Oak Hill Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 827 Georges Station Road, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395646
- Inspections on file
- 35
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Oak Hill Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain accurate records and proper accounting of controlled medications for two residents. In one case, a resident receiving hospice care did not have Ativan solution properly documented or accounted for after administration, and the medication was later found missing from the emergency narcotic E-box. In another case, multiple doses of Tramadol were signed out for a resident with atrial fibrillation, but there was no documentation on the MAR that these doses were administered. Staff did not follow required procedures for documenting and reconciling controlled substances.
The facility failed to accurately complete MDS assessments for multiple residents, leaving required sections for cognitive and mood interviews unassessed despite residents being able to participate. Additionally, several residents who received antibiotics during the assessment period were not properly coded as having received these medications in the MDS, resulting in incomplete clinical documentation.
The facility did not consistently monitor or document urinary output for three residents with indwelling catheters or nephrostomy tubes, and failed to obtain a physician's order for catheter use and care for one resident. These deficiencies were confirmed through record review, staff interviews, and direct observation.
A resident with an ileostomy experienced frequent leakage and improper care because staff did not use the physician-ordered supplies, instead relying on a single type of product stocked for all residents. Nursing staff and the DON confirmed that the correct supplies were not provided, resulting in ongoing issues for the resident.
The facility did not properly document the administration and disposal of controlled medications for three residents. For one resident, there was no evidence that removed Fentanyl patches were disposed of with a witness as required. For two other residents, doses of Tramadol were signed out but not documented as administered in the clinical records. The DON confirmed the lack of required documentation.
A resident with dementia and on hospice care did not receive the prescribed dose of diazepam gel for agitation, as staff repeatedly administered only one 0.5 ml syringe instead of the ordered two syringes per dose. This resulted in a significant medication error, as confirmed by facility records and administrator interview.
The facility did not provide all items listed on the planned lunch menu, as residents did not receive the dinner roll and margarine that were supposed to accompany their meal. The Dietary Manager confirmed the omission and was unaware these items were required.
During a lunch meal service, a test tray revealed that the broccoli served was overcooked, mushy, and not palatable. The Dietary Manager confirmed the issue with the broccoli's texture and palatability.
Surveyors observed that the ice machine in the pantry had a buildup of a white, slimy substance on the dispenser and screen, and that containers of fresh blueberries in the refrigerator were not labeled or dated. The Dietary Manager confirmed these sanitation lapses.
Two residents with cognitive impairment and a history of falls did not have complete clinical documentation, including missing nurse aide records for daily care and absent documentation of fall incidents and RN assessments. The DON confirmed that care was provided but not properly documented.
The QAPI committee failed to correct recurring deficiencies, including lack of notification of Medicare coverage changes, failure to meet professional standards, inadequate accident prevention, issues with oxygen therapy, untimely nurse aide evaluations, improper medication management, unsanitary food storage, and incomplete clinical records. Despite audit and review processes, the same issues persisted across multiple surveys.
The facility did not hold or document required care plan meetings for two residents, one with Parkinson's and one with dementia, and failed to invite them or their responsible parties to participate, as confirmed by interviews and record review.
A resident with moderate cognitive impairment and an indwelling urinary catheter was found with an uncovered urinary catheter drainage bag visible from the hallway, contrary to facility policy requiring privacy covers to maintain dignity. Staff confirmed that the bag should have been covered, but it was not.
A resident was not given the required Advanced Beneficiary Notice of Non-coverage when Medicare Part A coverage ended, as confirmed by clinical record review and staff interview. The facility initiated discontinuation of coverage but did not issue the necessary notice to the resident or their representative.
The facility did not provide required written notifications regarding hospital transfers and bed-hold policies to two residents and their representatives. One resident with dementia and another with multiple chronic conditions were transferred to the hospital, but neither received the mandated written notifications or bed-hold notices, as confirmed by the Nursing Home Administrator.
The facility did not develop individualized care plans for four residents, including those with chronic UTI on long-term antibiotics, a resident on dialysis with a bariatric air mattress, and a resident with an indwelling urinary catheter. These omissions were confirmed by review of records, staff interviews, and direct observation.
A registered nurse administered Epinephrine to a resident without a physician's order after the resident experienced shortness of breath following a dose of Amoxicillin Potassium Clavulanate. The resident had a history of respiratory failure and required staff assistance for daily care. Review of the clinical record confirmed there was no physician's order for the Epinephrine administration, which was not in accordance with facility policy and professional standards.
A resident who was cognitively intact and dependent on staff for bathing did not receive scheduled showers or baths on two occasions, with no documentation of care provided or refusals. The DON confirmed the absence of required documentation for these missed bathing sessions.
Two residents were provided with air mattresses as ordered by their physicians, but the facility did not complete required safety assessments prior to use. Observations confirmed the mattresses were in place, and the DON acknowledged that no specific safety assessments had been performed, contrary to facility policy.
A resident receiving IV Meropenem after dialysis did not have documented evidence that their midline catheter was flushed with saline before and after medication administration, as required by physician orders and facility policy. The DON confirmed the lack of documentation for these procedures.
A resident with heart failure and hypertension who required continuous supplemental oxygen did not have their oxygen tubing and canister replaced according to physician orders. Observations and staff interviews confirmed that the equipment was not changed on the scheduled day, resulting in a failure to provide respiratory care consistent with professional standards.
A resident with moderate cognitive impairment, a history of falls, and dementia was provided with bilateral enabler bars per physician order, but the facility did not complete or document the required safety assessment prior to their use. The DON confirmed the absence of this assessment, which is required by facility policy.
A required annual performance evaluation was not completed for a nurse aide, as confirmed by the absence of documentation and the Human Resource director's statement. This deficiency was identified during a review of personnel records.
Surveyors observed that a locked compartment in the medication refrigerator, containing an unopened bottle of liquid Ativan, was not permanently affixed and could be removed. Both a RN and the Nursing Home Administrator confirmed that the locked box should have been permanently secured, as required by facility policy.
A resident with dementia and a sacral pressure ulcer did not receive wound care in accordance with infection control policies when an LPN failed to perform hand hygiene between glove changes and did not wear a gown as required by enhanced barrier precautions, as confirmed by staff interviews and direct observation.
