Oak Hill Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Pennsylvania.
- Location
- 1020 North Union Street, Middletown, Pennsylvania 17057
- CMS Provider Number
- 395347
- Inspections on file
- 34
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Oak Hill Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors identified failures in psychotropic medication management, including missing 14-day stop dates for PRN orders, lack of side effect monitoring for two residents on psychotropic drugs, absence of informed consent for one resident started on an antipsychotic, and inadequate documentation of behavioral interventions and monitoring for a resident switched to Lorazepam gel after refusing oral medication.
The facility did not ensure that physician orders and professional standards were followed for four residents, including missed laboratory tests, delayed implementation of medication monitoring, incomplete weekly skin assessments, and failure to notify a physician of critical blood glucose levels. These deficiencies involved residents with dementia, cerebrovascular disease, diabetes, and other chronic conditions.
A resident with chronic pain and multiple diagnoses did not receive timely comprehensive pain assessments, and pain management interventions were not consistently aligned with the resident's stated goals. Documentation showed frequent administration of prn Tylenol and oxycodone, sometimes simultaneously and without clear parameters, with several instances of unknown or ineffective outcomes. Staff confirmed the lack of appropriate medication parameters and improper administration practices.
Two residents with renal failure did not have proper documentation or communication between the facility and the dialysis provider, despite physician orders and care plans specifying scheduled dialysis treatments. Required dialysis communication sheets were missing or incomplete, and the Nursing Home Administrator confirmed these records were not consistently maintained.
Annual performance evaluations were not completed for five nurse aides, as required by facility policy. Personnel records lacked documentation of these reviews, and the administrator confirmed that evaluations should have been conducted around each employee's hire date.
Two residents' care plans were not updated to include the use of enabler bars, a trapeze, or pacemaker safety precautions, despite physician orders and facility policy requiring comprehensive, person-centered care planning. Staff confirmed that these interventions and safety measures were in use but not documented in the care plans or Kardex.
A resident with dementia and hypertension, who was care planned for bilateral fall mats to prevent falls, was observed on multiple occasions without the required fall mats in place. The absence of these devices was confirmed by the NHA, indicating a failure to follow the resident's fall prevention interventions.
A resident with a Foley catheter did not receive proper catheter care as required by facility policy and physician orders. The catheter bag was observed in contact with the floor on multiple occasions, and documentation of catheter care was missing for several days and not completed every shift as ordered. Staff confirmed these lapses in care and documentation.
A resident with Alzheimer's disease and other mental health diagnoses did not receive timely dental services for denture replacement, despite multiple scheduled visits and documented need for assistance with dentures. The resident missed a key denture fitting appointment, and the dentist was unable to locate her during a scheduled visit, resulting in a delay in necessary dental care.
A resident with dementia suffered a femur fracture that was not promptly acted upon after confirmation by x-ray. Despite ongoing high pain scores and repeated administration of PRN oxycodone, there was a significant delay in notifying the provider and transferring the resident to the hospital. Documentation failed to show timely pain assessments or interventions after the fracture was identified, resulting in the resident not receiving adequate pain management or timely hospital care.
A resident with type II diabetes had a physician's order for Ozempic, but the medication was not administered on two occasions, and there was no documentation of follow-up with the pharmacy or physician regarding its absence. The DON confirmed the medication was never dispensed, and the clinical record lacked evidence of any actions taken to address the missing medication.
A resident with dysphagia, dementia, and muscle weakness was given a thin liquid by a volunteer, despite physician orders for nectar thickened fluids. The volunteer did not consult nursing staff before providing the drink, contrary to facility policy. The resident began coughing and was later diagnosed with bilateral lobe pneumonia and a small left-sided effusion.
Two residents with dysphagia did not receive drinks in the prescribed nectar thickened consistency. One resident was given thin liquids by a volunteer, resulting in coughing and subsequent bilateral lobe pneumonia with a small pleural effusion. Another resident was observed with thin water and a straw at bedside, despite orders for nectar thickened liquids and no straws. Facility staff and volunteers did not follow physician orders or facility policy regarding fluid consistency.
Oak Hill Center for Rehabilitation and Nursing failed to provide meals in the correct texture for residents requiring mechanical soft and pureed diets. A resident with swallowing difficulties was served a mechanical soft meal instead of a pureed diet due to outdated dietary slips and miscommunication. The error was identified during meal service and corrected, but it highlighted a lapse in following dietary orders.
The facility failed to meet the required nurse aide (NA) staffing ratios on several occasions, as evidenced by staffing documents and staff interviews. The facility did not maintain the minimum NA-to-resident ratios on the day shift for four days, on the evening shift for two days, and on the night shift for one day. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the required NA ratios.
The facility did not meet the required LPN staffing ratios on specific shifts. On an evening shift, the facility had a census of 127 residents but only maintained an LPN ratio of 4.0, below the required 4.23. On two night shifts, the facility had the same census but only maintained an LPN ratio of 3.0, below the required 3.18. The Nursing Home Administrator confirmed the staffing deficiencies.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. On three separate days, the facility provided less than the required hours, with 3.18 hours on two days and 3.17 hours on another. This was confirmed by the Nursing Home Administrator.
