Oak Ridge Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Taylor, Pennsylvania.
- Location
- 500 West Hospital Street, Taylor, Pennsylvania 18517
- CMS Provider Number
- 395564
- Inspections on file
- 42
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Oak Ridge Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and an elopement risk was left unattended at an outside medical appointment by a nurse aide, resulting in the resident attempting to leave the facility unsupervised. The incident was reported verbally to an LPN and documented, but was not escalated to administration or investigated according to policy, and the administration only became aware of the event during a survey.
The facility did not provide two residents with the required written notice and explanation of Medicare coverage termination, including information about the SNF-ABN and the right to appeal, prior to ending Medicare Part A services. One resident's responsible party was not contacted or informed, and another resident with moderate cognitive impairment signed the form without receiving an explanation or being told about appeal rights.
Two residents with significant medical and mobility issues experienced falls related to toileting, and the facility failed to implement or document required three-day bowel and bladder assessments as outlined in their care plans. Despite planned interventions for fall prevention and toileting support, the care plans were not revised in a timely manner to reflect post-fall needs, and the necessary assessments were not completed, as confirmed by the DON.
The facility did not follow its abuse prohibition policy by failing to obtain required references from previous employers for two newly hired staff members, as confirmed by a review of personnel files and administrator interview.
A resident with Alzheimer's dementia and hyperlipidemia experienced a significant decline and began hospice care, but the facility did not complete the required significant change MDS assessment to document this change, as confirmed by the DON.
A nurse administered Novolog insulin to a resident with diabetes when the resident's blood glucose did not meet the sliding scale criteria, and failed to provide the ordered Basaglar insulin, which was not available on the medication cart. The nurse also documented administration of Basaglar when only Novolog was given, and admitted to not verifying the medication type against physician orders. The DON confirmed these failures to follow professional standards.
A resident with osteoarthritis and intact cognition received PRN opioid pain medication for moderate to severe pain on multiple occasions without documented attempts of non-pharmacological interventions, contrary to facility policy. The DON confirmed that no evidence existed of alternative pain management strategies being tried before administering the opioid.
A resident with severe dementia exhibited increased behavioral symptoms, including anxiety and restlessness, but the facility did not update the care plan to include individualized, person-centered interventions or non-pharmacological approaches based on the resident's preferences and history.
A registered nurse administered expired Novolog insulin to a resident with diabetes and parkinsonism, failing to verify the medication label and disregarding physician orders. The nurse documented giving Basaglar insulin but actually gave Novolog, which was not indicated by the resident's blood glucose level at the time. The DON confirmed the nurse did not follow proper procedures, resulting in a significant medication error.
The facility failed to maintain sanitary food storage and service practices, leading to potential contamination. Observations revealed unsanitary conditions, such as juice dispensing guns in contact with bulk juice boxes, uncovered dishware, and flies in the dish room. Additionally, food particles and debris were found in dining areas, and chocolate shakes were not dated. The NHA confirmed these deficiencies.
The facility did not have the Medical Director or a designated physician present at the QAPI Committee meetings for four consecutive months. This was confirmed through sign-in sheets and an interview with the administrator, highlighting a failure to meet regulatory requirements for physician attendance.
The facility failed to maintain an effective pest control program, as evidenced by observations of flies in the kitchen and dead bugs in the dining area. A resident reported frequent insect sightings, and the maintenance director confirmed a lack of documented pest treatments and unaddressed pest control recommendations.
The facility failed to maintain a clean environment on the third floor dementia unit. Observations revealed sticky, dirty floors with dried liquid stains in the dining room and resident rooms. A strong urine odor was noted from a resident's mattress, and a room had a broken floor tile and damaged, soiled walls. The interim Nursing Home Administrator confirmed that these areas should be kept clean and sanitary.
The facility failed to resolve grievances from two residents, one regarding dietary preferences and the other about delayed call bell response, leading to a deficiency in grievance handling. A resident with gastroesophageal reflux disease was not consulted about her dietary preferences despite a grievance filed, while another resident with irritable bowel syndrome experienced prolonged incontinence due to staff's delayed response to her call bell. The facility lacked documentation of efforts to address these grievances.
A facility failed to implement individualized measures for a resident with declining continence, despite policy requirements. The resident, with diagnoses including congestive heart failure and dysphasia, was identified as incontinent. The care plan included evaluating urination patterns and assisting with toileting, but no retraining program was in place. The resident developed a stage 2 pressure ulcer, and the facility lacked evidence of interventions to address the decline in continence.
The facility failed to provide timely behavioral health services to two residents, one with adjustment disorder and major depressive disorder, and another with schizoaffective disorder. The first resident did not receive psychiatric services since February, despite expressing dissatisfaction with previous telehealth sessions and ongoing mental health struggles. The second resident, requiring specialized mental health services, experienced a significant delay in receiving psychological follow-up, contrary to recommendations.
The facility failed to attempt a gradual dose reduction (GDR) of psychoactive medications for two residents. One resident was on Trazadone and Lexapro, and the other on Depakote, Olanzapine, and Escitalopram Oxalate. Despite pharmacist recommendations for GDR, the physician disagreed without providing clinical rationale, and the facility lacked documentation to support continued dosages or GDR attempts.
