Oak Glen Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewisburg, Pennsylvania.
- Location
- 15 Ridgecrest Circle, Lewisburg, Pennsylvania 17837
- CMS Provider Number
- 395283
- Inspections on file
- 25
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Oak Glen Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility’s HIPAA policy requires all workforce members to safeguard PHI, but an administrative employee emailed a resident’s responsible party with attachments that included clinical progress notes for several other residents. This resulted in PHI for multiple residents being disclosed to an individual who was not authorized to receive their medical records, constituting a failure to maintain confidentiality of resident-identifiable information.
Two residents reported receiving cold coffee and food, and observation revealed staff serving meals and beverages at improper temperatures, with some items uncovered and lacking adequate utensils or lids. Food and drink temperatures were measured below acceptable standards, and staff confirmed shortages of necessary supplies during meal service.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a lack of structured measures to prevent and control infections among residents and staff.
Two residents seated together in the dining room experienced unequal meal service when a nurse aide instructed one not to touch their sandwich until the other had food, but then left to serve another table. One resident ate while the other waited, and the resident who had already eaten was served a hot meal before the other received any food. This sequence resulted in one resident eating in front of the other, compromising resident dignity.
A resident was moved to a different unit and assigned a roommate without receiving written notice or an explanation for the change. The resident was not shown the new room or given the opportunity to meet the new roommate, and staff confirmed that no written documentation was provided regarding the move.
Nursing staff, including RNs and LPNs, did not have documented competency evaluations for indwelling catheter care and medication administration, despite caring for residents with these needs. The facility could not provide evidence of completed competency assessments or demonstrations for these staff members when requested by surveyors.
A dietary aide, working independently, was found to be unaware of required dish machine temperature checks and had not received training or competency assessment for essential dietary duties. The dining director confirmed there was no documentation of training or competency for dietary staff.
The facility did not ensure complete and accurate clinical records for two residents by failing to document required meal intake monitoring as outlined in their care plans. Additionally, after a resident's death, an LPN destroyed controlled substances without a required witness signature, and no dual signature documentation was found, contrary to facility policy.
A resident who had previously received pneumococcal vaccines and whose responsible party had consented to further vaccination was not offered an additional pneumococcal vaccine dose, as recommended by CDC guidelines. Facility records showed no evidence of clinical review or decision-making regarding the administration of PCV20 or PCV21, and staff confirmed the vaccine was not offered.
Two residents who required staff assistance for personal hygiene did not receive timely or adequate support with showers and shaving. One resident went several days without a shower or shaving assistance, while another, with severe cognitive impairment, was observed with significant facial hair and received only a partial shave after the issue was identified. These deficiencies were confirmed through observation, record review, and interviews with staff and facility leadership.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A facility failed to maintain an orderly environment due to a leaking roof in a main hallway, affecting a resident. Observations showed water dripping through ceiling tiles onto the carpet, with trash cans placed to catch the water. The issue persisted since January, despite obtaining a repair quote in May. The director of maintenance and the administrator confirmed the ongoing problem.
The facility failed to provide adequate care for residents with cardiac pacemakers and central venous catheters. A resident with a PICC line lacked a care plan for arm use restrictions and emergency procedures. Another resident with a pacemaker had no plan for remote monitoring, and the facility did not verify the need for a pacemaker check machine. A third resident with an IJ CVC had no emergency procedures or documentation for a dressing change, and staff education lacked guidance on emergency measures and assessments for CVCs.
The facility's main kitchen was found to have several sanitation deficiencies, including dusty equipment, improperly stored food items, and expired products. Observations included a dusty fan in the dishwashing area, open and undated food items in storage, and expired products in the walk-in coolers. Additionally, shelves and a knife rack had accumulated dust and debris.
A facility failed to maintain consistent documentation regarding a resident's advance directives. The resident's clinical record showed a DNR order, but a form indicated the health care agent had not decided on CPR status. This inconsistency was confirmed by the Nursing Home Administrator.