The facility failed to ensure resident participation in the care planning process for two residents, as required by their New Admission Introduction & Handbook. Both residents, with conditions such as muscle weakness, chronic kidney disease, anemia, and pain, were not documented as having been invited to their care plan meetings. The Director of Social Services confirmed the absence of a process to ensure resident invitations to these meetings.
The facility did not provide the SNF-ABN form to two residents whose Medicare A coverage had ended, despite their plans to continue receiving skilled services. The Nursing Home Administrator acknowledged the error, which will be corrected.
The facility failed to ensure accurate resident assessments, leading to deficiencies in documenting significant weight loss and medication management for four residents. A resident with Parkinson's Disease experienced significant weight loss, which was not reflected in MDS assessments. Another resident's recommendation for a gradual dose reduction of Quetiapine was not documented due to a delay in scanning the consult. Additionally, a resident's physician-ordered GDR of Seroquel was not reflected in the MDS assessment. Lastly, a resident at risk for severe protein-calorie malnutrition was not marked as such in the MDS assessment.
The facility failed to provide adequate wound care for two residents with pressure ulcers. A resident with severe malnutrition and a stage 4 ulcer did not receive timely updated wound care orders, while another resident with paraplegia and a recurring ulcer experienced lapses in hand hygiene, barrier precautions, and unauthorized use of wound care products. These deficiencies were confirmed by the DON and NHA.
Two residents with limited mobility did not receive appropriate services to maintain or improve their mobility. One resident with a hand contracture had inconsistent documentation for prescribed splint and ROM exercises, while another resident with hemiplegia reported difficulty receiving assistance for daily ambulation. The facility's documentation practices were inadequate, as noted by the NHA.
The facility failed to provide appropriate care for two residents with feeding tubes, leading to deficiencies in monitoring and syringe changes. One resident lacked orders for G-tube site care, while another had insufficient orders for PEG tube syringe changes. These oversights were acknowledged by the facility's administration.
The facility failed to conduct timely trauma assessments and develop individualized care plans for two residents with PTSD. One resident's care plan lacked details on PTSD triggers, while another's records did not reflect her PTSD diagnosis or personalized interventions, despite her request for continued therapy and identification of specific triggers.
The facility failed to assess and obtain informed consent for the use of enabler bars/side rails for two residents. One resident with paraplegia and morbid obesity had side rails without documented consent or risk review. Another resident with COPD and CHF had an enabler rail without proper assessment, despite an initial evaluation indicating no need for side rails. Consent forms for both residents were signed after the observation.
The facility failed to store medications securely, leaving them at the bedside of three residents without self-administration orders. Medications, including a powder for a rash and discontinued creams, were found in resident rooms for staff convenience, contrary to policy. The DON confirmed these should have been stored in locked compartments.
The facility failed to implement enhanced barrier precautions (EBP) correctly, as observed when a nurse aide was seen handling soiled linen without a gown, despite EBP signage on the resident's door. Interviews revealed staff confusion about EBP application, leading to incorrect signage and lack of PPE use. The Infection Control Professional confirmed the oversight, and the Nursing Home Administrator and DON acknowledged the need for proper EBP implementation.
The facility failed to inspect side rails for two residents, leading to potential entrapment risks. One resident had bilateral enabler bars installed without timely safety measurements, while another had a side rail installed with no inspection documentation. The Nursing Home Administrator confirmed the lack of evidence for these inspections.
The facility failed to follow professional standards in medication administration and wound care for two residents. One resident did not receive prescribed eye drops due to a lack of physician orders, and another resident received unauthorized collagen with silver during wound care. Additionally, there was a delay in starting NPWT as ordered by a wound care specialist.
A facility failed to provide appropriate respiratory care for a resident with bipolar disorder and hypertension. The resident was observed using oxygen at 4 liters per minute, contrary to the physician's order of 2 liters per minute. Additionally, the facility did not document the maintenance of the resident's oxygen equipment as required, including changing the humidifier bottle and cleaning the oxygen concentrator filter.
A resident with ESRD did not receive appropriate dialysis care as the facility failed to avoid using the arm with the dialysis graft for blood pressure measurements and did not weigh the resident before dialysis sessions. Additionally, the dialysis order was not entered timely, and a communication sheet was missing. Interviews confirmed these documentation and care deficiencies.
A resident with CHF and vitamin deficiency did not receive necessary dental services as recommended by a dental consult. Despite the resident's concern about the lack of routine dental care, there was no evidence of follow-up dental services after a recommended cleaning and checkup. The facility acknowledged the need for a system to track dental appointments.
A resident with a history of UTIs and other conditions suffered harm due to the facility's failure to provide catheter care, administer antibiotics, and obtain timely lab results. The resident's condition worsened, leading to hospitalization for septic shock. Additionally, the facility failed to document wound treatments and obtain weekly weights as ordered.
