Oakwood Heights Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Oil City, Pennsylvania.
- Location
- 10 Vo Tech Drive, Oil City, Pennsylvania 16301
- CMS Provider Number
- 395502
- Inspections on file
- 25
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Oakwood Heights Village during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including dementia and diabetes, did not receive premedication with both PRN Lorazepam and Morphine prior to care as ordered by the physician. Facility staff failed to accurately transcribe the physician's order, resulting in the omission of instructions to administer both medications together before care. Documentation showed the resident was repositioned multiple times without evidence of the required premedication, and nursing notes indicated increased discomfort and anxiety during care.
A resident with diabetes, dementia, and hypertension did not have complete and accurate documentation of oral hygiene care in their clinical record, as required by facility policy. Multiple shifts and days showed missing or 'not applicable' entries for oral care, and the DON confirmed the lack of proper documentation.
A resident with Alzheimer's Disease and Parkinsonism, who was non-verbal and required two-person assistance for bed mobility, was injured when an agency CNA attempted to reposition the resident alone, contrary to the care plan. The resident fell from bed, sustaining a forehead laceration and an intraventricular hemorrhage. Staff interviews confirmed the two-person assist requirement was documented and known, but not followed, resulting in actual harm.
A resident with significant cognitive and physical impairments, who required two staff for bed mobility, was rolled in bed by a single agency CNA, contrary to the care plan and task orders. This resulted in the resident falling from bed, sustaining a forehead laceration and an intraventricular hemorrhage. The CNA was unaware of the resident's need for two-person assistance and did not follow established protocols, leading to actual harm.
A resident suffered a head laceration requiring staples after being incorrectly transferred with an oversized sling using a Hoyer lift. The facility lacked a process to ensure proper sling sizing, leading to the resident slipping through the sling. Staff interviews confirmed the absence of documentation for correct sling size in the resident's records.
The facility failed to maintain food safety and sanitation standards, with expired food items found in the kitchen and pantries, and improper labeling and storage practices. Additionally, a homemaker employee did not follow proper hygiene protocols during food handling. These issues were confirmed by staff, indicating non-compliance with facility policies.
A facility failed to document a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident with multiple health conditions. The resident's orders for Lunesta, a sleeping pill, lacked the required stop date and justification for extended use, as confirmed by an LPN, violating facility policy and regulatory requirements.
The facility did not label multi-dose insulin vials with the date they were opened, nor did it discard expired vials on the third-floor medication cart A. The policy requires vials to be dated upon opening and discarded after 28 days. An LPN confirmed the requirement to date vials to ensure timely disposal.
The facility failed to meet the required nurse aide (NA) staffing ratios over a 14-day period, with shortages noted on multiple days and shifts. The facility did not maintain the minimum staffing levels of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. The Nursing Home Administrator confirmed these deficiencies.
The facility did not meet the required 3.2 hours of direct resident care per day on six occasions, with the lowest being 2.64 hours. This was confirmed by the Nursing Home Administrator.
The facility failed to provide timely medication delivery for three residents, resulting in missed doses of essential medications. A resident with epilepsy missed doses of Lacosamide, another with pneumonia missed doses of Cefazolin, and a third with an infection missed doses of Piperacillin. The Director of Nursing confirmed the delays in pharmacy delivery, which were not in line with the facility's policy on medication availability.
A resident with diabetes was incorrectly administered Novolog insulin instead of the prescribed Novolog 70/30 mix insulin upon admission to the LTC facility. This error went unnoticed for several weeks, leading to an incident where the resident was found clammy and sweaty with low blood glucose levels. The mistake was confirmed by an RN and corrected after discovery.
The facility failed to provide an environment that enhances the quality of life for a resident with multiple diagnoses, including dementia and bipolar disorder. Despite the resident's expressed desire for social interaction, they were observed multiple times sitting alone in their room without personal interactions. Interviews with the DON and Director of Activities confirmed that the resident should not be left alone for extended periods.
The facility failed to follow essential safety measures, resulting in falls for two residents. One resident was pushed in a wheelchair without leg rests, causing a fall, while another was transferred by one staff member instead of the required two, leading to a fall.
A facility failed to provide appropriate care for a resident with a urinary catheter. Observations showed the urinary drainage bag lying flat on the floor with the drainage spout touching the floor. An LPN confirmed that the bag should not be on the floor and should have a privacy cover. The resident had a history of UTI, hypertension, and hyperlipidemia.
Failure to Accurately Transcribe and Administer Premedication Orders for Comfort
Penalty
Summary
The facility failed to accurately transcribe and implement a physician's order for premedication to promote comfort and prevent discomfort during care for one resident. The physician's order specified that the resident should be premedicated with Ativan (Lorazepam) 0.5 mg and Morphine 10 mg every two hours as needed prior to care. However, the facility's transcribed orders did not include the instruction to administer both medications together prior to care, and the Morphine order lacked the premedication instruction entirely. Review of the Medication Administration Record (MAR) and nursing documentation showed that the resident was repositioned multiple times, but there was no evidence that both PRN Lorazepam and PRN Morphine were administered together as ordered before care was provided. The resident, who had diagnoses including diabetes, dementia, and hypertension, was observed to experience increased discomfort, moaning, and anxiety during repositioning and incontinence care, as documented in nursing progress notes. Staff interviews confirmed that the orders were not transcribed as written by the physician, and the Director of Nursing acknowledged the omission. Facility policy required that PRN medication orders specify the reason for administration and symptoms for which the medication is prescribed, but these requirements were not met in this case.