A facility failed to maintain a resident's ambulation status as part of a restorative program. The program required daily ambulation with a front-wheeled walker, but documentation showed the task was not completed on several days. The resident refused the task during the day shift, and the evening shift marked it as not applicable without further explanation. The ADON confirmed the task should be completed daily, but there was no documentation reviewing the resident's plan or refusals.
A facility failed to properly use a positional device for a resident with contractures, as observed with a travel neck pillow incorrectly positioned behind the resident's neck. Staff interviews revealed a lack of documentation and guidance on the correct use of the pillow, contributing to the deficiency in care for the resident's range of motion limitations.
A facility failed to provide timely access to a complete medical record for a resident during a survey. Despite attempts to resolve the issue, the surveyor was unable to access all necessary physician orders, including medications and advance care planning decisions, until the third day of the survey. This delay impeded the survey process.
A resident did not receive an offer for a COVID-19 vaccine booster as per CDC guidelines, despite being eligible. The resident's last booster was in early 2023, and there was no record of refusal or offer for a 2024 booster. Staff interviews confirmed the lack of documentation in the resident's medical records.
Unauthorized Disclosure of Multiple Residents’ PHI via Email
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information (PHI) for multiple residents when responding to a medical record request. The facility’s HIPAA Privacy and Security Policy, dated March 20, 2025, states that all workforce members are responsible for safeguarding PHI in any form and defines PHI as information that identifies or can reasonably be used to identify a resident and relates to the resident’s health condition, care, or payment for care. Despite this policy, an administrative employee (Employee 1) sent an email to the responsible party of Resident 1 in response to a request for that resident’s medical record. During an interview and concurrent review of the email, it was determined that Employee 1 erroneously attached and transmitted PHI belonging to multiple other residents, including Residents 3, 5, and 8, in addition to the requested information for Resident 1. The extra attachment contained progress notes from the clinical records of these additional residents, whose responsible party had not authorized this individual to receive their records. The email, sent on February 10, 2026, at 3:01 PM, therefore disclosed confidential medical record information for Residents 3, 5, and 8 to an unauthorized recipient. In a subsequent phone meeting, the Nursing Home Administrator confirmed that sending the PHI for these residents was a mistake.
Failure to Provide Palatable Food and Beverages at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food and beverages that were palatable and served at appropriate temperatures for residents on the Evergreen unit. Two residents reported that their coffee and food were sometimes cold, with one resident specifically stating the coffee was cold when eating in the dining room. During observation of lunch meal service, staff were seen serving meals from a steam table and distributing beverages from a cart. As meal service concluded, staff assembled trays for room delivery, placing uncovered beverages and food items on trays, some of which were served in disposable foam containers without lids. Staff were observed struggling with a depleted coffee supply, resulting in only half-filled cups, and acknowledged a lack of sufficient plate covers, silverware, and beverage lids in the dining room. When a resident's tray was delivered, it contained lukewarm food and beverages, with temperatures measured below acceptable standards for palatability: beef stroganoff at 104°F, carrots at 103.5°F, coffee at 99.1°F, tomato soup at 104.8°F, and milk at 53.7°F. The food service manager confirmed that there should have been an adequate supply of silverware, food, beverages, and lids, and acknowledged that the temperatures recorded were not within acceptable ranges. These findings were reviewed with the Nursing Home Administrator.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Ensure Resident Dignity During Meal Service
Penalty
Summary
During a lunch meal service on the Memory Care unit, two residents were seated together in the dining room awaiting their meals. A nurse aide placed a sandwich in front of one resident and instructed them not to touch it because the other resident at the table had not yet received anything, then proceeded to serve another table. Despite the instruction, the resident picked up the sandwich, prompting the aide to remind them not to touch it. The resident explained they were just looking at the sandwich. The resident then consumed the sandwich while the other resident at the table watched and waited, as the hot lunch meal had not yet arrived. Later, the resident who had already eaten the sandwich was served a hot meal before the other resident, who continued to wait. The second resident did not receive their meal until after the first resident had finished eating both the sandwich and the hot meal. These events were observed and later reviewed with facility leadership.