The facility failed to adhere to care plans for two residents, resulting in missed showers and weights. One resident with heart failure and hypertension did not receive the ordered showers and was weighed only once instead of weekly. Another resident with heart failure and dementia was weighed only twice instead of weekly as ordered. The DON and Nursing Home Administrator confirmed these discrepancies.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to comply with regulatory requirements regarding the use and monitoring of psychotropic medications for several residents. For one resident with major depressive disorder and dementia, PRN (as needed) psychotropic medication orders for ABH Gel and Seroquel were issued without a documented 14-day stop date or rationale for continued use, contrary to facility policy. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that such orders should have a 14-day stop date documented and followed. Additionally, two residents receiving psychotropic medications, including antipsychotics and anxiolytics, did not have documented monitoring for side effects as required. One resident with dementia, agitation, and depression had multiple psychotropic medications ordered, but there was no documentation of side effect monitoring in the clinical record. The NHA confirmed that side effect monitoring should have been in place. Another resident with major depressive disorder and anxiety disorder was prescribed Lorazepam gel after previously refusing the oral form, but there was no documentation of side effect or behavior monitoring, nor evidence of nonpharmacological interventions or care planning for medication refusal. Furthermore, the facility failed to obtain proper informed consent for the initiation of psychotropic medication for a resident with anxiety disorder and paranoid schizophrenia. The clinical record lacked a signed informed consent form from the resident or their representative for the use of olanzapine. The NHA stated that it was the facility's expectation to obtain such consent. These deficiencies were identified through policy reviews, clinical record reviews, and staff interviews.
Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and physician orders for four residents. For one resident with dementia, laboratory tests including a complete blood count, metabolic profile, lipid panel, hemoglobin A1C, and anticonvulsant drug levels were ordered to be performed every six months starting on a specific date, but there was no evidence these labs were obtained or results documented. The Nursing Home Administrator confirmed the labs were not completed as ordered. Another resident with dementia, hypertension, and atrial fibrillation had a consultant pharmacist's recommendation for digoxin drug level monitoring, basic metabolic profile, and daily pulse checks, which was signed by the provider. However, there was a delay of approximately nine weeks before the pulse monitoring order was implemented, and no order for a digoxin level was found in the clinical record. The Director of Nursing confirmed that these interventions should have been implemented when the recommendation was signed. A third resident with cerebrovascular disease and major depressive disorder had physician orders and care plan interventions for weekly skin assessments due to risk of skin breakdown. Documentation showed that several weekly skin assessments were missing over a three-week period. Additionally, a resident with diabetes and anxiety disorder had orders for twice-daily blood glucose checks with physician notification required for results above 400 or below 60. The Medication Administration Record showed multiple instances of blood glucose readings above 400, but there was no documentation that the physician was notified as required.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with a history of pain, osteoarthritis, and multiple sclerosis. Facility policy required comprehensive pain assessments upon admission, quarterly, with significant changes, and with new or worsening pain, as well as documentation of pain management interventions consistent with the resident's goals. However, the resident did not receive a comprehensive pain assessment for over eight months, despite ongoing pain management issues. When an assessment was completed, the resident reported almost constant pain and set a pain goal, but there was no evidence that pain management interventions were consistently aligned with this goal. Medication administration records revealed that the resident received as-needed (prn) Tylenol and oxycodone for varying pain levels, including instances where both medications were given simultaneously on multiple occasions. There were also several doses where the effectiveness of the medication was either unknown or documented as ineffective. Additionally, prn medications were administered without clear parameters, and some doses were given for pain levels of zero or for fever when the resident did not have an elevated temperature. Staff interviews confirmed that prn pain medications lacked appropriate parameters and that the two medications should not have been administered together.
Failure to Document and Communicate Dialysis Care for Residents
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received care and services consistent with professional standards, the comprehensive person-centered care plan, and the residents' goals and preferences. For two residents with diagnoses including end stage renal disease and chronic kidney disease, physician orders and care plans specified scheduled dialysis treatments. However, documentation of communication between the facility and the dialysis provider was either missing or incomplete. Specifically, for one resident, there were no dialysis communication sheets available for review, and for the other, there was a lack of documented communication for a period during which the resident attended multiple dialysis sessions. Interviews with the Nursing Home Administrator confirmed that dialysis communication sheets were not consistently completed or available for review, and that these records were not uploaded to the electronic health record. The facility's own policy required immediate communication with the attending physician, resident or representative, and dialysis staff regarding significant changes in the resident's status, but there was no evidence that this communication occurred or was documented as required.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides, as required by policy. Personnel records for these nurse aides, who were hired between December 2021 and February 2024, did not contain documentation of annual performance reviews. During an interview, the Nursing Home Administrator confirmed that there was no additional documentation available and acknowledged that annual performance reviews should be completed around each employee's hire date.
Failure to Update and Revise Care Plans for Assistive Devices and Pacemaker Precautions
Penalty
Summary
The facility failed to review and revise the care plans for two residents as required by both facility policy and regulatory standards. For one resident with dementia, hypertension, and atrial fibrillation, the clinical record showed the use of bilateral enabler bars and a pacemaker monitoring unit, but the care plan did not include interventions or safety precautions related to the enabler bars or the pacemaker. Documentation confirmed the enabler bars were ordered and placed, and the resident had a pacemaker since 2018, yet these were never addressed in the care plan or its revision history. The Nursing Home Administrator and Director of Nursing confirmed that these items should have been included in the care plan. Another resident with morbid obesity and lumbar spondylolisthesis used bilateral enabler bars and a trapeze for bed mobility and transfers, with staff performing safety checks as ordered by the physician. Although there was a signed consent and risk-benefit form for the use of bed rails, the care plan and Kardex did not document the use of the enabler bars or trapeze. The Nursing Home Administrator confirmed via email that these devices were not documented in the care plan or Kardex, despite their use and the associated physician orders.