Surveyors identified unsanitary conditions in the kitchen, including food and debris buildup on meal carts and a grease trap, as well as a dirty wall-mounted fan operating near the food prep area. Additionally, required dishwasher temperature logs were incomplete for multiple days and meals, with the Dietary Manager confirming these issues.
A resident filed a grievance about a nurse aide's behavior in the dining room, which was investigated by the facility. Although the investigation was completed and actions were taken, the facility failed to provide the resident with a written report of the findings, as required by their policy.
A facility failed to clarify a physician's order for a resident's Restorative Nursing ROM program, which involved using a weighted dowel rod. The order lacked specifics on the weight, frequency, and repetitions, and there was no evidence of physician contact for clarification. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to accurately document a resident's participation in a Restorative Nursing ROM program. Physician's orders required the program to maintain upper extremity strength, but records for several months showed multiple instances marked as 'N/A' without evidence of completion or refusal. The Nursing Home Administrator confirmed the documentation issues.
The facility was found to have unsanitary conditions in the kitchen, including a black substance on the wall near the dishwasher, dusty shelves, and a dish warmer tray with a thick substance. The Dietary Manager confirmed these issues, acknowledging that the kitchen and equipment should be clean and free of debris.
The facility failed to maintain a clean environment for four residents, as their wheelchairs were observed with significant dust and debris over several days. Interviews with staff confirmed that the wheelchairs should have been clean, indicating a lapse in maintaining a safe and comfortable environment.
The facility did not complete annual performance evaluations for three nurse aides as required by their policy. The evaluations for these aides, who were hired in early 2023, were due in early 2024 but were not documented. This was confirmed by the Nursing Home Administrator.
The facility failed to document the administration of controlled medications for three residents, as doses of MS Contin and oxycodone were signed out but not recorded in the MARs or nursing notes. This lack of documentation was confirmed by the Nursing Home Administrator.
The facility failed to document the opportunity for residents to formulate advance directives and their decisions to accept or decline assistance. This deficiency affected four residents, including those with chronic obstructive pulmonary disease, cerebral infarction, hemiplegia, and acute respiratory failure. Despite discussions occurring, documentation was missing, as confirmed by the Social Service Coordinator.
The facility did not issue timely Medicare non-coverage notices for two residents discharged without documented evidence of such notices, as required by policy. An interview with the Nursing Home Administrator confirmed the oversight, which was identified through a review of facility policies, clinical records, and staff interviews.
The facility failed to verify the nursing license of a registered nurse and the registry status of a nurse aide in a timely manner, as required by their abuse prevention policy. This oversight was confirmed by the HR Director, indicating a lapse in compliance with state regulations.
The facility failed to provide written notification to two residents, their representatives, and the state LTC ombudsman regarding their hospital transfers. Despite the facility's policy requiring such notifications, two cognitively intact residents with chronic congestive heart failure were transferred without receiving the necessary written communication. The Nursing Home Administrator confirmed the oversight.
The facility did not provide bed-hold notices to the responsible parties of two residents who were transferred to the hospital, despite the residents being cognitively intact and requiring assistance due to chronic congestive heart failure. This was confirmed by the Nursing Home Administrator and violated resident rights as per facility policy.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident, with a history of atrial fibrillation and thrombosis, was prescribed rivaroxaban, an anticoagulant. However, there was no documented baseline care plan addressing the resident's anticoagulant therapy, a deficiency confirmed by the Nursing Home Administrator.
A facility failed to follow a physician's orders for a resident's wound care. The resident required assistance for daily care and had an order to cleanse and wrap a wound on the right shin. Observations showed the wrap was not applied, despite records indicating the treatment was completed. The resident was unaware of any changes, and the administrator confirmed the discrepancy.
A resident with cerebral palsy and severe cognitive impairment did not receive required pressure-relieving interventions as per physician's orders. Observations showed the absence of a right palm guard splint and a heel pro, confirmed by staff interviews, leading to a deficiency in care.
The facility failed to conduct safety assessments for two residents, leading to deficiencies in their care. One resident, with a Stage 4 pressure ulcer, was provided an air mattress without assessing potential safety hazards. Another resident, at risk for falls, was transported in a wheelchair without leg rests, with no assessment or care plan regarding this preference. These oversights were confirmed by facility staff.
A resident with atrial fibrillation and heart failure was not provided with the prescribed oxygen therapy. The resident was ordered to receive continuous oxygen at 3 liters per minute, but observations showed the flow rate was set at 1.5 liters per minute. This was confirmed by both a registered nurse and the DON.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying specific triggers or implementing measures to prevent re-traumatization. The resident, who was cognitively intact and required assistance for daily care, had diagnoses including schizophrenia and PTSD. The care plan noted PTSD and anxiety, but there was no evidence of trauma-informed care assessments. The Nursing Home Administrator admitted that such assessments were not being conducted.
The facility did not label multi-dose medication containers with the date they were opened, as required by its policy. During an observation, surveyors found opened and undated vials of Levemir and glargine insulin, and a bottle of Latanoprost solution eye drops on a medication cart. Interviews with staff confirmed that these medications should have been dated upon opening.
The facility did not employ a full-time qualified dietitian, as required for its food and nutrition service. The Dietary Manager and Nursing Home Administrator confirmed that the facility had been without a dietitian since the previous dietitian's employment ended, and no consultant was employed either.
A facility failed to maintain accurate clinical records for a resident who was documented as receiving wound care for a non-existent condition. Despite physician's orders for wound care on a reddened area, observations and staff interviews confirmed the absence of such a condition, indicating inaccurate documentation in the Treatment Administration Records.
A facility failed to obtain necessary hospice documentation for a resident receiving hospice services. The required hospice election of benefits form and certification of terminal illness form were not present in the resident's or hospice provider's records, despite the facility's policy mandating their acquisition. This deficiency was confirmed through staff interviews and record reviews.
The QAPI committee failed to address recurring deficiencies related to abuse and neglect policies, quality of care, and pharmacy services. Despite developing plans of correction, the committee did not successfully implement these plans, as evidenced by repeated citations in a recent survey.
The facility failed to ensure that two nurse aides received the required 12 hours of annual in-service training, and one nurse aide did not receive mandatory training on abuse and dementia care. This was confirmed through a review of training records and an interview with the Nursing Home Administrator.