The facility failed to comply with pharmacy supplies expiration and labeling policies on two resident units. Expired and improperly labeled items were found, including Foley catheter devices, povidone/iodine swabs, needles, and wound dressings. Opened items lacked dates, and the medication refrigerator was improperly maintained. An LPN confirmed these findings, and the NHA and DON acknowledged the issues.
The facility did not routinely offer evening snacks to residents, resulting in a 15-hour gap between dinner and breakfast. Residents reported receiving snacks only upon request, and there was no evidence of snacks being offered to those on the Dementia unit. The administrator could not provide documentation of routine snack offerings.
The facility failed to update its facility-wide assessment to address the needs of its Dementia/Memory care unit, affecting 61 residents with Dementia/Alzheimer's and 43 residents on a locked unit. Previous surveys had identified deficiencies in dementia care and behavioral health services, including resident-to-resident abuse. The facility did not ensure necessary staff resources to meet licensure and certification standards.
The facility failed to maintain dignity and privacy for two residents. One resident with dementia was left without window coverings, compromising privacy, while another was left incontinent for 15 hours after a delayed response to a call bell. The latter also experienced anxiety from being manhandled during transfers. Interviews confirmed the facility's failure to treat residents with dignity and respect.
A resident with a history of aggressive behavior physically abused another resident in the Dementia Unit Dayroom. Despite staff attempts to manage the aggressor's escalating behaviors, the incident occurred, resulting in the victim being pulled to the ground by her hair. The facility was aware of the aggressor's history but failed to prevent the altercation, highlighting a deficiency in ensuring resident safety.
A facility failed to implement its abuse policy and conduct a thorough assessment after a resident-to-resident altercation. Resident 60 pulled Resident 85 by her hair, causing her to fall. The RN's assessment of Resident 85 was inadequate, lacking comprehensive documentation as required by the facility's policy. The Director of Nursing confirmed the failure to document a complete assessment.
A registered nurse failed to administer scheduled medications to five residents, signing the MAR as if they had been given. The facility did not conduct a thorough investigation into this potential neglect, as required by their policy, and there was no documentation in the residents' records about the missed medications.
A facility failed to include necessary interventions in a resident's care plan to monitor respiratory status and oxygen use. The resident, with shortness of breath and cognitive impairment, frequently turned off the oxygen concentrator, but staff did not ensure continuous oxygen delivery. The care plan lacked specific actions for monitoring oxygen saturation or guidelines for staff intervention.
A resident with a history of stroke and severe cognitive impairment had a physician's order for oxygen therapy at 2 L/min. However, observations revealed the oxygen concentrator was set to 3 L/min, not following the prescribed order. This was confirmed by an LPN and acknowledged by the NHA and DON, indicating a deficiency in nursing services.
A facility failed to provide person-centered care for a resident with ESRD requiring hemodialysis. The care plan did not include the resident's specific schedule preferences or provisions for transportation and meal accommodations related to the dialysis schedule. The DON confirmed the care plan's inadequacy in addressing these needs, resulting in a deficiency.
The facility failed to maintain accurate clinical records for two residents. One resident had an undocumented skin injury, while another had a boil with no documented healing progress. The DON confirmed the lack of documentation for both cases.
A facility failed to provide a working call system for a severely cognitively impaired resident. During an observation, it was found that there was no call bell connected or available in the resident's room, and no alternative method for summoning assistance was present. Interviews with an LPN and the Nursing Home Administrator confirmed that call bells should be accessible at each resident's bedside.
The facility did not implement procedures to ensure safe smoking for a resident with COPD, despite having a non-smoking policy. The resident was allowed to smoke without a care plan or revised smoking policy, as confirmed by the Nursing Home Administrator and DON during a survey.
The facility failed to protect residents from being disenrolled from Medicare health plans without informed consent. Residents were disenrolled without proper documentation of their requests or understanding of the implications, and cognitive assessments were not conducted prior to signing disenrollment forms. The facility lacked policies and procedures for assisting residents with health plan changes.
The facility failed to implement individualized care plans for two residents with dementia, leading to repeated falls and inappropriate behaviors. Despite having care plans, interventions were not effectively applied, resulting in safety concerns and incidents. The facility did not adequately address specific behaviors or provide necessary diversional activities.
The facility's QAPI committee failed to correct deficiencies related to abuse and dementia care. A resident exhibited inappropriate behavior towards cognitively impaired residents, and another resident experienced multiple falls due to unmanaged dementia-related behaviors. The facility did not revise care plans or implement effective interventions, leading to repeated issues.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident, also cognitively impaired, in an LTC facility. The facility's policy to protect residents lacking capacity to consent was not followed, as evidenced by incidents of physical affection between the two residents. The care plan for the resident exhibiting these behaviors did not address or prevent such incidents, leading to a substantiated case of abuse.
A facility failed to justify the increase of an antipsychotic medication for a resident with dementia and Parkinsonism. After the resident became verbally aggressive, the dosage of Quetiapine Fumarate was increased without documented clinical rationale or evidence of considering less restrictive alternatives. The facility did not address potential underlying causes of the behavior, as confirmed by the DON.