Failure to Provide Required Fall Prevention Devices
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for one resident. According to the facility's policy on managing falls and fall risk, staff are required to implement interventions based on each resident's specific risks, including the use of bilateral fall mats as indicated in the care plan. Review of the clinical record for a resident with dementia and hypertension showed that fall mats were to be in place at both sides of the bed, as documented in the care plan. However, during observations on two separate occasions, the resident was found lying in bed without any fall mats present, and none were found in the room. In a subsequent interview, the Nursing Home Administrator confirmed that the fall mats were not in place as required by the care plan.
Failure to Provide Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate catheter care and services to prevent urinary tract infections for a resident with a Foley catheter. Facility policy required that catheter tubing and bags be kept off the floor and that catheter care be documented with the date, time, and staff providing care. Observations on two separate occasions showed the resident's catheter bag in direct contact with the floor, contrary to policy. Staff interviews confirmed that the catheter bag should not have been on the floor. Additionally, review of the resident's clinical record revealed a lack of documentation for catheter care from the time of hospital readmission with a Foley catheter until several days later. Although there was a physician order for catheter care every shift, documentation was missing for multiple days and, when initiated, was only recorded for the day shift. The DON confirmed that catheter care should have been provided every shift, and the NHA acknowledged that the orders for catheter care were not re-populated until several days after the resident's return.
Failure to Provide Timely Dental Services and Denture Fitting
Penalty
Summary
The facility failed to provide routine and emergency dental services for a resident diagnosed with Alzheimer's disease, adjustment disorder with mixed anxiety, and depression. According to the facility's policy, selected dentists must be available for follow-up care, and social services are responsible for assisting residents with appointments. The resident, who had Medicaid managed care coverage, reported not having seen a dentist for the replacement of two missing upper right teeth. Documentation showed that the resident was in the process of receiving new dentures, with several dental visits scheduled and impressions taken for fabrication. However, the resident's care plan required assistance with inserting and removing dentures, and records indicated that both upper and lower dentures were ill-fitting and had plaque buildup. Despite being scheduled for a step 4 denture fitting, the resident was not seen by the dentist as planned. On one occasion, the dental provider made four attempts to see the resident during a scheduled visit but was unable to locate her. The dentist visits the facility approximately every six weeks, and the resident should have been seen prior to the next scheduled visit for her denture fitting. This lapse resulted in the resident not receiving timely dental care as required by facility policy and regulatory standards.
Delayed Hospital Transfer and Inadequate Pain Management Following Fracture
Penalty
Summary
A resident with Alzheimer's Disease and dementia, residing on a locked memory care unit, experienced a fall and subsequently complained of right thigh pain. An initial x-ray of the right hip was negative for fracture, and the resident was prescribed oxycodone for pain as needed. Over the following days, the resident continued to report significant pain, with documented pain scores ranging from 4 to 8, and received several doses of pain medication. Despite ongoing pain and difficulty ambulating, a second x-ray was not ordered until the next day, which revealed an acute right femur fracture late in the evening. After the positive fracture diagnosis, there was no documentation that the physician was notified promptly, nor was there evidence of further pain assessment or administration of pain medication throughout the night. The provider was not made aware of the x-ray results until the following morning, at which point the resident was assessed and orders were given for hospital transfer. This resulted in a delay of approximately 9.5 hours from the time the fracture was confirmed to the time the resident was sent to the hospital. There was also no documentation of when EMS was called or when the resident was actually transferred. During this period, the resident did not receive additional pain management or documented assessments for pain or discomfort. Upon hospital admission, the resident required surgical intervention for the fracture and was administered IV morphine for pain control. The facility failed to provide timely transfer to the hospital following confirmation of the femur fracture and did not adequately monitor or manage the resident's pain prior to transfer.
Failure to Provide Ordered Diabetes Medication Due to Lack of Pharmacy Follow-Up
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with diagnoses including type II diabetes mellitus and muscle weakness. The resident had a physician's order for Ozempic, to be administered subcutaneously every Sunday for diabetes management. Review of the Medication Administration Record (MAR) for June 2025 showed that on two Sundays, nursing staff documented 'other/see note,' but there was no further documentation in the progress notes or clinical record to indicate that the medication was administered on those dates. Additionally, there was no evidence that the facility received the medication or that any follow-up was conducted regarding its absence. An interview with the Director of Nursing (DON) confirmed that the pharmacy had never dispensed the Ozempic to the facility, and the DON could not provide additional information about the missing medication. Further review of the clinical record revealed no documentation that the physician was notified about the unavailability of the medication or that any follow-up actions were taken. The Nursing Home Administrator stated that staff are expected to follow up with the pharmacy and physician when medications are not available, but this was not documented in the resident's record.