Failure to Provide Written Notice and Choice Prior to Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to a resident prior to a facility-initiated room change. The resident, who was observed in a wheelchair near the nurses' station, reported uncertainty about the reason for his move, the specific room he would be moving to, and whether he would have a roommate. He stated that he had not been shown any potential new rooms and that being told a room number would not be meaningful without seeing the room. The resident indicated he was informed of the move a couple of days prior but did not receive written documentation. Review of the clinical record showed that a social worker documented a discussion with the resident about the room change and noted the resident was agreeable, but there was no evidence that written notice was provided to the resident or his responsible party. Additionally, there was no documentation that the resident was given the opportunity to see the new room or meet his new roommate, despite the fact that he would now have a roommate when he previously did not. Facility staff confirmed the lack of written notice and documentation regarding the room change.
Lack of Documented Competency for Catheter Care and Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff, including registered nurses and licensed practical nurses, possessed the appropriate competencies and skill sets necessary for the care and assessment of residents with indwelling urinary catheters and for medication administration. Documentation review revealed that, out of a 100 resident census, 15 residents had indwelling urinary catheters and multiple residents received medications. When surveyors requested evidence of staff competencies for indwelling catheter care and medication administration for three employees, the facility was unable to provide documentation of completed competency evaluations or demonstrations in these areas. Staff interviews confirmed the absence of such documentation, indicating that the required competencies had not been verified for the involved employees.
Lack of Competent Dietary Staff and Training for Essential Kitchen Duties
Penalty
Summary
The facility failed to provide sufficient and competent dietary staff to perform essential kitchen duties, as evidenced by the experience of a dietary aide who had been employed for one month. During an observation, the aide was found washing breakfast dishes and flatware in the main kitchen using an industrial dishwashing machine. When asked about the dish machine temperature log, which is necessary to ensure proper sanitization, the aide stated she was unaware of the log, did not know how to check or record the temperatures, and had not been shown how to perform these tasks since being hired. She also indicated she was working independently, responsible for washing breakfast dishes before the designated dishwasher arrived later in the morning. Further interview with the dining director confirmed there was no evidence that the dietary aide, or any other dining/dietary staff, had been trained or deemed competent to perform dishwashing or other essential dietary duties independently. There was no written documentation of training or competency for dietary staff since the aide's hire date. These findings were reviewed with the Nursing Home Administrator.
Incomplete Clinical Records and Improper Medication Destruction Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents. For two residents with care plans addressing potential alterations in nutritional status and pressure ulcers, the care plans required staff to monitor and record meal intake at every meal. However, clinical record reviews revealed that meal intake was not documented on several specified dates as directed by the care plans. This lack of documentation was confirmed by staff interviews, indicating that the required monitoring and recording of nutritional intake did not occur as outlined. Additionally, for a resident who had passed away, the facility did not properly document the destruction of controlled substances as required by policy. The medication disposition logs for lorazepam and morphine indicated that these medications were destroyed by an LPN, but the witness signature fields were left blank, and no documentation of dual signatures could be found. This failure to document the destruction of medications was confirmed by staff and was not in accordance with the facility's policy, which requires the presence and attestation of at least two licensed healthcare professionals.
Failure to Administer Pneumococcal Vaccine to Eligible Resident
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to a resident who was eligible and had provided consent to receive it. According to the facility's Infection Control - Vaccination Policy, residents are to be offered immunizations in accordance with CDC guidelines unless medically contraindicated or previously vaccinated. Clinical record review showed that the resident had previously received both the PPSV23 and PCV13 vaccines, with the last dose administered more than five years prior to the current review. Despite this, there was no documentation that the interdisciplinary team reviewed the resident's condition or made a decision regarding the administration of a subsequent dose of PCV20 or PCV21, as recommended by CDC guidelines for adults who have completed the earlier vaccine series. The resident's responsible party had signed a consent form for pneumococcal vaccination, indicating willingness to proceed with further immunization. However, staff interviews confirmed that the resident was not offered the vaccine, and there was no evidence of shared clinical decision-making or assessment for additional vaccination. The deficiency was identified through policy review, clinical record examination, and staff interviews, and was confirmed by the infection control prevention coordinator and discussed with the Nursing Home Administrator.