Failure to Investigate Resident Neglect After Unattended Medical Appointment
Penalty
Summary
The facility failed to thoroughly investigate an incident in which a resident with severe cognitive impairment and a known risk for elopement was left unattended during an outside medical appointment. The resident, who had a diagnosis of dementia and heart failure, was accompanied to a cardiology appointment by a nurse aide. After the appointment, the nurse aide left the resident alone in a lobby area while she used the restroom. During this time, the resident was observed by a transportation driver and another individual attempting to leave the facility, and was stopped outside by a driver who questioned her about her caregiver's whereabouts. Upon returning to the facility, the nurse aide verbally reported the incident to an LPN, who provided immediate education to the aide and wrote a witness statement, which was then given to an RN Supervisor. However, the RN Supervisor did not report the incident to the Nursing Home Administrator or the Director of Nursing, believing the information to be a rumor. The transportation driver, who also witnessed the incident, informed the RN Supervisor but did not escalate the report to facility administration. As a result, the facility did not follow its written abuse policy, which requires immediate reporting and investigation of any allegations of abuse or neglect. The administration was not made aware of the incident until it was discovered during a survey investigation. No immediate investigation was initiated, and statements from all involved parties were not collected as required by policy and federal regulations.
Failure to Provide Required Medicare Coverage Termination Notices and Appeal Rights
Penalty
Summary
The facility failed to provide required written notice of Medicare coverage termination, including an explanation of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) and the right to appeal, to residents and/or their representatives prior to the end of Medicare Part A services. For one resident with Parkinson's disease, muscle weakness, and diabetes, the clinical record showed that the SNF-ABN form was completed and the responsible party's information was documented, but there was no evidence that the resident or her responsible party received the notice, reviewed the form, or were informed of the opportunity to appeal. The resident's daughter confirmed during an interview that she was not contacted regarding the SNF-ABN and was not advised of the right to appeal. For another resident with Parkinson's disease and a history of falls, who had moderate cognitive impairment, the SNF-ABN form was signed by the resident, and the social worker documented no appeal. However, there was no evidence that the resident was provided with an explanation of the form or informed of the right to appeal. The resident stated in an interview that he was asked to sign the form without any explanation or information about the right to appeal the denial of coverage. The Nursing Home Administrator acknowledged the findings when reviewed by the surveyor.
Failure to Implement and Revise Individualized Care Plans for Toileting and Safety Needs
Penalty
Summary
The facility failed to fully develop and implement person-centered, comprehensive care plans to address the individualized toileting and safety needs of two residents. For one resident with a history of hemiplegia, hemiparesis, gait abnormalities, and narcolepsy, the care plan included scheduled toileting and fall prevention interventions. However, after multiple falls in the bathroom, including incidents resulting in a laceration and a hematoma, the facility did not complete or document a three-day bowel and bladder assessment as required by the care plan. Additionally, the care plan was not revised in a timely manner to reflect post-fall interventions or assessment results. Another resident with diagnoses including diabetes mellitus and congestive heart failure, and moderate cognitive impairment, experienced a fall with injury while attempting to go to the bathroom. The care plan for this resident included interventions such as a three-day bowel and bladder tracking assessment and a bed alarm to alert staff of unsafe transfers. Despite these planned interventions, the facility did not complete the required bowel and bladder assessment following the fall. Interviews with the Director of Nursing confirmed that the planned fall interventions, including the three-day bowel and bladder assessments, were not implemented for either resident. The clinical records and care plans did not reflect timely or complete documentation of these interventions, resulting in a failure to meet the residents' individualized care needs as required.
Failure to Obtain Required Employment References During Staff Hiring
Penalty
Summary
The facility failed to fully implement its abuse prohibition procedures by not adequately screening two of five newly hired employees. According to the facility's Resident Abuse policy, screening potential employees requires obtaining references from their most recent or previous employers. A review of personnel files showed that for one Dietary Manager and one Housekeeping staff member, there was no documentation that the facility had contacted their previous employers for references or employment verification. The Nursing Home Administrator confirmed that there was no evidence of such contact for these two employees, indicating the facility did not follow its own established policy for employee screening.
Failure to Complete Significant Change MDS Assessment After Hospice Election
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a notable decline in condition and elected to receive hospice care. The resident, admitted with diagnoses including Alzheimer's dementia and hyperlipidemia, began hospice services on July 1, 2024. Despite federal requirements mandating a significant change MDS assessment within 14 days of such an event, there was no documented evidence that this assessment was completed to reflect the initiation of hospice services. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the required comprehensive assessment had not been performed.
Failure to Administer Insulin According to Physician Orders and Professional Standards
Penalty
Summary
A registered nurse failed to provide nursing services consistent with professional standards of quality by not following physician's orders and not ensuring accurate medication administration for a resident diagnosed with Type 2 Diabetes Mellitus and parkinsonism. During a medication administration observation, the nurse checked the resident's blood sugar, which was 169 mg/dL, and administered 10 units of Novolog insulin. However, the physician's sliding scale order for Novolog required administration only when blood glucose readings exceeded 200 mg/dL, and the resident's blood sugar did not meet this criterion. Additionally, the nurse was supposed to administer Basaglar, a long-acting insulin, as per the active physician order, but this medication was not available on the medication cart at the time of inspection. A review of medication usage showed that Novolog insulin had been administered multiple times without qualifying blood sugar levels, and the nurse documented that Basaglar was given when it was not. The nurse admitted to failing to verify the medication type against the physician's orders prior to administration. The Director of Nursing confirmed that the nurse did not verify the insulin type, administered the incorrect medication, and failed to provide nursing services in accordance with professional standards of practice.