Neglect Resulting in Harm Due to Improper Fluid Consistency Provided by Volunteer
Penalty
Summary
The facility failed to protect a resident from neglect when a volunteer provided a drink of thin liquid to a resident with physician orders for nectar thickened fluids. The resident, who had diagnoses including dysphagia, dementia, and muscle weakness, was in the activity room when the volunteer, without consulting nursing staff, gave the resident a thin liquid beverage. Facility policy and volunteer guidelines specifically instructed that volunteers should not provide food or drink to residents without first asking the resident's nurse, and that pre-thickened liquids should be provided per physician orders. As a result of receiving the incorrect liquid consistency, the resident began coughing and subsequently developed bilateral lobe pneumonia with a small left-sided effusion, as confirmed by a chest X-ray. The incident was documented in the clinical record and facility investigation, with staff interviews confirming that the volunteer did not follow established protocols regarding dietary restrictions and fluid consistencies for residents with swallowing difficulties.
Failure to Provide Prescribed Fluid Consistencies Results in Resident Harm
Penalty
Summary
The facility failed to ensure that residents with physician-ordered thickened liquids received drinks in the appropriate consistency, resulting in actual harm to one resident. One resident with diagnoses including dysphagia, dementia, and muscle weakness had a physician order for nectar thickened fluids. Despite this, the resident was given a thin liquid drink by a volunteer during an activity, which led to the resident coughing immediately after ingestion. The incident was documented in the clinical record and confirmed by the volunteer, who admitted to providing the thin liquid without thickening it first. A subsequent chest x-ray revealed the resident developed bilateral lobe pneumonia with a small left-sided effusion, and the resident required antibiotic treatment. Another resident, also diagnosed with dysphagia, dementia, and muscle weakness, had a physician order for nectar thickened liquids and no straws. However, observation revealed a Styrofoam cup with a straw containing thin liquid water at the resident's bedside. The nurse aide responsible for passing the water was unaware of the thickened liquid order and confirmed that the resident was dependent on staff for drinking. The speech language pathologist also confirmed that the resident should be receiving nectar thickened liquids per the current order. Facility policy required that pre-thickened liquids be provided per physician orders and that volunteers not provide food or drink to residents without consulting nursing staff. Despite these policies, both a volunteer and a nurse aide failed to follow the prescribed fluid consistencies for residents with dysphagia, resulting in one resident suffering actual harm and another being placed at risk.
Failure to Provide Appropriate Meal Textures
Penalty
Summary
Oak Hill Center for Rehabilitation and Nursing failed to meet the requirements for providing meals in a form designed to meet individual needs, specifically for residents requiring mechanical soft and pureed diets. On April 22, 2025, during lunch service, the facility served a mechanical soft meal that did not adhere to the planned menu textures. The chicken enchilada casserole was served with a whole flour tortilla instead of being chopped, and the black beans were served whole rather than ground. This was confirmed by the Nursing Home Administrator during a staff interview. Additionally, a resident with diagnoses including diabetes type II and essential hypertension was affected by this deficiency. The resident had been downgraded to a pureed diet due to difficulty swallowing, as noted by a speech therapist. However, the resident was served a mechanical soft diet instead of the required pureed diet. The dietary slip used during meal tray-line service was outdated and incorrectly listed the resident's diet, leading to the resident receiving the wrong meal texture. The error was identified and corrected during the meal service, but it highlighted a failure in communication and adherence to dietary orders.
Plan Of Correction
1) Facility cannot retroactively correct. Updated diet tickets were immediately printed for current residents. 2) Director of Nursing/Dietary Manager/Designee conducted an audit of current residents' diet orders to ensure they were accurate on newly printed diet slips and to ensure that no other residents received an inaccurate diet. No other concerns were identified. 3) NHA/Designee reeducated the dietary manager and dietary staff on the components of this regulation with an emphasis on ensuring that dietary tickets are printed daily so that they may accurately reflect the residents' most recent diet order. 4) NHA/Designee will conduct random audits of 5 residents' meal trays and tray tickets 3x a week x 4 weeks, then once a week x 2 months to ensure that tickets have been printed daily, and that residents have received the correct physician-ordered meal. The findings of these audits will be brought to the QAPI committee monthly or until substantial compliance is met and maintained. Auditing schedule to be modified if needed.
Failure to Meet Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not maintain the minimum required NA-to-resident ratios on the day shift for four out of seven days reviewed, on the evening shift for two out of seven days, and on the night shift for one out of seven days. The specific dates of non-compliance were December 29, 2024, January 2, 3, and 4, 2025, for the day shift; December 31, 2024, and January 3, 2025, for the evening shift; and January 1, 2025, for the night shift. The facility's census and staffing ratio information revealed that on these dates, the NA ratios were below the required levels. For instance, on December 29, 2024, the day shift had a NA ratio of 12.0 instead of the required 12.30 for 123 residents. Similarly, on January 1, 2025, the night shift had a NA ratio of 7.0 instead of the required 8.47 for 127 residents. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged the facility's failure to meet the required NA ratios during an interview on January 9, 2025.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review CNA staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of CNA staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review CNA ratios to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected CNA ratios 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) on specific shifts. On December 31, 2024, during the evening shift, the facility had a census of 127 residents but only maintained an LPN ratio of 4.0, falling short of the required 4.23. Additionally, on the same date and the night shift of January 1, 2025, the facility had the same census of 127 residents but only maintained an LPN ratio of 3.0, below the required 3.18. These deficiencies were confirmed by the Nursing Home Administrator during an interview on January 9, 2025, who acknowledged the accuracy of the staffing information and the failure to meet the required LPN ratios on the specified shifts.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review LPN staffing ratios for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of LPN staffing ratios to ensure ongoing compliance. Facility will conduct daily staffing meeting to review LPN ratios to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected LPN ratios 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. This deficiency was identified during a review of staffing documents and confirmed through staff interviews. Specifically, on January 1, 2025, the facility provided only 3.18 hours of direct care per resident, 3.17 hours on January 2, 2025, and 3.18 hours on January 3, 2025. The Nursing Home Administrator confirmed the accuracy of the staffing information during an interview on January 9, 2025.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review PPDs for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of PPD to ensure ongoing compliance. Facility will conduct daily staffing meeting to review PPDs to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected PPDs 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.