Failure to Provide ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were dependent on staff for personal hygiene. One resident, who was totally dependent on two staff members for showers, had not received a shower or shaving assistance since admission. Observations revealed the resident's hair was uncombed and oily, and he had several days' growth of facial hair. Documentation showed that showers were scheduled for specific days, but there was no evidence that these were provided as required, and the first documented shower occurred only after the surveyor's observation. Another resident, assessed as requiring partial to moderate assistance for personal hygiene and having severe cognitive impairment, was observed with significant facial hair and stated he needed to shave. Although the resident was shaved the following day, the shave was incomplete, leaving whiskers in several areas. Both cases were reviewed with facility leadership, confirming the lack of adequate ADL assistance for these dependent residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Facility Fails to Address Leaking Roof in Main Hallway
Penalty
Summary
The facility failed to provide adequate maintenance services to maintain an orderly environment in a main hallway, impacting Resident 29. Observations revealed a leaking roof in the hallway near the beauty shop, with water dripping through ceiling tiles onto the carpet. Two large trash cans were placed under the leak to catch the water, but the surrounding carpet was wet, and a musty odor was present. Interviews with Resident 29's family and the director of maintenance confirmed the ongoing issue, with the director noting the leak had persisted since his employment began in January 2024. A quote to fix the leak was obtained in May 2024, but the facility had delayed addressing the issue. The administrator confirmed these findings and acknowledged efforts to resolve the problem.
Deficiencies in Care for Residents with Cardiac Pacemakers and Central Venous Catheters
Penalty
Summary
The facility failed to provide the highest practicable care for residents with cardiac pacemakers and central venous catheters. For Resident 27, the facility did not have a care plan that included instructions to avoid using the right arm for venipuncture or blood pressure assessments, nor did it have emergency procedures in place for potential complications with the PICC line. The facility also lacked a policy or procedure for emergency care related to PICC lines, and there was no signage or indication of restrictions or emergency procedures in Resident 27's room. Resident 61, who had a cardiac pacemaker, did not have a care plan that included the use of a pacemaker check machine. The facility did not contact the resident's primary care physician or cardiologist to determine if remote monitoring was required while the resident was in the facility. Additionally, the facility staff did not inquire if the resident used a pacemaker check machine at home, and there was no pacemaker check device available in the resident's room. For Resident 82, the facility did not have emergency procedures in place for the IJ CVC, and there was no mention of the IJ CVC on the Kardex used by nurse aides. The facility also failed to document a dressing change for the IJ CVC, which was performed without a physician's order. The education provided to staff did not address emergency measures or ongoing assessments necessary for residents with a CVC, and there was no evidence that staff were measuring exposed tubing to verify that there was no migration of the access tubing.
Sanitation Deficiencies in Kitchen Storage and Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions in its main kitchen, as observed during an initial tour with the General Dietary Manager. Several issues were identified, including a large circulating fan in the dishwashing area with a significant build-up of dust on the protective guards. In the dry storage room, an open container of peanut butter was found without an open date. In the walk-in freezer, a package of croissants was open and uncovered, exposing them to ambient air. Further observations in the walk-in cooler revealed a head of celery and several packages of butter that were either open or partially open, with some lacking open dates. Additionally, an open package of mixed vegetables had a build-up of moisture and no open date, and onions with expired facility use-by dates were found. Another walk-in cooler contained a container of heavy cream, a box of cooked chicken, and an opened package of provolone cheese, all with expired facility use-by dates. Two stainless steel shelves had a build-up of debris and dust, with one shelf containing a dead winged insect. A knife rack and the wall section behind it also had a build-up of dust.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to establish clear and consistent resident wishes regarding advance directives for one resident. A clinical record review for the resident revealed a current physician's order indicating a DNR (Do Not Resuscitate) code status. However, a facility form titled 'Decision of Agent, Guardian, or Health Care Representative Cardiopulmonary Resuscitation Status of Incompetent Resident' showed that the resident's health care agent did not wish to decide on the CPR status at that time. This discrepancy between the physician's order and the resident's code status form was confirmed by the Nursing Home Administrator during an interview.