Failure to Attempt Non-Pharmacological Pain Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to follow its own policy regarding pain management for a resident with osteoarthritis of the right knee, who was cognitively intact and able to report pain levels. The facility's policy, last reviewed on April 8, 2025, required that non-pharmacological interventions be considered and attempted, either alone or in conjunction with medications, prior to administering pharmacological pain relief. Examples of such interventions included environmental adjustments, physical interventions, exercise, and cognitive or behavioral strategies. A review of the resident's clinical record and medication administration record (MAR) revealed that, over a period from March 1, 2025, through April 24, 2025, opioid pain medication (Oxycodone HCl 5mg) was administered on an as-needed (PRN) basis for reported moderate to severe pain on multiple occasions. On each of these occasions, there was no documented evidence that non-pharmacological interventions were attempted prior to the administration of the opioid medication, despite the resident's pain levels being within the range specified for PRN use. An interview with the Director of Nursing (DON) confirmed the absence of documentation regarding the use of non-pharmacological pain management strategies before administering opioid medication. This lack of documented attempts to use alternative pain management methods prior to pharmacological intervention constituted a failure to comply with both facility policy and regulatory requirements.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the dementia-related behavioral symptoms of a resident diagnosed with severe cognitive impairment. The resident, who was admitted with a diagnosis of dementia, exhibited increased behaviors such as self-rising, anxiety, and restlessness almost daily during the month of April 2025. Despite these documented changes in behavior, the resident's care plan, last revised in June 2024, did not include any new interventions or strategies to address these emerging symptoms. A review of the clinical record and care plan revealed no evidence that the facility assessed the resident's preferences, social history, routines, or interests to create individualized, non-pharmacological interventions. There was also no documentation of purposeful or meaningful activities tailored to the resident's needs to enhance well-being. An interview with the Nursing Home Administrator confirmed that the facility could not provide evidence of having developed or implemented a person-centered plan for the resident's dementia care.
Significant Medication Error Due to Improper Insulin Administration
Penalty
Summary
A registered nurse failed to properly verify and administer insulin to a resident with Type 2 Diabetes Mellitus and parkinsonism. The nurse administered 10 units of Novolog insulin using a pen that had expired beyond the manufacturer-recommended 28-day usage period. The nurse did not check the expiration date on the insulin pen prior to administration, as required by facility policy. Additionally, the nurse documented that Basaglar insulin was given, but in reality, Novolog was administered instead. Review of the resident's physician orders showed that Basaglar was to be administered once daily, and Novolog was to be given only per a sliding scale for elevated blood glucose levels. At the time of administration, the resident's blood glucose did not meet the threshold for Novolog per the sliding scale, and Basaglar was not available on the medication cart as required. Documentation revealed that Novolog had been administered multiple times without corresponding elevated blood sugar readings, and the nurse admitted to not following the physician's orders or verifying the medication label. The Director of Nursing confirmed these findings, resulting in a significant medication error.
Unsanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for food storage and service, leading to potential contamination and microbial growth in food. During an initial tour of the dietary department, unsanitary practices were observed, including juice dispensing guns in contact with bulk juice boxes and a buildup of a red, gel-like substance inside the nozzles. Clean dishware and beverage pitchers were left uncovered in the dry storage room. Clean thermal bowls and cups were placed next to dirty dishes, and cleaned cooking equipment was stored next to dirty items. Additionally, small black flies were observed in the dish room, indicating poor sanitation. Further observations in the 2nd floor dining area revealed food particles and debris on the floor, dirt accumulation around the room's perimeter, and a brown substance on the wall. Nine chocolate shakes in the refrigerator were not dated, making it impossible to determine their thaw dates. In the Memory Care Unit's pantry, dirt and debris were found on the floor, and the outside of a refrigeration door was sticky with food splatters. Cleaned thermal mugs were placed on a visibly dirty tray. The Nursing Home Administrator confirmed these deficiencies, acknowledging the failure to maintain sanitary conditions and proper food labeling.
Medical Director Absence at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director or a designated physician attended the Quality Assurance Process Improvement (QAPI) Committee meetings for four consecutive months, from January 2024 through April 2024. This was identified through a review of the QAPI Committee meeting sign-in sheets, which showed the absence of the Medical Director or any other physician at these meetings, whether virtually or in-person. An interview with the facility administrator on May 9, 2024, confirmed the absence of a physician at the monthly/quarterly QAPI meetings during this period.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and interviews. During an initial tour of the kitchen, several small black flies were observed flying around clean cooking equipment, and the Certified Dietary Manager (CDM) confirmed that drain flies were frequently present due to the damp environment. Additionally, in the 2nd floor dining area, small dead black bugs were found on the floor, windowsills, and air-conditioning units, with a loose windowsill allowing gaps to the outside. A dead, large-winged insect was also observed on the floor. The Director of Maintenance admitted that while pest treatments were performed on floor drains, there was no documented evidence of regular treatments in the kitchen area. A cognitively intact resident reported that small dark insects were a common sight in the facility, particularly during meals, which was bothersome. The facility's most recent pest control report indicated routine pest control for rodents and insects, but also noted issues such as door gaps and building exterior cracks that allowed pest access. The maintenance director confirmed that the facility had not acted on the pest control company's recommendations to secure these areas, nor could they provide evidence of routine preventative measures to deter pests.