Failure to Include Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents were included and provided the right to participate in the person-centered care planning process. This deficiency was identified for two residents, Resident 25 and Resident 31, during a review of 32 residents. The facility's New Admission Introduction & Handbook states that care plans are created for each resident upon admission and reviewed quarterly, with an expectation that residents will be invited to participate in care plan meetings routinely. However, interviews with both residents revealed that they did not recall being invited to their recent quarterly care plan meetings. Resident 25, who has diagnoses including muscle weakness and chronic kidney disease, and Resident 31, who has diagnoses including anemia and pain, both lacked documentation in their clinical records regarding their invitation and participation in care plan meetings. An interview with the Director of Social Services confirmed that there was no process in place to ensure residents were invited to participate in their care plan meetings, despite the expectation that all residents who can participate should be invited.
Failure to Provide SNF-ABN Forms to Residents
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to two residents, which is necessary to inform them of items and services no longer deemed eligible for coverage under Medicare A. For Resident 2, the clinical record indicated that the last covered day of Medicare A services was September 1, 2024, yet the facility did not offer the SNF-ABN form as the resident planned to remain in the skilled nursing facility and receive skilled services. Similarly, for Resident 108, the clinical record showed the last covered day of Medicare A services was August 9, 2024, and the facility again failed to provide the SNF-ABN form as the resident intended to continue receiving skilled services in the facility. An interview with the Nursing Home Administrator confirmed the facility's acknowledgment of providing the incorrect document, which will be corrected going forward. This deficiency was identified under the regulation 28 Pa. Code 201.14 (a) Responsibility of licensee.
Inaccurate Resident Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate resident assessments for four residents, leading to deficiencies in the documentation of significant weight loss and medication management. Resident 33, diagnosed with Parkinson's Disease and moderate protein-calorie malnutrition, experienced significant weight loss over several months. However, the Minimum Data Set (MDS) assessments conducted in August and November 2024 did not reflect this weight loss, as confirmed by the Registered Dietician and acknowledged by the Nursing Home Administrator (NHA). Resident 37, with diagnoses including dementia and major depressive disorder, had a recommendation for a gradual dose reduction (GDR) of Quetiapine, which was not documented in the MDS assessment. The NHA revealed that the Registered Nurse Assessment Coordinator inaccurately coded the MDS assessment due to a delay in scanning the consult into the electronic health record. Similarly, Resident 46, diagnosed with dementia and anxiety disorder, had a physician's order for a GDR of Seroquel, which was not reflected in the October 2024 MDS assessment. Resident 67, diagnosed with dementia, hypertension, and dysphagia, was assessed to be at risk for severe protein-calorie malnutrition. However, the MDS assessment in September 2024 did not indicate this risk, despite a care plan focus on malnutrition and dehydration. The Regional Director of Clinical Services confirmed that the MDS assessment should have marked the resident as at risk for malnutrition, a point acknowledged by the NHA.
Deficient Wound Care Practices for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as evidenced by the care provided to two residents. Resident 64, who had severe protein calorie malnutrition and a stage 4 pressure ulcer, did not receive updated wound care orders in a timely manner. The Director of Nursing acknowledged that the new order recommendation from October 11, 2024, should have been updated by October 12, 2024, but the nurse failed to include the +Ag (silver) in the order. This oversight resulted in the resident not receiving the appropriate wound care treatment as recommended by the wound care consult. Resident 84, diagnosed with paraplegia and a recurring stage 4 sacral pressure ulcer, also experienced deficiencies in wound care. During a wound care observation, the wound nurse did not perform hand hygiene before, during, or after the procedure, and did not wear a gown despite the resident being on enhanced barrier precautions. Additionally, the soiled dressing was not dated, and collagen with silver was applied without an order. The Nursing Home Administrator confirmed these lapses in protocol, indicating a failure to adhere to professional standards of practice in wound care management.
Failure to Provide Mobility Assistance and Document Care
Penalty
Summary
The facility failed to provide appropriate services and assistance to maintain or improve mobility for two residents with limited mobility. Resident 37, who has a contracture of the left hand and is dependent on a wheelchair, had physician orders for a splint and active range of motion (ROM) exercises. However, documentation revealed that these interventions were frequently marked as not applicable or left blank over several months, indicating a lack of consistent implementation of the prescribed care. The Nursing Home Administrator acknowledged that refusals should be documented and evaluated for tolerance, but this was not reflected in the records. Resident 55, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, reported difficulty in receiving assistance for daily ambulation with a walker, as prescribed. The resident's care guide indicated a requirement for ambulation to and from the dining room, but there was no documented evidence that this program was being carried out. The Nursing Home Administrator noted that the task was not entered correctly for documentation, which led to a lack of recorded evidence of the ambulation assistance being provided.
