxygen saturation dropped to the high 70s despite using BiPAP. The staff attempted to resolve the issue by adjusting the oxygen delivery method and flow rate, which eventually improved the resident's oxygen saturation to 99 percent. However, there was no documentation of a comprehensive respiratory assessment or physician notification during this critical period. Later, the resident was found without spontaneous respirations and no palpable carotid pulse, prompting the initiation of CPR. The facility's failure to notify the physician of the resident's deteriorating condition and the need to alter treatment significantly contributed to the deficiency. The report highlights the lack of documentation and communication with the physician regarding the resident's condition and treatment changes.
Failure to Administer Physician-Ordered Supplemental Oxygen
Penalty
Summary
The facility failed to ensure the application of physician-ordered supplemental oxygen consistent with professional standards of practice for three residents. For Resident 4, there was an active physician's order for supplemental oxygen at two liters per minute (lpm) continuously, but observations revealed the oxygen was running at three lpm. Resident 4 mentioned that staff increased her oxygen due to a recent upper respiratory infection. Employee 1, the assistant director of nursing, confirmed these findings. Resident 5 had a physician's order for oxygen at three lpm with instructions to maintain oxygen saturation above 90 percent. However, documentation showed that the oxygen was administered at higher rates of five to six lpm, despite oxygen saturation levels being above 90 percent. For Resident 15, there was a physician's order for continuous supplemental oxygen at three lpm, but observations revealed she was without oxygen in her room and in the common area due to a lack of portable oxygen tanks. Employee 14 assisted Resident 15 with potentially contaminated tubing, and Employee 6 confirmed the lack of necessary equipment for portable oxygen use. These findings were confirmed by Employee 1.
Lack of Competency Verification for IV Therapy Administration
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for a resident with intravenous access needs. Specifically, the facility did not provide evidence of competencies or specialized training for LPNs responsible for administering intravenous medication via a PICC line. This deficiency was identified during a review of facility policies, clinical records, and personnel records, as well as through interviews and observations. The facility's policy on infusion therapy required that clinicians practice within their scope of practice and competency level, but the facility did not verify or document the necessary qualifications for the staff involved. Resident 163, who was admitted for intravenous antibiotic therapy, had a physician's order for PICC line care and medication administration. However, it was observed that an LPN without specialized IV certification was initially responsible for the resident's care, although another LPN with certification later performed the task. The medication administration record showed that multiple LPNs, including those without documented competencies, were involved in the resident's care. Interviews with facility staff confirmed the lack of documented training or competencies for these employees, which was a violation of state regulations and facility policies.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to ensure that the attending physicians addressed and responded to pharmacy recommendations for three residents. For Resident 4, a consultant pharmacist recommended a trial dose reduction of Buspirone and Venlafaxine on March 10, 2024. However, there was no evidence that the attending physician addressed this recommendation. Additionally, the consultant pharmacist did not review Resident 4's medication regime in June 2024. Employee 1 confirmed these findings during an interview. For Resident 32, a pharmacy recommendation dated September 23, 2024, requested an AIMS evaluation due to the use of Risperidone. The clinical record lacked documentation that nursing staff completed this evaluation. Employee 1 confirmed this during an interview. Similarly, for Resident 15, a pharmacy recommendation on May 19, 2024, suggested evaluating a gradual dose reduction of Clonazepam, Duloxetine, and Olanzapine. The attending physician did not act on this recommendation, as confirmed by Employee 1.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food and maintain food service equipment in a safe and sanitary manner, leading to potential food contamination in the main kitchen. During an observation, it was found that several food items in the freezer, such as French fries, sausage, meatballs, and tater tots, were opened and unsecured without any open or use-by dates. Additionally, an open bag of corn was found with a use-by date that had already passed. In the walk-in refrigerator, a gallon-sized container of ranch dressing and gallons of milk were found without proper use-by dates, with the ranch dressing being past its expiration date. In the dry storage room, open bags of rice, pasta, and potato flakes were also found without open or use-by dates. The facility's kitchen equipment and environment were not maintained in a sanitary condition. The exterior of the convection oven had significant grease and debris buildup, and the controls were covered in black grease. The floor under the sink was dusty and contained debris, including broken glass. The area next to the sink, where clean dishes were stored, was dirty with food debris. Additionally, the cart used for clean resident meal trays was observed to have debris and food crumbs on each shelf. These findings were reviewed with the Nursing Home Administrator and the assistant director of nursing.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
The facility failed to assist dependent residents with activities of daily living, as evidenced by the cases of two residents. Resident 21, who was assessed as totally dependent on the physical assistance of two staff members for transferring, required a passive mechanical lift for transfers. However, observations on two consecutive days revealed that Resident 21 remained in bed due to the unavailability of slings for the lift. This was confirmed by a nurse aide who stated that there was no other reason for the resident to remain in bed. Resident 53, who required partial/moderate assistance for bathing, was observed with disheveled hair and unable to recall her last shower after returning from dialysis. Her clinical records indicated that her last shower was documented on November 1, 2024, with one refusal and two bed baths recorded since then. There were no further attempts documented to assist her with a shower, despite facility protocol requiring additional offers and documentation of refusals. These deficiencies were confirmed in interviews with facility staff.