Failure to Maintain Clean Environment in Dementia Unit
Penalty
Summary
The facility failed to provide adequate housekeeping services to maintain a clean environment on the third floor dementia unit. Observations on May 8, 2024, revealed that the large dining room floor was sticky, dirty, and soiled with dried liquid stains, and dirt, dried liquid stains, and food crumbs were present on the window sills. In several resident rooms, the floors were dirty and sticky, with one room emitting a strong urine odor from the resident's mattress. Another room had a broken floor tile under the bed and a wall with deep gouges and heavily soiled wallpaper. These conditions were confirmed during an interview with the interim Nursing Home Administrator, who acknowledged that resident rooms and dining/activity areas should be maintained in a clean and sanitary manner.
Failure to Address Resident Grievances in a Timely Manner
Penalty
Summary
The facility failed to adequately address and resolve grievances filed by two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident 76, who was admitted with diagnoses including gastroesophageal reflux disease and muscle weakness, expressed dissatisfaction with her full liquid diet and the lack of a bedtime snack. Despite a grievance filed by her guardian, the resident reported that no staff had visited her to discuss her dietary preferences, indicating a lack of timely follow-up by the facility. Resident 90, admitted with irritable bowel syndrome and requiring extensive assistance with activities of daily living, filed a grievance regarding the staff's failure to respond promptly to her call bell during the night shift, resulting in her being left incontinent for 15 hours. The facility did not provide evidence of investigating or addressing this grievance, nor did they follow up with the resident to determine if her concerns were resolved. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of documented efforts to resolve these grievances, highlighting a deficiency in the facility's grievance handling process.
Failure to Implement Individualized Continence Care
Penalty
Summary
The facility failed to assess and implement individualized measures to meet the toileting needs of a resident who experienced a decline in continence. The facility's policy on urinary incontinence required the physician and staff to review the progress of individuals with impaired continence and document responses to interventions. However, the facility did not develop or implement interventions for the resident, who was admitted with diagnoses including congestive heart failure, abnormal gait, and dysphasia, and was identified as incontinent of bowel and bladder. The resident's care plan included evaluating urination patterns, applying barrier cream, and assisting with toileting. Despite a decline in bladder continence noted in the resident's assessments, no bladder or bowel retraining program was in place. The resident developed a stage 2 pressure ulcer, and the facility's documentation showed no evidence of interventions to address the decline in continence. The Director of Nursing confirmed the lack of evidence for measures to decrease urinary incontinence and prevent related complications.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents, leading to deficiencies in maintaining their highest practicable physical, mental, and psychosocial well-being. Resident 90, who was admitted with diagnoses including adjustment disorder, major depressive disorder, and acute stress reaction, reported not receiving psychiatric services since February 2024. The resident expressed dissatisfaction with previous telehealth services, citing distractions and a lack of engagement from the psychologist. Despite the resident's ongoing struggles with anxiety and depression, there was no documented follow-up on her psychological needs from February 20, 2024, to the survey's conclusion on May 10, 2024. Similarly, Resident 28, diagnosed with schizoaffective disorder and requiring specialized mental health services, did not receive timely psychological follow-up. Although a psychological evaluation in October 2023 recommended individual psychotherapy within four weeks, the resident was not seen by psychological services until March 25, 2024. The Director of Nursing and Nursing Home Administrator confirmed the lack of timely psychological services for both residents, acknowledging the failure to adhere to recommended follow-up care.
Failure to Attempt Gradual Dose Reduction of Psychoactive Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychoactive medications for two residents, which was identified through clinical record reviews and staff interviews. Resident 52 was admitted with diagnoses including dementia and had physician orders for Trazadone and Lexapro, both antidepressants. A pharmacist consult requested a GDR for these medications, but the physician disagreed without providing an individualized clinical rationale. The facility could not provide documented evidence supporting the continued use of the current doses or any GDR attempts in the past year. Resident 77, also diagnosed with dementia and bipolar disorder, had physician orders for Depakote, Olanzapine, and Escitalopram Oxalate. The pharmacist recommended dose reductions for these medications, but the physician disagreed, citing potential clinical deterioration without documented evidence of behaviors. The facility lacked documentation to support the continued dosages or any GDR attempts for Resident 77 in the past year. The Nursing Home Administrator and Director of Nursing confirmed the absence of GDR attempts for both residents.