Deficiencies in Enteral Feeding Care for Residents
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications. For Resident 53, who has diagnoses of hemiplegia, hemiparesis, and dysphagia, the clinical record revealed an order for bolus feeding via a gastrostomy tube five times daily. However, there were no orders for G-tube site monitoring and care or syringe changes, which are necessary to prevent complications such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. During an interview, the Nursing Home Administrator, Director of Nursing, and Employee 1 acknowledged that orders should have been in place for these aspects of care. Similarly, for Resident 67, who has a gastrostomy with PEG tube, dementia, and dysphagia, the physician orders indicated that the PEG tube syringe was to be changed weekly, which was insufficient. The resident receives bolus enteral feedings five times a day via an open system. The Director of Nursing later revealed that the order for syringe changes should have been daily, not weekly, indicating a lapse in ensuring proper care and monitoring for residents with feeding tubes.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to complete timely trauma assessments and develop individualized care plans for trauma-informed care for two residents diagnosed with PTSD. Resident 10's clinical record showed a diagnosis of PTSD and traumatic brain injury, but there was no evidence of trauma-informed care assessments or follow-up care related to the PTSD diagnosis. The care plan for Resident 10 included a focus area for PTSD but lacked details on the source of PTSD or known triggers. Interviews with facility staff, including the Nursing Home Administrator and Director of Nursing, confirmed that no trauma assessment had been completed for Resident 10. Resident 105, who also had a PTSD diagnosis, expressed a desire to continue therapy sessions with a VA counselor. Her clinical records, however, did not reflect a PTSD diagnosis or any personalized interventions to prevent re-traumatization. Despite her request for continued counseling and her identification of specific triggers, such as the sounds of gunfire and being approached from behind, these were not documented in her care plan. The Director of Nursing was unable to find any information regarding Resident 105's PTSD diagnosis in her clinical records, although the VA confirmed her past services for PTSD. The Nursing Home Administrator acknowledged that social services should have conducted an initial trauma assessment and included this information in the resident's care plan.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of enabler bars/side rails for two residents, leading to a deficiency. For Resident 84, who has paraplegia and morbid obesity, bilateral side rails were observed attached to the bed without any documentation of a signed consent or a review of the risks and benefits with the resident or their representative. The Bed Rail Safety and Informed Consent Form for this resident was not signed until the day after the observation. Similarly, for Resident 105, who has COPD and CHF, an enabler rail was observed on the left side of the bed. Although the initial evaluation indicated that side rails were not necessary, a physician's order for a side rail was effective the same day. However, there was no additional evidence of an assessment to determine the appropriateness and safety of the enabler rail for this resident. The Bed Rail Safety and Informed Consent Form for Resident 105 was also not signed until the day after the observation. The Nursing Home Administrator confirmed the lack of timely consent and assessment for both residents.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that prescription medications and treatments were stored in locked compartments and only accessible by authorized personnel for three residents. Resident 2 had a medication cup with a powder substance at the bedside, which was used for a rash but was not authorized for self-administration. The Assistant Director of Nursing confirmed that the powder should not have been stored at the bedside, and the Director of Nursing reiterated that Resident 2 had no orders for self-administration. Resident 80 had a tube of Nystatin-Triamcinolone cream and a bottle of Nystatin powder left in a wash basin on the bed, despite the cream being discontinued earlier. The resident did not self-administer these medications, and the Director of Nursing confirmed they should have been stored in the treatment or medication cart. Resident 84 had a medication cup with Triad cream at the bedside, which was left there for staff convenience, despite the resident having no self-administration orders. The Director of Nursing confirmed that the cream should not have been left at the bedside.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) appropriately, as observed during a tour of the nursing units. EBP signage was present on the doors of three residents, but there was no personal protective equipment (PPE) storage bin located outside of the rooms or on a door hanger. Employee 14, a nurse aide, was observed at the bedside of a resident with open wounds, bagging soiled linen without wearing a gown. This indicates a lack of adherence to the facility's policy on EBP, which requires the use of gowns and gloves during high-contact resident care activities. Interviews with staff revealed a lack of understanding and implementation of EBP. Employee 14 and Employee 13, an LPN, could only provide a reason for EBP for one resident, who had open wounds. The Infection Control Professional confirmed that PPE should have been available and used, and subsequently removed the EBP signage from the doors of two residents for whom EBP did not apply. The Nursing Home Administrator and Director of Nursing acknowledged that only residents on EBP should have signage, and that staff should be aware of the reasons for EBP and use appropriate PPE.
Failure to Inspect Side Rails for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular inspections of side rails/enabler bars to identify areas of possible entrapment for two residents. For Resident 43, who has diagnoses including abnormalities of gait and hypertension, bilateral enabler bars were installed on the bed. However, the safety measurements for these rails were not documented until five days after installation. This delay in documentation indicates a lapse in the facility's adherence to its policy on the proper use of side rails, which requires assessment of the space between the mattress and side rails to reduce entrapment risk. Similarly, for Resident 105, who has chronic obstructive pulmonary disease and congestive heart failure, a side rail was installed on the left side of the bed. Despite an order for this installation being effective for nearly two months, there was no evidence of any inspection or measurement of the side rail to identify possible entrapment areas. The Nursing Home Administrator confirmed the absence of documentation for these inspections, further highlighting the facility's failure to comply with safety protocols for side rail usage.