Deficiencies in Resident Care and Adherence to Care Plans
Penalty
Summary
The facility failed to provide the highest practicable care for several residents, as evidenced by the lack of adherence to physician orders and care plans. For Resident 21, there was a failure to apply a left ankle splint as ordered by the physician. The splint was observed stored on top of furniture in the resident's room instead of being applied, and passive range of motion exercises were not performed as required. This deficiency was confirmed during an interview with the assistant director of nursing and the Nursing Home Administrator. Resident 163's care was also deficient, as the facility did not initiate a care plan for her PICC line until three days after her admission, which was beyond the required 48 hours. The care plan lacked necessary details such as limb restrictions, bathing restrictions, and emergency procedures. Observations revealed that there were no measures in place to prevent the inadvertent use of the resident's left arm, and the room was not equipped with necessary signage or supplies for emergency procedures. This was confirmed through interviews with staff and the Nursing Home Administrator. For Resident 25, the facility failed to follow the care planned intervention regarding the use of Geri-sleeves to protect skin integrity. The resident was repeatedly observed without Geri-sleeves or long sleeves, contrary to the care plan. Additionally, there was no care plan associated with the resident's neurostimulator, despite a history of pressure ulcers and a video visit with neurology indicating the need for monitoring for side effects. Staff were unaware of any specific care interventions or precautions related to the neurostimulator, highlighting a significant oversight in the resident's care.
Failure to Administer Correct Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide the highest practical care to promote pressure ulcer healing for Resident 25, who had a pressure ulcer on the right ischium. The physician orders for Resident 25 included instructions to apply Medihoney Wound and Burn Dressing External Paste mixed with Zinc Oxide External Paste 40 percent to open skin areas on the buttocks and groin every shift. However, during an observation of wound care, it was noted that Employee 12, an LPN, prepared and administered a mixture of Medihoney and Zinc Oxide 20 percent paste instead of the prescribed 40 percent concentration. Additionally, the Desitin cream, which was recommended by the wound care staff, was not used. Interviews with Employee 12 and Employee 1, the assistant director of nursing, revealed that the facility had the Desitin cream and the correct 40 percent concentration of zinc oxide paste available, but it was unclear why the correct treatment was not administered. The deficiency was communicated to the Nursing Home Administrator, highlighting the failure to adhere to the physician's orders and wound care recommendations, which could potentially impact the healing process of the pressure ulcer.
Controlled Substance Accountability and Security Deficiency
Penalty
Summary
The facility failed to ensure proper accountability and security of controlled substances on one of its nursing units. The policy for controlled substances, last reviewed on January 3, 2024, did not include specific instructions for licensed staff to possess keys to controlled substance containers in the medication cart or to reconcile the count of controlled substances at the time of administration. During an observation, a licensed practical nurse (LPN) on the second-floor nursing unit prepared medications for a resident without referring to the controlled substance record to verify the remaining tablet count. The LPN left the medication cart unlocked and unattended, and upon return, documented the number of tablets without verifying the actual count. The LPN also prepared medications for another resident, noting a discrepancy in the controlled substance count for Tramadol. The record indicated 86 tablets should be present, but only 85 were found. The LPN did not document the administration of the medication at the time of administration or reconcile the count. The LPN later documented the administration of the medication without verifying the count. The facility's Medication Administration Competency Checklist for the LPN did not include appropriate administration of controlled substances. An interview with the assistant director of nursing revealed that the facility's expectation is for nurses to sign for controlled substances at the time of administration and ensure the count is correct. However, the facility policy did not direct staff to reconcile the number of tablets left at the time of administration. The policy also incorrectly stated that the Director of Nursing and charge nurse have a set of keys to controlled substance containers, whereas the LPN has a set of keys to the medication cart for their shift, and the Director of Nursing has a master set of keys.
Incomplete Clinical Documentation for Resident's Weight Monitoring
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for a resident, identified as Resident 45. A physician's order dated October 11, 2024, required weekly weight monitoring for the resident, which was also recommended by dietary staff following a noted weight loss. However, the electronic health record for Resident 45 showed weights recorded on October 7, November 7, and November 11, 2024, but lacked evidence of weekly weights as ordered. During a meeting with the Nursing Home Administrator and the assistant director of nursing, it was revealed that the weights were documented by hand on a separate sheet but were not transcribed into the electronic health record, as was the usual practice by dietary staff. This oversight resulted in an incomplete clinical record for the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for two residents, leading to deficiencies in infection prevention and control. For Resident 25, who had a pressure ulcer on the right ischium, the facility did not ensure that staff utilized enhanced barrier precautions (EBP) during wound care. Despite a sign indicating the need for EBP outside the resident's room, staff members, including two LPNs, did not wear gowns during high-contact activities such as wound cleaning and treatment application. The Assistant Director of Nursing confirmed that the resident was on EBP and that staff should have used the appropriate personal protective equipment. For Resident 163, who was admitted for intravenous antibiotic therapy via a peripherally inserted central catheter (PICC), the facility also failed to implement EBP. There was no signage or supplies in the resident's room to indicate the need for EBP, and an LPN did not wear a gown while disconnecting the IV tubing and flushing the line. The oversight was confirmed by the LPN and another staff member, who then sought additional supplies to implement the necessary precautions. These deficiencies were identified during a survey, and the facility's management was informed of the issues. The report highlights the failure to adhere to infection control protocols as outlined by the Center for Medicaid and Medicare Services, which requires EBP for residents with chronic wounds or indwelling medical devices during high-contact care activities.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Sunbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunbury Skilled Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 11 | 0 |
| Nottingham Village | 3.5 mi | ★★★★★ | 8 | 0 |
| Manor At Penn Village, The | 5.3 mi | ★★★★★ | 16 | 0 |
| Buffalo Valley Lutheran Villag | 9.8 mi | ★★★★★ | 19 | 0 |
| Oak Glen Healthcare And Rehabilitation Center | 10.5 mi | ★★★★★ | 17 | 0 |
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