Medication Storage and Expiration Compliance Issues
Penalty
Summary
The facility failed to adhere to pharmacy supplies expiration and use-by dates on two of its resident units, specifically the First and Second Floors. During a review of the facility's policies and observations in the medication room on the second floor, several expired and improperly labeled items were found. These included expired Foley catheter securement devices, povidone/iodine swab sticks, BD Eclipse Needles, needleless sterile connectors, safety needles, central line trays, Opti foam heel wound dressings, urostomy pouches, urine BD vacutainer kits, sterile urine cups, Comfort foam Ag wound dressings, and Bisacodyl medicated laxative suppositories. Additionally, there were opened items without dates, such as Santyl Collagenase, Normal Saline Irrigation Solution, alcohol, hydrogen peroxide, and an Apisol injection vial, which did not comply with the facility's policy for multidose medications. The medication refrigerator was found to have a thick layer of ice, scattered dark substances, and frozen paper towels, with no evidence of temperature monitoring as required by the facility's policy. Employee 1, an LPN, confirmed these findings. During an interview, the Nursing Home Administrator and the Director of Nursing acknowledged that expired pharmacy products should have been removed and discarded, and the medication refrigerator should have been defrosted, cleaned, and monitored for temperature. These deficiencies indicate a failure to maintain medication storage and preparation areas in a clean, safe, and sanitary manner, as per the facility's policies.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to provide a nourishing evening snack for residents when more than 14 hours elapsed between the supper meal and breakfast the next day. This deficiency was observed in four residents out of a sample of 23. The facility's policy, last reviewed in February 2024, mandates the provision of adequate nutrition, yet the scheduled meal times revealed a 15-hour gap between dinner and breakfast. During a group interview, residents reported that snacks were not routinely offered in the evenings, and they only received snacks upon request. Additionally, residents on the Dementia unit also experienced a 15-hour gap without evidence of being offered a nourishing snack. The facility administrator could not provide documented evidence that residents were routinely offered and provided with a bedtime snack.
Failure to Update Facility-Wide Assessment for Dementia Care
Penalty
Summary
The facility failed to timely review and update its facility-wide assessment to identify the specific personnel and resources necessary to care for its current resident population. The assessment, last reviewed on April 15, 2024, did not address the needs of the locked third-floor Dementia/Memory care unit, which houses 61 residents with documented diagnoses of Dementia/Alzheimer's disease and 43 residents residing on the locked dementia unit. This oversight was identified during a survey ending on May 10, 2024, when the facility provided an assessment tool that lacked documentation on the specific needs of these residents. Previous surveys conducted on January 25, 2024, and February 27, 2024, had already identified deficiencies related to inadequate dementia care and behavioral health services, including instances of resident-to-resident abuse. During the current survey, the facility was also cited for failing to provide behavioral health services to meet the mental health needs of a resident with a diagnosed mental disorder. The facility did not update its assessment to ensure that it had the necessary staff resources with the required skills and competencies to care for its resident population, thus failing to meet minimum licensure and certification standards.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the personal dignity, privacy, and quality of life for two residents. Resident 49, who has dementia and exhibits behaviors such as moving furniture and removing window coverings, was observed in a room without curtains, shades, or blinds, leaving him visible from the street. Despite the resident's behavior of removing window coverings, the facility did not replace them or explore alternative solutions to ensure his privacy. Resident 90, who is cognitively intact, reported that a nurse aide did not assist her after she rang the call bell, leaving her incontinent for 15 hours. Additionally, she experienced anxiety due to being manhandled during transfers with a mechanical lift, following a previous traumatic transfer incident that resulted in a broken leg and surgery. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to consistently treat residents with dignity and respect, including timely responses to requests for assistance.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect Resident 85 from physical abuse by Resident 60, despite being aware of Resident 60's history of aggressive behavior. Resident 85, who was severely cognitively impaired with Alzheimer's disease and other mental health disorders, was involved in an altercation with Resident 60 in the Dementia Unit Dayroom. Resident 60, also severely cognitively impaired, had been exhibiting increased agitation and aggressive behaviors prior to the incident. On the day of the incident, Resident 60 was observed pacing and insisting on going home, which staff attempted to manage by redirecting her to her room. The incident occurred when Resident 60 approached Resident 85, who was seated at a different table, and pulled her by the hair, causing her to fall to the ground. Staff intervened by separating the residents, and an RN assessment found no injuries to either resident. Despite the lack of physical injuries, the facility's failure to prevent the altercation highlights a deficiency in ensuring a safe environment for Resident 85, who was supposed to be protected from abuse. The facility's awareness of Resident 60's escalating behaviors and history of aggression, combined with the failure to effectively manage these behaviors, contributed to the incident. The Director of Nursing confirmed the facility's awareness of Resident 60's behaviors and acknowledged the failure to protect Resident 85 from physical abuse. The incident was reported to the local police and the Aging Agency, and both residents' families and physicians were notified.
Failure to Implement Abuse Policy and Conduct Thorough Assessment
Penalty
Summary
The facility failed to implement its established abuse prohibition policy and procedures in response to an incident involving two residents. Resident 60, who was observed packing her clothes and insisting she was going home, engaged in a physical altercation with Resident 85 in the Dementia Unit Dayroom. Resident 60 pulled Resident 85 by her hair, causing her to fall to the ground. Staff intervened by separating the residents and notifying the responsible parties and physicians. However, the RN's assessment of Resident 85 was inadequate, as it did not include a thorough physical assessment or documentation of the required assessment data as outlined in the facility's Abuse Policy. The RN's documentation only noted that there were no signs of injury or distress and that vital signs were within normal limits. The RN failed to document a comprehensive assessment, including pain assessment, current behavior, medications, behaviors over the past 24 hours, active diagnoses, and recent labs. This lack of thorough documentation and assessment was confirmed during an interview with the Director of Nursing, who acknowledged the failure to provide documented evidence of a complete physical assessment following the incident of physical abuse.