Medication Administration and Wound Care Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration for two residents. For one resident with dry eye syndrome, the facility did not include the prescribed eye drops in the resident's medication orders, despite a consultation indicating the need for Systane ophthalmic solution. The resident expressed concern about not receiving the eye drops, and it was confirmed by the Director of Nursing that the medication was not added to the orders until a later date. For another resident with paraplegia and a stage 4 sacral pressure ulcer, the facility did not follow the physician's order for negative pressure wound therapy (NPWT). During an observation, a Licensed Practical Nurse applied collagen with silver to the wound without a physician's order. Additionally, the NPWT was not initiated on the date specified by the wound care specialist, and no explanation was provided for the delay. The Nursing Home Administrator confirmed that there should have been a physician's order for the use of collagen with silver.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who was reviewed for respiratory care. The resident, who has diagnoses including bipolar disorder and hypertension, was observed using oxygen at 4 liters per minute, despite a physician's order for oxygen at 2 liters per minute. The resident's care plan indicated an intervention of oxygen via nasal prongs at 2 liters as ordered, but observations on two separate occasions revealed the resident using oxygen at a higher rate. Additionally, the facility did not document the maintenance of the resident's oxygen equipment as required. The resident's clinical record showed a new order to change the humidifier bottle, clean the oxygen concentrator filter, and change the oxygen tubing, all starting on a specific date. However, the treatment administration records for October and November failed to show that these tasks were completed prior to the specified date. An interview with the Director of Nursing revealed that the resident should have a titrate oxygen order, with a baseline of 2 liters per minute, increasing to 4 liters per minute during activities.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with End Stage Renal Disease (ESRD), hypertension, and diabetes mellitus. The resident's care plan included an intervention to avoid drawing blood or taking blood pressure in the arm with the dialysis graft. However, blood pressure was repeatedly documented in the resident's left arm, which had the dialysis access, on multiple occasions. Additionally, there was a missing communication sheet for dialysis on a specific date, and the resident's dialysis order was not entered in a timely manner upon admission. Furthermore, the facility did not weigh the resident prior to dialysis on several occasions, as required by the resident's care plan. The resident had been attending dialysis sessions three times a week since admission, but the dialysis order was only entered two weeks later. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these deficiencies, acknowledging the lack of timely documentation and incorrect recording of blood pressure measurements.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident with dental concerns. The resident, who has congestive heart failure and a vitamin deficiency, expressed concern about the lack of routine dental care, despite having her own teeth and being accustomed to maintaining them. A dental consult form from December 1, 2023, recommended a dental cleaning and checkup in six months, but there was no evidence in the resident's clinical record of any additional dental services being received since that date. The Nursing Home Administrator acknowledged that the dental provider is responsible for tracking and scheduling follow-up appointments, but also noted the need for the facility to implement a system to track these appointments.
Failure to Implement Proper Care Leads to Resident Harm
Penalty
Summary
The facility failed to implement treatment and care in accordance with professional standards of practice, resulting in actual harm to a resident who developed a urinary tract infection and septic shock. The resident, who had a history of urinary tract infections and other medical conditions, had orders for foley catheter care every shift. However, the Treatment Administration Record (TAR) showed that catheter care was not completed on several occasions. Additionally, a urinalysis ordered stat was delayed, and the specimen was contaminated, leading to a lack of timely and appropriate treatment. The resident's antibiotic medication, Doxycycline, was not administered as ordered due to unavailability in the facility's backup supply, and there was no documentation of physician notification for the missed dose. The delay in obtaining the urine specimen and administering the antibiotic contributed to the resident's deteriorating condition, as evidenced by elevated white blood cell counts and subsequent hospitalization for septic shock. The resident's condition worsened, with symptoms including decreased responsiveness, low blood pressure, and increased respiratory rate, leading to emergency medical intervention. Further deficiencies were noted in the facility's failure to document wound treatments and obtain weekly weight measures as ordered. The lack of documentation and adherence to physician orders for wound care and weight monitoring further exemplified the facility's failure to provide comprehensive care. Interviews with the Director of Nursing and Nursing Home Administrator revealed awareness of these issues, but the deficiencies resulted in significant harm to the resident, necessitating hospitalization.
Failure to Adhere to Care Plans for Two Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents, leading to deficiencies in meeting their physical needs. Resident 3, diagnosed with heart failure and hypertension, was admitted to the facility and had physician orders for twice-weekly showers and weekly weights for four weeks. However, the resident only received one shower and was weighed only once during the specified period, contrary to the orders. The Director of Nursing confirmed the discrepancies, attributing the missed showers to an incorrect entry of the bath/shower order. Resident 10, diagnosed with heart failure and dementia, also experienced a deficiency in care. The resident had orders for weekly weights for four weeks following admission. Despite this, the resident was weighed only twice, once on the admission date and once several weeks later. The Director of Nursing and the Nursing Home Administrator both acknowledged that the resident should have been weighed weekly as per the physician's orders. These failures indicate a lack of adherence to the prescribed care plans for both residents.
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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