Failure to Accurately Account for and Document Controlled Medications
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications in its emergency narcotic E-box and for two residents. According to facility policy, nurses are required to fully document the removal of emergency medications, including completing and faxing a sign-out sheet to the pharmacy, logging entries with signatures, and reconciling medication counts with controlled substance records. However, for one resident receiving hospice care for ovarian cancer, there was no documentation on the controlled substance record for two doses of Ativan solution that were administered, and the medication was later found missing from the E-box. The missing Ativan was not reported to the Director of Nursing, management, or pharmacy as required, and staff did not follow proper procedures for counting and documenting medications when accessing the E-box, making it impossible to determine when the medication went missing. For another resident with a diagnosis of atrial fibrillation, controlled substance records indicated that multiple doses of Tramadol were signed out on various dates. However, there was no documented evidence on the Medication Administration Record (MAR) that these doses were actually administered to the resident. This discrepancy was confirmed by the Nursing Home Administrator, who acknowledged the lack of documentation for the signed-out doses. The deficiencies were identified through review of facility policy, clinical records, a facility investigation, and staff interviews. The findings demonstrate that the facility did not adhere to its own policies and procedures for the documentation and accounting of controlled substances, resulting in unaccounted-for medications and incomplete records for the residents involved.
Inaccurate MDS Assessments and Medication Coding
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for nine out of 26 residents reviewed. Specifically, for several residents who were able to make themselves understood and were able to understand others, the MDS assessments were coded to indicate that a Brief Interview for Mental Status (BIMS) and a mood interview should be conducted. However, the corresponding sections for these assessments (Sections C0200-C0500 for BIMS and Section D0150 for mood interview) were left as not assessed, despite the residents' ability to participate in these interviews. This was confirmed through review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, which indicated that these sections should have been completed for residents who were at least sometimes understood. Additionally, the facility failed to accurately code the administration of antibiotic medications in the MDS assessments for three residents. Physician's orders and Medication Administration Records (MARs) showed that these residents received antibiotics during the seven-day look-back period, but the MDS assessments were coded to indicate that no antibiotics were administered. This discrepancy was confirmed by the Nursing Home Administrator, who acknowledged that the MDS assessments did not reflect the actual administration of antibiotics as required by the RAI User's Manual. The deficiencies were identified through a review of clinical records, MDS assessments, and staff interviews, which revealed that required assessment sections were either not completed or inaccurately coded. The failure to accurately complete and code the MDS assessments resulted in incomplete documentation of residents' cognitive status, mood, and medication administration during the assessment periods.
Failure to Monitor Urinary Output and Obtain Catheter Orders
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of urinary output for three residents with indwelling urinary catheters or nephrostomy tubes, as required by facility policy. For one resident with moderate cognitive impairment and a foley catheter, there was no documented evidence that staff measured or recorded urine output, despite care plan instructions to report changes in urine characteristics. Another resident with a nephrostomy tube and diagnoses including heart failure had multiple shifts where urinary output was not documented, as confirmed by review of clinical records and interview with the Director of Nursing. Additionally, a third resident with moderate cognitive impairment and an indwelling urinary catheter did not have a physician's order for the catheter or for catheter care documented in the clinical record. Observations confirmed the presence of the catheter and drainage bag, but there was no evidence of urine output monitoring or documentation of catheter care. The Director of Nursing confirmed the lack of required documentation and physician's orders for these residents.
Failure to Provide Physician-Ordered Ileostomy Supplies
Penalty
Summary
Staff failed to provide proper ileostomy care for a resident who required such services. The facility's policy required staff to review the resident's care plan and assess for any special needs, and the physician's orders specified the use of particular ileostomy supplies, including specific brands and types of barriers, pouches, and accessories. However, observations revealed that the resident's ileostomy pouch was leaking, and the resident reported frequent leakage and multiple changes in a single day since returning from the hospital. The supplies in use did not match the physician's orders, as the facility only stocked a single type of ileostomy product for all residents, regardless of individual needs or orders. Interviews with nursing staff and the DON confirmed that the correct, physician-ordered supplies were not being used for the resident's ileostomy care. The failure to provide the ordered supplies resulted in ongoing leakage issues for the resident, contrary to both the care plan and physician's instructions. This deficiency was identified through review of policies, clinical records, direct observation, and staff interviews.
Failure to Document Administration and Disposal of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for three residents. Facility policy required that the administration of medication be documented by initialing the Medication Administration Record (MAR) after each dose, and that the disposal of controlled substances be witnessed and documented by two staff members. For one resident receiving a Fentanyl transdermal patch for pain management, there was no documented evidence that the removed patches were disposed of in the presence of a nurse and a witness as required by policy. This lack of documentation was confirmed by the Director of Nursing. Additionally, for two other residents prescribed Tramadol, a controlled opioid medication, the controlled drug accountability records showed that doses were signed out for administration, but there was no documented evidence in the clinical records that these doses were actually administered. The Director of Nursing confirmed the absence of documentation for the administration of these controlled drugs. These findings indicate that the facility did not follow its own policies for documenting the administration and disposal of controlled substances for these residents.
Failure to Administer Correct Dose of Controlled Medication
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of an incorrect dose of a controlled medication to a resident. Facility policy required that medications be administered according to prescriber orders, with staff verifying the right resident, medication, dosage, time, and method of administration. For a resident with dementia who was receiving hospice services, physician orders specified that 10 mg of diazepam gel should be administered every two hours as needed for agitation, using two 0.5 ml syringes per dose. Review of the controlled drug record revealed that, on multiple occasions, staff signed out and administered only one 0.5 ml syringe of diazepam instead of the prescribed two syringes. This discrepancy was confirmed by the Nursing Home Administrator, who acknowledged that staff had not followed the prescribed dosing instructions on several documented dates and times. The failure to administer the correct dose constituted a significant medication error for the resident involved.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to follow its pre-approved planned menu for the lunch meal on June 16, 2025. A group of residents reported that they did not always receive the items listed on the menu. Review of the posted menu for that day's lunch indicated that residents were to receive honey pot roast, fried potatoes, seasoned red cabbage, bread pudding, a dinner roll with margarine, and a beverage. However, observations during the lunch meal revealed that the dinner roll and margarine were not provided to the residents, including one resident who specifically did not receive these items. The Dietary Manager confirmed that the dinner roll and margarine were not served and was unaware that they were supposed to be included with the meal.