Failure to Maintain Resident's Ambulation Status
Penalty
Summary
The facility failed to maintain a resident's ambulation status, specifically for Resident 17, who was part of a restorative program aimed at improving her ability to ambulate with a front-wheeled walker. The program required the resident to be ambulated in straight paths with the assistance of one staff member, while another staff member followed with a wheelchair. The task was scheduled to be completed every shift to ensure it was done at least once a day. However, documentation revealed that the task was not completed on several days, specifically on September 16, 18, 21, 22, 23, 24, and 25, 2024. On these dates, the resident refused the task during the day shift, and the evening shift marked the task as not applicable, with no further explanation provided. The Assistant Director of Nursing confirmed that the expectation was for the task to be completed once a day, and it was scheduled every shift to provide flexibility in case one shift could not complete it. Despite this, there was no documentation indicating that the resident's plan was reviewed in light of her refusals or why the task was deemed not applicable during the evening shifts. The lack of documentation and follow-up on the resident's refusals and the task's applicability contributed to the facility's failure to provide the necessary care to maintain the resident's ambulation status.
Improper Use of Positional Device for Resident with Contractures
Penalty
Summary
The facility failed to appropriately use a positional device for a resident with contractures, leading to a deficiency. Observations revealed that the resident was using a travel neck pillow incorrectly, with the bulk of the pillow positioned directly behind her neck, pushing it further forward. This was observed on two separate occasions. The resident's clinical record did not document the use of the travel neck pillow until after the surveyor's observations, indicating a lack of proper documentation and guidance for staff on its use. Interviews with staff, including an occupational therapist and a nurse aide, confirmed the improper use of the travel pillow. The occupational therapist indicated that the pillow should be positioned to the left side of the resident's neck for support, but there was no documentation to instruct staff on this positioning. Additionally, the nurse aide admitted to placing the pillow directly behind the resident's neck and moving it when assisting with feeding, yet there was no documented evidence to guide this practice. The lack of documentation and staff instruction contributed to the deficiency in providing appropriate care for the resident's range of motion limitations.
Deficiency in Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to a complete medical record for one of the residents during a survey. On the first day of the onsite survey, the surveyor, along with the Nursing Home Administrator and the Assistant Director of Nursing, discovered that the electronic medical record for a resident did not include all physician orders, specifically missing medications and advance care planning decisions. Despite the Nursing Home Administrator's assurance that the information technology department had updated the surveyor's profile to allow full access, the surveyor was unable to access the complete records on the first and second days of the survey. The issue persisted into the third day of the survey, with the surveyor repeatedly addressing the inaccessibility problem with the Nursing Home Administrator, Director of Nursing, and other staff members. It was only after further intervention by the facility's information technology department that the surveyor's user profile was adjusted to permit access to the resident's complete electronic medical record. This delay in providing access to the necessary medical records impeded the survey process, highlighting a deficiency in the facility's ability to ensure timely access to resident information.
Failure to Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to a resident, identified as Resident 59, as required by current CDC guidelines. These guidelines recommend that everyone aged six months and older should receive the 2024-2025 COVID-19 vaccine to maintain up-to-date protection. Resident 59 was admitted to the facility on August 19, 2022, and received his most recent COVID-19 booster on February 14, 2023. However, there was no evidence in his medical records that the facility offered any additional doses of the COVID-19 vaccine after this date. Interviews with several staff members, including a registered nurse/infection control prevention coordinator, a licensed practical nurse, a registered nurse, and a medical records employee, confirmed that Resident 59's electronic and physical medical records did not indicate any offer of a COVID-19 booster in 2024. Additionally, there was no documentation of refusal by Resident 59 or his responsible party that would prevent further vaccination. The deficiency was discussed with the Nursing Home Administrator during the survey process.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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