Failure to Investigate Medication Errors
Penalty
Summary
The facility failed to thoroughly investigate potential neglect involving five residents who did not receive their scheduled medications on April 27, 2024. Employee 10, a registered nurse, signed the Medication Administration Records (MAR) indicating that all medications had been administered, but the medications were later found in the medication cart. The residents affected included those with diagnoses such as dementia, diabetes, and cerebral infarction, and they missed medications like atorvastatin, metropolol, Sevelamer, dipyridamole, memantine, Eliquis, metformin, and Toresmide. The facility's policy requires a complete investigation into such incidents, but there was no documented evidence of an investigation into the potential neglect by Employee 10. The facility did not obtain witness statements from staff or cognitively intact residents, and there was no documentation in the residents' clinical records indicating the missed medications. Interviews with the administrator and director of nursing confirmed the lack of a thorough investigation, violating several Pennsylvania Code regulations related to the responsibility of the licensee, management, resident rights, and nursing services.
Failure to Monitor Resident's Respiratory Status and Oxygen Use
Penalty
Summary
The facility failed to identify and implement necessary interventions in the care plan of a resident who required monitoring of respiratory status and oxygen use. The resident, who was admitted with diagnoses including shortness of breath and urinary retention, exhibited behaviors such as unplugging and removing oxygen, which were not addressed in the care plan. The care plan included interventions for the resident's behaviors but did not specify actions to monitor respiratory status, such as checking oxygen saturation levels or guidelines for when to notify nursing staff if the oxygen therapy was interrupted. Observations revealed that the resident was frequently found with the oxygen concentrator turned off, despite wearing a nasal cannula, and staff did not intervene to ensure continuous oxygen delivery as prescribed. The resident was noted to be severely cognitively impaired, and a physician's order required continuous oxygen at four liters per minute. The Director of Nursing and Nursing Home Administration confirmed the omission of respiratory monitoring measures in the care plan, which contributed to the deficiency.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to consistently administer oxygen therapy as ordered for a resident, leading to a deficiency. The resident, who was admitted with a history of falling and hemiplegia following a stroke, had a physician's order for oxygen therapy at 2 liters per minute via nasal cannula as needed for shortness of breath. However, observations on two separate occasions revealed that the resident's oxygen concentrator was set to 3 liters per minute, which was not consistent with the physician's orders. The deficiency was confirmed through observations and staff interviews. On both occasions, the oxygen concentrator was observed running at an incorrect flow rate, and this was confirmed by an LPN. Further confirmation came from interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the physician's order for supplemental oxygen was not followed for the resident. This failure to adhere to the prescribed oxygen therapy regimen constitutes a deficiency in the facility's provision of nursing services.
Deficiency in Person-Centered Dialysis Care Coordination
Penalty
Summary
The facility failed to provide person-centered care and coordination of individualized services for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident, who also had dementia, was admitted with a care plan that included interventions to coordinate care with a dialysis center and monitor the dialysis access site. However, the care plan did not reflect the resident's specific schedule preferences or provisions for transportation and meal accommodations related to the dialysis schedule. A physician order indicated that the resident's dialysis was scheduled for 4:00 a.m. on specific days, and the resident's wife was allowed to transport him. Despite this, the care plan lacked details on the resident's transportation preferences and meal schedule adjustments needed for dialysis days. The Director of Nursing confirmed that the care plan did not adequately address these aspects, leading to a deficiency in providing comprehensive and individualized care for the resident.
Deficiency in Clinical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, as identified during a survey. For one resident, who was admitted with a history of falling and hemiplegia following a stroke, a skin injury was observed on the left lower extremity during an inspection. However, there was no documentation in the clinical record regarding the assessment or cause of this injury. The Director of Nursing confirmed the absence of any documentation related to the injury. For another resident, who was admitted with type 2 diabetes mellitus and a history of boils, a boil on the left inner labia majora was noted to have burst. Although treatment was administered as per the physician's order, there was no documentation in the clinical record regarding the healing progress, status, or resolution of the boil. The Director of Nursing and Nursing Home Administrator confirmed the lack of documentation tracking the healing and resolution of the resident's boil.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible in the room of Resident 52, who is severely cognitively impaired. During an observation on May 9, 2024, it was noted that there was no call bell connected to the wall outlet or present anywhere in the room. Additionally, there was no alternative method for the resident to summon assistance, such as a tap bell. Instead, two plugs were inserted into the wall outlet call bell unit to circumvent the alarm when the outlet is unplugged. An interview with a licensed practical nurse confirmed that Resident 52 did not have access to a call bell while in bed, and verified that call bells are supposed to be placed within reach of residents at their bedside. The Nursing Home Administrator also confirmed that call bells should be placed at each resident's bedside, in accordance with 28 Pa. Code 205.67 (j) Electric Requirements for existing and new construction.
Failure to Implement Safe Smoking Procedures for Resident
Penalty
Summary
The facility failed to implement established procedures to ensure safe smoking practices for a resident identified as a current smoker. During an onsite survey, it was observed that the facility had a policy indicating it was a non-smoking facility, prohibiting smoking within the facility or on its grounds. However, the Nursing Home Administrator acknowledged that one resident, identified as a current smoker, was allowed to smoke. A review of the resident's clinical record showed that the resident was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD), but there was no care plan addressing the resident's smoking until the surveyor's inquiry. The facility lacked a smoking policy to address the decision to allow the resident to smoke, and the issue was only brought to attention during the survey. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of a care plan and a revised smoking policy for the resident.