Failure to Serve Palatable Food During Lunch Meal Service
Penalty
Summary
The facility failed to serve food that was palatable, as required by regulations. On June 17, 2025, a review of the posted lunch menu indicated that residents were to receive smothered pork chop, mashed potatoes, steamed broccoli, pineapple delight cake, a dinner roll with margarine, and a beverage. During the lunch meal service on the French Hall, a test tray was observed and tasted at 12:14 p.m., after the food cart had left the kitchen at 11:53 a.m. and arrived on the nursing unit at 11:54 a.m., with the last resident served at 12:14 p.m. The broccoli on the test tray was found to be mushy and not palatable. The Dietary Manager confirmed at the time of observation that the broccoli was overcooked and mushy.
Failure to Maintain Sanitary Food Storage and Ice Machine Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas, as evidenced by observations and record reviews. The ice machine in the pantry room was found to have a buildup of a white, slimy substance on the plastic dispenser and the black metal screen where leftover ice fell, despite cleaning records indicating the machine had been sanitized less than a month prior. Additionally, three small containers of fresh blueberries were observed in the pantry refrigerator without any labels or dates. The Dietary Manager confirmed that the ice machine required cleaning and that the blueberries should have been labeled and dated.
Incomplete Clinical Documentation and Missing Incident Records
Penalty
Summary
The facility failed to ensure that clinical records for two residents were complete and accurately documented, as required by accepted professional standards. For one resident with moderate cognitive impairment and a history of falls, nurse aide documentation was missing for multiple days in June for essential care tasks such as bed mobility, snacks, continence, fluid intake, hygiene, toilet use, and transfers. For another resident, also with moderate cognitive impairment and a history of falls, there was no documentation in the clinical record of two separate fall incidents or of registered nurse assessments following those falls. Additionally, nurse aide documentation for daily care tasks was missing on numerous shifts across May and June. Interviews with the Director of Nursing confirmed that both residents received their care, but staff failed to document the care provided in the clinical records as required. The lack of documentation included both routine care and incident-related assessments, specifically after falls, which were not recorded in the clinical records. These findings were based on reviews of clinical records, facility investigations, and staff interviews.
Repeated QAPI Failures Lead to Ongoing Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed these issues. Despite developing plans of correction after previous surveys, the facility continued to have repeated deficiencies in several areas, including failure to notify residents of changes in Medicare coverage, not providing services that meet professional standards, and not preventing accident hazards. The QAPI committee was responsible for reviewing audit results and monitoring compliance, but the same deficiencies were identified in subsequent surveys, indicating that the committee's actions were ineffective. Deficiencies were also noted in the areas of oxygen therapy, timely completion of nurse aide performance evaluations, accountability and proper storage of controlled medications, and ensuring that medications were properly labeled and stored. Additionally, the facility failed to maintain sanitary conditions in food storage and preparation, and did not ensure that clinical records were complete and accurately documented. These issues were cited under multiple federal tags, including F582, F658, F689, F695, F730, F755, F761, F812, and F842. The repeated nature of these deficiencies across multiple survey periods demonstrates that the QAPI committee did not successfully implement or sustain corrective actions. The committee's ongoing review and audit processes did not result in effective resolution of the cited issues, leading to continued noncompliance with state and federal regulations governing the quality of care and services provided.
Failure to Conduct and Document Resident Care Plan Meetings
Penalty
Summary
The facility failed to routinely conduct care plan meetings and invite residents or their responsible parties to participate in the development and implementation of person-centered care plans. Review of facility policy indicated that residents and/or their responsible parties should be given the opportunity to review and participate in care plan conferences. However, for two residents reviewed, there was no documented evidence that such meetings were held or that invitations were extended to the residents or their responsible parties. One resident, who was able to understand and communicate and required assistance with activities of daily living due to Parkinson's disease, reported that neither she nor her responsible party had been invited to care plan meetings. Another resident, who was cognitively impaired and required assistance due to dementia with behavioral disturbances, also had no documentation of care plan meetings or invitations. Facility leadership confirmed that care plan meetings were not being held at least quarterly as required.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and an indwelling urinary catheter was observed lying in bed with the urinary catheter drainage bag, containing urine, hanging on the bed frame and visible from the hallway. Facility policy requires that urinary catheter bags be kept covered to maintain resident dignity. Staff interviews confirmed that catheter drainage bags are expected to have privacy covers, but in this instance, the resident's bag did not have one, resulting in a failure to uphold the resident's right to dignity as outlined in facility policy and state regulations. The resident involved had a diagnosis of neurogenic bladder and required an indwelling urinary catheter, as documented in the admission MDS assessment. The lack of a privacy cover for the catheter bag was confirmed by both an LPN and the Nursing Home Administrator during interviews.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the required Advanced Beneficiary Notice of Non-coverage (ABN) to a resident or the resident's representative when Medicare Part A coverage ended. Clinical record review showed that Medicare coverage for the resident began on January 11, 2025, and the last covered day was February 12, 2025, with the facility initiating discontinuation of coverage before benefit days were exhausted. Documentation confirmed that the ABN was not issued to the resident. This was verified during an interview with the Nursing Home Administrator, who acknowledged that the notice was not provided as required.
Failure to Provide Written Transfer and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for transfer to the hospital, as well as to issue required bed-hold notices to the responsible parties for two residents. According to the facility's policy, residents and/or their representatives must receive written information about bed-hold policies both in advance (such as at admission) and at the time of transfer, or within 24 hours if the transfer is emergent. For one resident with moderate cognitive impairment and dementia, who was transferred to the hospital for pneumonia, there was no documented evidence that either the transfer notification or the bed-hold notice was provided to the resident or their representative. Similarly, another resident, who was cognitively intact and had diagnoses including heart failure, hypertension, and kidney failure, was transferred to the hospital after experiencing shortness of breath and fatigue. There was no documentation that written notification of the transfer or a bed-hold notice was provided to this resident or their responsible party. Interviews with the Nursing Home Administrator confirmed that these notifications were not given as required by facility policy and state regulations.
Failure to Develop Individualized Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop individualized care plans for four residents, as evidenced by a review of clinical records and staff interviews. For one resident who was cognitively intact and frequently incontinent, there was no documented care plan addressing the long-term use of Methenamine Hippurate for chronic urinary tract infections, despite ongoing physician orders and nurse practitioner notes indicating the need for suppressive therapy. Another resident, who required assistance with daily care and had dementia, also received Methenamine for recurrent urinary tract infections without a corresponding care plan to address this antibiotic use. Additionally, a resident with cognitive intactness, a pressure ulcer, renal failure, and on dialysis had no care plans developed for the use of a bariatric air mattress or for dialysis treatments, even though these interventions were ordered and observed in use. A fourth resident, with moderate cognitive impairment, neurogenic bladder, and an indwelling urinary catheter, did not have a care plan addressing the care and treatment needs related to the catheter, despite observations confirming its use. These deficiencies were confirmed through interviews with the Director of Nursing and the Nursing Home Administrator.
Medication Administered Without Physician's Order
Penalty
Summary
A registered nurse administered Epinephrine to a resident without a physician's order. The resident, who was cognitively intact and required staff assistance for daily care, had a diagnosis of respiratory failure and was receiving Amoxicillin Potassium Clavulanate per physician's order. After receiving the antibiotic, the resident complained of shortness of breath, and the nurse, suspecting a reaction to the new medication, gave 1 gram of Epinephrine in the resident's right thigh. A review of the clinical record showed no documented evidence of a physician's order for the administration of Epinephrine. The facility's policy required that all medications be administered in accordance with prescriber's orders, and the Pennsylvania Nurse Practice Act mandates that registered nurses carry out nursing care actions within professional standards, including obtaining necessary orders for medications.
Failure to Provide Scheduled Showers/Baths and Document Care
Penalty
Summary
The facility failed to provide scheduled showers or baths to a resident who was cognitively intact but dependent on staff for bathing assistance. According to facility policy, staff are required to document when a shower is provided and notify a supervisor if a resident refuses care. Review of the resident's care plan and bathing records showed that the resident was scheduled to receive showers or baths twice weekly, but there was no documentation that these were offered or provided on two specific dates. The resident expressed dissatisfaction about not receiving scheduled showers, and the DON confirmed the lack of documentation and evidence of refusals for those dates.
Failure to Complete Air Mattress Safety Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible by not completing air mattress safety assessments for two residents. According to the facility's policy, support surfaces such as air mattresses are to be used in accordance with manufacturer recommendations, including consideration of contraindications, and should be subject to scheduled inspection and replacement. However, for one resident with dementia who required staff assistance for daily care, and another resident who was cognitively intact and had a pressure ulcer, there was no documented evidence that an assessment for potential safety hazards was completed prior to the placement of air mattresses on their beds. Observations confirmed that both residents were in bed with air mattresses in place, and interviews with the Director of Nursing verified that no specific safety assessments had been conducted for either resident regarding the use of these mattresses. Physician's orders for both residents included the use of air mattresses, but the lack of documented safety assessments constituted a failure to follow facility policy and regulatory requirements.
Failure to Document IV Catheter Flushing as Ordered
Penalty
Summary
The facility failed to ensure that a resident's long-term intravenous catheter was flushed as ordered by the physician. According to the facility's policy, IV catheters are to be flushed with 10 milliliters of saline before and after medication administration. A resident who was readmitted and required IV therapy had physician's orders for IV Meropenem to be administered on specific days after dialysis. Documentation showed that the medication was administered as ordered, but there was no evidence that the midline was flushed before and after administration on the specified dates. The Director of Nursing confirmed the absence of documentation for the required flushing procedure.
Failure to Replace Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to a resident who required continuous supplemental oxygen. According to the resident's clinical record, physician's orders specified that oxygen tubing and canister were to be changed every Tuesday night and as needed. However, observations on two consecutive days revealed that the oxygen tubing and humidification bottle tubing in use were dated significantly earlier than the required replacement schedule, indicating they had not been changed as ordered. Interviews with nursing staff and the Nursing Home Administrator confirmed that the oxygen set-up should have been replaced according to the physician's orders, but this was not done. The resident had diagnoses including heart failure and high blood pressure and required assistance with daily care tasks.
Failure to Complete Bed Rail Safety Assessment Prior to Use
Penalty
Summary
The facility failed to complete a required safety assessment prior to the use of bed enabler bars for one resident. According to the facility's bed safety policy, the interdisciplinary team is responsible for assessing the resident's sleeping environment, including safety, medical conditions, comfort, and freedom of movement, as well as obtaining input from the resident and family. The policy also requires regular inspection of beds and related equipment to identify risks, including potential entrapment hazards. For a resident with moderate cognitive impairment, a history of falls, and a diagnosis of dementia, physician orders directed the use of bilateral enabler bars. Observations confirmed that these bars were in place, but there was no documented evidence that a safety assessment had been completed prior to their application. The DON confirmed that the required assessment was not performed for this resident.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete an annual performance evaluation for one of three nurse aides reviewed, specifically for Nurse Aide 4. Documentation showed that an annual performance evaluation was due in March 2025 for this nurse aide, but there was no evidence that the evaluation had been completed as required. This was confirmed during an interview with the Human Resource director, who was unable to provide documentation of the required evaluation. The deficiency was cited under 28 Pa. Code 201.18(e)(1) Management.