Failure to Ensure Informed Consent for Medicare Plan Changes
Penalty
Summary
The facility failed to develop and implement policies and procedures to protect residents from being disenrolled from their Medicare health plans without their informed consent. This deficiency was identified through a review of clinical records, CMS guidance, facility documentation, and staff interviews. The facility did not ensure that residents were competent to make informed decisions about their health plan changes, nor did they provide adequate explanations of the risks involved in disenrollment, both verbally and in writing. Resident 11, who was cognitively intact with a BIMS score of 13, was disenrolled from a Medicare Advantage Plan without documented evidence of her initiating the request or understanding the implications. The facility did not assess her cognitive abilities before having her sign the disenrollment form. Similarly, Resident 16, who was moderately cognitively impaired with a BIMS score of 10, was disenrolled without involving his health care decision maker, his daughter, and without providing her with a written explanation of the risks involved. Resident 17, who was cognitively intact, was also disenrolled without documented evidence of initiating the request. Resident 21, who was moderately cognitively impaired, was disenrolled without assessing his current cognitive function or involving his responsible party, his daughter. Interviews with facility staff revealed that the facility lacked policies and procedures for assisting residents with health plan changes and failed to ensure residents' cognitive abilities were assessed before signing disenrollment forms.
Failure to Implement Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized plans to manage dementia-related behavioral symptoms for two residents, leading to multiple incidents and falls. Resident 14, who was severely cognitively impaired and had a history of falls, experienced several incidents due to poor safety awareness and wandering behavior. Despite having a care plan that included diversional activities and safety checks, these interventions were not effectively implemented, resulting in repeated falls and injuries. Resident 14's care plan included activities such as music, television shows, and pet visits to manage her dementia-related behaviors. However, the facility did not consistently provide these activities, and the resident continued to experience falls, including unwitnessed incidents in the dayroom and her bedroom. The facility's reliance on 15-minute safety checks proved ineffective, as evidenced by the resident's repeated falls and injuries, including a laceration that required hospital evaluation. Resident 19, also severely cognitively impaired, exhibited intrusive wandering and inappropriate sexual behaviors. The facility's care plan for Resident 19 did not address these specific behaviors or provide interventions for staff to manage them. This oversight led to incidents where Resident 19 engaged in inappropriate interactions with other residents, which were not adequately addressed in the care plan. The facility's failure to implement person-centered, interdisciplinary care plans for these residents resulted in ongoing behavioral issues and safety concerns.
Failure to Address Abuse and Dementia Care Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address and correct quality deficiencies related to abuse and dementia care, as identified in surveys conducted on January 25, 2024, and February 27, 2024. Despite having a plan of correction in place, the facility did not effectively implement or sustain the necessary changes. Specifically, the facility did not revise the care plan for a resident who exhibited inappropriate behavior, such as kissing cognitively impaired female residents, which was identified as a form of potential sexual abuse and harassment. This behavior was observed on two separate occasions, and the facility did not take adequate steps to protect other residents. Additionally, the facility failed to manage dementia-related behavioral symptoms effectively, as evidenced by a resident who experienced six falls in February 2024 due to dementia-related behaviors. The facility did not implement individualized interdisciplinary plans to manage these symptoms and ensure resident safety. The QAPI committee did not identify these ongoing deficiencies or develop effective plans to sustain corrections, leading to repeated issues in both abuse prevention and dementia care.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect Resident 18 from sexual abuse by another resident, Resident 19. Resident 18 was severely cognitively impaired with a BIMS score of 6, indicating an inability to consent to sexual activity. Despite this, Resident 18 was found in a situation with Resident 19, who also had severe cognitive impairment, where they were engaged in a kiss. The facility's policy requires that residents suspected of lacking the capacity to consent to sexual activity be protected from abuse, but this was not adequately ensured in this case. Resident 19, who was admitted with diagnoses including dementia and severe cognitive impairment, was observed on two occasions engaging in physical affection with other residents. The care plan for Resident 19 did not address these behaviors or include interventions to prevent such incidents. The facility's failure to identify and manage Resident 19's behaviors, and to ensure Resident 18's protection, resulted in a substantiated case of resident abuse. The Nursing Home Administrator confirmed the deficiency, acknowledging that Resident 18 was not free from sexual harassment by Resident 19.
Failure to Justify Increased Antipsychotic Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints that were not required for medical treatment. Resident 19, who was admitted with diagnoses including Parkinsonism, dementia with behavioral disturbances, and adult failure to thrive, was prescribed Quetiapine Fumarate (Seroquel) 25 mg. Following an incident where the resident became verbally aggressive after being redirected from a female resident, the CRNP discussed increasing the dosage to 75 mg. However, the facility did not provide physician documentation of the clinical rationale for this increase. The facility did not demonstrate that less restrictive alternatives were considered or attempted, nor did it provide evidence of an appropriate assessment and care planning by the interdisciplinary team. The clinical record lacked documentation that the facility staff or physician had identified and addressed potential underlying causes of the resident's behavior, such as environmental factors. The Director of Nursing confirmed the absence of documentation justifying the increased dosage of the antipsychotic drug to control the resident's behavior.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