Controlled Substance Storage Not Permanently Secured
Penalty
Summary
The facility failed to ensure that controlled substances were stored in accordance with its own policy and regulatory requirements. During an observation in the medication room on the French unit, surveyors found that a locked compartment in the medication refrigerator, which contained an unopened bottle of liquid Ativan (a controlled medication), was not permanently affixed to the refrigerator and could be removed. This was confirmed by both a registered nurse and the Nursing Home Administrator, who acknowledged that the locked box should have been permanently secured as per facility policy and professional standards.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and adherence to enhanced barrier precautions (EBP) during wound care for a resident. During an observed wound care procedure, an LPN did not wear a gown as required by the facility's EBP policy and did not perform hand hygiene after removing gloves and before donning new gloves. Instead, the LPN reached into her pocket to put on new gloves and continued with the wound care process, including cleaning the wound and applying medication and dressings, without using hand sanitizer or washing hands as required by both facility policy and CDC/CMS guidelines. The resident involved had a diagnosis of dementia and required staff assistance for daily care needs, including treatment for a sacral pressure ulcer. Physician orders specified daily wound care, and the facility's policies, as well as updated CDC and CMS guidance, required the use of gowns and gloves during high-contact care activities for residents with wounds, regardless of MDRO status. Interviews with the LPN and the Nursing Home Administrator confirmed that the required infection control practices were not followed during the observed wound care event.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the food service area as required by policy. Observations in the main kitchen revealed that two meal serving carts had a buildup of food and debris on the lower metal edge between the bumpers. Additionally, a large black grease trap box located under the three-compartment sink had a significant accumulation of food and debris on its top surface. A wall-mounted fan near the food preparation area was found to have a buildup of black dust and debris on its cage and was operating while food was being prepared, potentially dispersing contaminants toward the food prep area. Review of the dishwasher temperature log for April showed incomplete documentation, with missing wash and rinse temperature records for several days and meals. Specifically, there were no recorded temperatures for all meals from April 9 through 12, and no records at all from April 13 through 20. The Dietary Manager confirmed the presence of food and debris on the carts and grease box, the need for cleaning the fan, and acknowledged that staff were responsible for documenting dishwasher temperatures for every meal.
Failure to Provide Written Grievance Decision
Penalty
Summary
The facility failed to provide a written copy of the grievance/complaint decision to a resident who had filed a verbal grievance. The facility's policy, dated June 7, 2024, requires that residents or their representatives be informed both verbally and in writing of the findings of any grievance investigation and the actions to be taken. The policy specifies that this should occur within five working days of the grievance being filed. However, in this case, the resident filed a grievance on September 9, 2024, regarding a nurse aide's behavior in the dining room, which included rushing the resident and displaying an attitude that made the environment uncomfortable. The facility completed the investigation by September 13, 2024, and documented the findings, which included educating the nurse aide and considering additional assistance during meal times. Despite this, there was no documented evidence that the resident received a written report of the investigation's findings by October 22, 2024. This was confirmed during an interview with the Nursing Home Administrator, indicating a failure to adhere to the facility's grievance policy and to ensure the resident's right to be informed of the grievance outcome.
Failure to Clarify Physician's Order for Restorative Nursing Program
Penalty
Summary
The facility failed to clarify a questionable physician's order for a resident, as required by professional standards of quality. According to the Pennsylvania Nurse Practice Act, registered nurses are responsible for collecting and analyzing data to determine nursing care needs and carrying out actions that promote well-being. In this case, a physician's order dated August 25, 2024, instructed that the resident participate in a Restorative Nursing Range of Motion (ROM) program using a weighted dowel rod to maintain upper extremity strength. However, there was no documented evidence that the physician was contacted to clarify the specifics of the order, such as the weight of the dowel rod or the frequency and number of repetitions. This oversight was confirmed during an interview with the Nursing Home Administrator on October 22, 2024.
Incomplete Documentation of Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that the clinical records for a resident were complete and accurately documented. Physician's orders dated August 25, 2024, required the resident to participate in a Restorative Nursing Range of Motion (ROM) program to maintain upper extremity strength using a weighted dowel rod. However, documentation for August, September, and October 2024 showed multiple instances where staff marked the program as 'N/A' during various shifts, with no evidence that the program was completed or that the resident refused it. An interview with the Nursing Home Administrator confirmed the lack of accurate documentation for the resident's ROM program on the specified dates.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as required by professional standards for food service safety. During an observation in the main kitchen, it was noted that there was a black, removable substance on the wall near the dishwasher. Additionally, kitchen shelves, where clean pots and serving pans were stored, were found to have dust and debris on them. The dish warmer tray also had a thick, removable substance on it. These observations were confirmed by an interview with the Dietary Manager, who acknowledged that the kitchen, shelving, and equipment should be clean and free of debris, but were not.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for four residents, as evidenced by observations of their wheelchairs over several days. Resident 4's wheelchair had a moderate accumulation of removable, dried-on debris on the oversized right armrest. Resident 8's cushioned wheelchair had a moderate to large amount of thick, removable dust and debris on the metal supports under the seat, along with dirt and sticky debris causing the seat cushion to adhere to the wheelchair seat. Resident 9's wheelchair was observed with a large amount of removable dust and debris on the wheels and metal supports under the chair. Resident 29's wheelchair had an accumulation of removable, white, dried-on debris on the front wheels. Interviews with facility staff confirmed the deficiency. The Housekeeping Supervisor acknowledged that the wheelchairs should have been clean and expressed the belief that nurse aides were responsible for cleaning them. The Nursing Home Administrator also confirmed that the removable dust, dirt, and debris on the wheelchairs should not have been present and that they should have been cleaned. These observations and interviews indicate a failure to uphold the residents' right to a safe, clean, and comfortable environment as required by the relevant state codes.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for three of five nurse aides reviewed. According to the facility's policy dated June 7, 2024, job performances of each employee should be reviewed and evaluated at least annually. However, there was no documented evidence that the required annual performance evaluations were completed for Nurse Aides 6, 7, and 8, who were due for evaluations in March, February, and April 2024, respectively. This deficiency was confirmed during an interview with the Nursing Home Administrator, who could not provide evidence of the completed evaluations.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for three residents, as identified through a review of facility policies, clinical records, and staff interviews. For Resident 2, a dose of MS Contin was signed out on the controlled drug record for administration on June 6, 2024, but there was no documented evidence in the Medication Administration Record (MAR) or nursing notes that the medication was administered. This discrepancy was confirmed by the Nursing Home Administrator. Similarly, for Resident 11, multiple doses of oxycodone were signed out on the controlled drug record in March and April 2024, but there was no documentation in the nursing notes or MARs to confirm administration. Resident 20 also had several doses of oxycodone signed out from February to May 2024, with no corresponding documentation of administration. The Nursing Home Administrator confirmed the lack of documentation for these residents, indicating a failure to maintain proper records of controlled medication administration.
Failure to Document Advance Directive Opportunities
Penalty
Summary
The facility failed to document the opportunity for residents to formulate advance directives and the residents' decisions to accept or decline assistance in doing so. This deficiency was identified for four out of 28 residents reviewed. The facility's policy, dated June 7, 2024, requires that upon admission, residents are provided with information about their rights to accept or refuse medical treatment and to formulate advance directives. The policy also mandates that any decision regarding advance directives should be prominently documented in the medical record. For Resident 6, who was cognitively intact and required extensive assistance due to chronic obstructive pulmonary disease, there was no documented evidence that information on advance directives was provided or that assistance was offered. Similarly, Resident 26, who had cerebral infarction and required assistance, had no documentation of advance directive discussions with the family or their decision to accept or decline assistance. Resident 34, with hemiplegia and a history of traumatic brain injury, also lacked documentation of advance directive information and assistance offers, despite being cognitively intact. Resident 41, who was cognitively intact and had acute respiratory failure, also did not have documented evidence of being provided with information on advance directives or being offered assistance. Interviews with the Social Service Coordinator confirmed that discussions occurred but were not documented. The Nursing Home Administrator believed the facility's process met regulatory requirements, despite the lack of documentation for these residents.
Failure to Issue Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue timely notices of Medicare non-coverage for two discharged residents, as required by their policy and the Medicare Claims Processing Manual. The policy, dated June 7, 2024, mandates that Skilled Nursing Facility Beneficiary Notices be provided to inform beneficiaries when Medicare-covered services are ending and how to appeal. However, for Resident 44, who was discharged home on May 1, 2024, and Resident 45, who was discharged on February 28, 2024, there was no documented evidence that these notices were issued prior to the end of their Medicare coverage. An interview with the Nursing Home Administrator on June 11, 2024, confirmed the absence of documentation for the issuance of these notices, acknowledging that they should have been provided. This oversight was identified during a review of facility policies, clinical records, and staff interviews, indicating a failure to comply with the regulatory requirement to inform residents of their Medicare coverage status and potential liability for services not covered.
Failure to Verify Nursing Licenses and Registry Status
Penalty
Summary
The facility failed to ensure proper verification of nursing licenses and nurse aide registry status for its staff, leading to deficiencies in compliance with state regulations. Specifically, the facility did not verify the nursing license of a registered nurse with the State Board of Nursing until three months after her start date. Additionally, the facility did not verify the standing of a nurse aide on the Pennsylvania Nurse Aide Registry until over two weeks after her start date. These oversights were confirmed during an interview with the Human Resources Director, who acknowledged the lack of documented evidence for timely verification. The facility's policy on abuse prevention, dated June 7, 2024, mandates conducting employee background checks and ensuring that no individuals with findings of abuse, neglect, or exploitation are employed. However, the failure to verify the professional credentials of the registered nurse and the nurse aide in a timely manner indicates a lapse in adherence to this policy. This deficiency was identified during a review of personnel files and staff interviews, highlighting a gap in the facility's management and responsibility as per the state code requirements.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to two residents, their representatives, and the state long-term care ombudsman regarding the reason for their transfer to the hospital. This deficiency was identified during a review of policies, clinical records, and staff interviews. The facility's policy, dated June 7, 2024, mandates that written notification must be given to residents, their representatives, and the ombudsman when a resident is transferred or discharged. However, this procedure was not followed for two residents who were transferred to the hospital. Resident 6, who was cognitively intact and required extensive assistance for daily care due to chronic congestive heart failure, was transferred to the hospital on February 21, 2024, without receiving the required written notification. Similarly, Resident 26, also cognitively intact and needing assistance for daily care with the same diagnosis, was transferred on March 8, 2024, without the necessary notification. The Nursing Home Administrator confirmed that the required notifications were not provided for these transfers, as stipulated by the facility's policy and resident rights under 28 Pa. Code 201.29(j).
Failure to Provide Bed-Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed-hold notice to the responsible parties of two residents who were transferred to the hospital. According to the facility's policy dated June 7, 2024, a notification should be given to residents or their representatives regarding their rights to hold their current bed in the facility during hospitalizations or temporary leaves for medical or therapeutic reasons. However, for Resident 6, who was cognitively intact and required extensive assistance due to chronic congestive heart failure, there was no documented evidence of such a notice being provided when they were transferred to the hospital on February 21, 2024. Similarly, Resident 26, also cognitively intact and requiring assistance due to chronic congestive heart failure, was transferred to the hospital on March 8, 2024, without a bed-hold notice being provided to their responsible party. This deficiency was confirmed during an interview with the Nursing Home Administrator on June 13, 2024. The lack of documentation and failure to provide the required notices were identified as violations of 28 Pa. Code 201.29(j) concerning resident rights.
Failure to Develop Baseline Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The baseline care plan is intended to include the minimum healthcare information necessary to properly care for a resident until a comprehensive assessment and interdisciplinary person-centered care plan are developed. In this case, the facility did not create a baseline care plan for a resident who was admitted with significant medical needs, including the requirement for an anticoagulant medication. The resident in question was admitted with a history of atrial fibrillation, transient ischemic attack, and thrombosis, and was prescribed rivaroxaban, an anticoagulant, to manage these conditions. Despite these critical health needs, there was no documented evidence of a baseline care plan addressing the resident's anticoagulant therapy. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of the necessary documentation.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow physician's orders for a resident's wound care, leading to a deficiency. Resident 41, who required assistance for daily care needs, had a physician's order dated June 5, 2024, to cleanse the right shin with normal saline, pat dry with an ABD pad, and wrap with rolled gauze. However, observations on June 10 and 11, 2024, revealed that the resident did not have the wrap on her right leg, despite the Treatment Administration Record (TAR) indicating that the treatment was completed on those dates. The resident was unaware of any discontinuation of the wraps, and the Nursing Home Administrator confirmed that the treatment was signed off as completed but was not actually performed as ordered.
Failure to Implement Pressure-Relieving Interventions
Penalty
Summary
The facility failed to ensure that pressure-relieving interventions were in place for a resident at risk for pressure ulcers. The resident, who was severely cognitively impaired and dependent on staff for care, had limited range of motion and contractures due to cerebral palsy. Physician's orders required the resident to have a right palm guard splint and a heel pro to prevent skin injury. However, observations revealed that the resident was not wearing the right palm guard splint while in a wheelchair and in bed, and the heel pro was not positioned under the resident's heels as required. Interviews with staff, including a nurse aide and the Director of Therapy and Nursing Home Administrator, confirmed the absence of the required protective devices. The facility's policy on mobility and skin integrity stipulated that protective devices should be provided as established by the physician, yet these interventions were not implemented as care planned, leading to a deficiency in the resident's care.
Failure to Conduct Safety Assessments for Residents
Penalty
Summary
The facility failed to complete safety assessments for two residents, leading to deficiencies in their care. Resident 11, who was cognitively impaired and had a Stage 4 pressure ulcer, was ordered to have an air mattress for pressure relief. However, there was no documented evidence that the use of the air mattress was assessed for potential safety hazards before being placed on the resident's bed. This lack of assessment was confirmed by the Director of Nursing, indicating a failure to adhere to the facility's policy for bed safety. Resident 26, who was cognitively intact but required moderate assistance and was at risk for falls, was observed being transported in a wheelchair without leg rests. The resident preferred not to use the footrests, and there was no documented assessment to determine if this was safe. Additionally, there was no care plan in place regarding the resident's preference, nor was there any safety education provided about the dangers of not using footrests during transportation. The Nursing Home Administrator confirmed these oversights, highlighting a failure to ensure safe transport for the resident.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician for a resident. The resident, who was cognitively intact and had diagnoses of atrial fibrillation and heart failure, was supposed to receive continuous oxygen at a flow rate of 3 liters per minute via nasal cannula. However, observations on June 11, 2024, revealed that the resident was receiving oxygen at a reduced flow rate of 1.5 liters per minute. This discrepancy was confirmed by a registered nurse and the Director of Nursing, who acknowledged that the oxygen flow rate should have been set at 3 liters per minute as per the physician's order.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with Post Traumatic Stress Disorder (PTSD). Specifically, for one resident, the facility did not identify specific triggers that could re-traumatize the resident or implement measures to prevent or minimize these triggers. The resident, who was cognitively intact and required assistance for daily care needs, had diagnoses including schizophrenia and PTSD. A review of the resident's care plan indicated the presence of PTSD and anxiety, but there was no documented evidence of trauma-informed care assessments being completed. An interview with the Nursing Home Administrator revealed that the facility was not conducting trauma-informed care assessments, which they acknowledged should have been done. The facility also did not assess or identify specific triggers that may re-traumatize residents with past traumas, failing to prevent such triggers from occurring for the resident in question.
Failure to Label Multi-Dose Medications
Penalty
Summary
The facility failed to comply with its policy on medication labeling and storage, as evidenced by the lack of proper labeling on multi-dose containers of medications. During an observation of the Colonial Wing medication cart, surveyors found an opened and undated vial of Levemir insulin, an opened and undated vial of glargine insulin, and an opened and undated bottle of .005 percent Latanoprost solution eye drops. The facility's policy, dated June 7, 2024, requires that multi-dose medications be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. Interviews with a registered nurse and the nursing home administrator confirmed that these medications should have been labeled with the date they were opened, in accordance with the manufacturer's instructions.
Failure to Employ Qualified Dietitian
Penalty
Summary
The facility failed to employ a full-time qualified dietitian, which is a requirement for the food and nutrition service. This deficiency was identified through observations and staff interviews. The Dietary Manager revealed that the facility had been without a qualified dietitian since May 20, 2024, following the end of the previous dietitian's employment. Further confirmation came from the Nursing Home Administrator, who stated that as of June 13, 2024, the facility had neither a dietitian nor a dietitian consultant employed.
Inaccurate Clinical Documentation for Wound Care
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for one of the residents reviewed. The resident, who was cognitively intact and required extensive assistance for daily care tasks, had physician's orders for wound care on a reddened area on the right lower back. However, observations revealed that there was no reddened area or dressing present on the resident's back, contradicting the documentation in the Treatment Administration Records (TAR) that indicated wound care was completed on specific dates. Interviews with registered nurses and the Nursing Home Administrator confirmed that the resident did not have a reddened area requiring wound care, and therefore, documentation indicating that wound care was performed was inaccurate. This discrepancy between the actual condition of the resident and the documented care highlights a failure in maintaining accurate clinical records as per the facility's policy and accepted professional standards.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to obtain necessary documentation from the contracted hospice provider for a resident receiving hospice services. Specifically, the facility did not secure the hospice election of benefits form and the certification of terminal illness form for a resident who was cognitively impaired and required assistance with daily care needs. These forms are crucial as they indicate the resident's waiver of traditional Medicare Part A payments for treatment related to the terminal illness and certify the resident's terminal diagnosis and life expectancy of six months or less. The deficiency was identified through a review of facility policies, clinical records, and staff interviews. The facility's policy, dated June 7, 2024, clearly states the responsibility of obtaining these documents from the hospice provider. However, as of June 12, 2024, there was no documented evidence in either the resident's clinical record or the hospice provider's record that these forms were obtained. This was confirmed during an interview with the Nursing Home Administrator.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by the results of a survey ending in June 2024. The deficiencies identified were related to the development and implementation of abuse and neglect policies, quality of care, and pharmacy services. These issues were previously cited in a survey ending in August 2023, indicating that the facility's plans of correction were not successfully implemented to ensure ongoing compliance with regulations. The facility had developed plans of correction for each deficiency, which included completing audits and reporting the results to the QAPI committee for review. However, the current survey revealed that the QAPI committee did not successfully implement these plans. Specifically, deficiencies were cited under F607 for abuse and neglect policies, F684 for quality of care, and F755 for pharmacy services, demonstrating a failure to maintain compliance with the required standards.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training annually, as mandated by state and federal guidelines. Specifically, Nurse Aide 6 and Nurse Aide 7 did not have documented evidence of completing the necessary training hours within their respective annual periods. This deficiency was identified through a review of the facility's list of employed nurse aides, their hire dates, and training hours, as well as staff interviews. Additionally, the facility did not provide Nurse Aide 6 with the required annual in-service training on resident abuse, abuse reporting, and dementia care. The facility's policy, dated June 7, 2024, mandates such training to prevent abuse, identify and report abuse, and manage aggressive resident behaviors. The Nursing Home Administrator confirmed the lack of documentation for these trainings during an interview, further substantiating the deficiency.
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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