Incomplete Documentation of Oral Hygiene Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation of oral hygiene care for one resident. According to the facility's mouth care policy, the date and time of mouth care should be recorded in the resident's clinical record. Review of the clinical record for a resident with diagnoses including diabetes, dementia, and hypertension revealed multiple instances across various shifts where documentation of oral care was missing or marked as not applicable. Specifically, there were several days and shifts where no record indicated that oral hygiene was completed. The Director of Nursing confirmed during an interview that the clinical record lacked complete documentation for oral hygiene and acknowledged that such care should be performed and documented as ordered.
Failure to Follow Two-Person Assist Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, Parkinsonism, and muscle weakness, who was non-verbal and totally dependent on two staff for bed mobility and repositioning, was not provided care according to their established care plan. The resident's care plan and task orders clearly indicated that two staff members were required to assist with rolling and repositioning in bed. Despite this, an agency CNA attempted to roll the resident independently during morning care, without seeking assistance or following the documented care instructions. During the attempted repositioning, the resident rolled out of bed and struck their head on the roommate's bed frame, resulting in a 3 cm laceration to the right forehead and subsequent bruising. The resident was found to be in significant pain and was later transferred to the hospital, where a CT scan revealed a small, acute bilateral intraventricular hemorrhage. The resident's non-verbal status prevented them from providing any account of the incident. Staff interviews confirmed that the resident always required two-person assistance for bed mobility, and this information was accessible in the task orders. The agency CNA involved acknowledged in a written statement that they were unaware of the resident's stiffness and did not receive information about the need for two-person assistance. The incident was witnessed by another CNA, who found the resident partially out of bed and bleeding. The facility's investigation confirmed that the agency CNA did not follow the care plan or task orders, resulting in actual harm to the resident.
Failure to Provide Required Assistance During Bed Mobility Results in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, Parkinsonism, and muscle weakness, who was non-verbal and totally dependent on two staff for bed mobility, was not provided the required level of assistance during repositioning in bed. The resident's care plan and task orders clearly indicated that two staff were needed for rolling side to side, and this requirement was documented in multiple reviews and confirmed by staff interviews. Despite these documented requirements, an agency CNA attempted to roll the resident independently without assistance. During this process, the resident rolled out of bed and struck their head on the roommate's bed frame, resulting in a 3 cm laceration to the right forehead and subsequent bruising. The incident was witnessed by another CNA who responded to noises from the room and found the resident partially out of bed and the agency CNA attempting to assist them back onto the bed. Following the incident, the resident was assessed and found to have a significant laceration and was in considerable pain. A CT scan at the hospital revealed a small acute bilateral intraventricular hemorrhage. The agency CNA involved stated they were unaware of the resident's stiffness and did not know that two staff were required for the task. The failure to follow the care plan and task orders for bed mobility assistance directly resulted in actual harm to the resident.
Failure to Ensure Proper Sling Sizing Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for Resident R46 by not ensuring the correct sizing of a mechanical lift sling, which resulted in actual harm. Resident R46, who was dependent on staff for transfers and cognitively intact, was incorrectly transferred using a Hoyer lift with an extra-large sling instead of the appropriate medium size. This error led to the resident slipping through the sling, causing a head laceration that required staple repair. The facility's policy on Safe Resident Handling/Transfers mandates proper sling sizing, but this was not adhered to in this instance. Interviews with staff revealed a lack of process or documentation in the resident's clinical record to indicate the correct sling size for transfers. The Director of Nursing confirmed the inappropriate use of the sling size and acknowledged the absence of a process to ensure proper sling size determination. This deficiency was identified through a review of facility policy, investigation documents, clinical records, and staff interviews, highlighting a failure in the facility's management and nursing services as per the cited Pennsylvania Code regulations.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its own policies regarding food safety and sanitation, as evidenced by several observations during a kitchen tour and pantry inspections. In the main kitchen, multiple food items were found stored beyond their use-by dates, including barbecue pork, chili, hard-boiled eggs, potato salad, coleslaw, and yogurt. These items were confirmed by a dietary employee to be past their expiration and should have been discarded. Additionally, in the First Floor pantry, a jar of homemade jelly was found without a resident name and with an open date from several months prior, and ice packs used for resident treatments were improperly stored with food items. On the Third Floor, a loaf of homemade bread and a pizza box lacked proper labeling with resident names or dates. During a tray line observation, a homemaker employee failed to maintain proper hygiene practices by not changing gloves or washing hands after handling various items before touching residents' food. This was confirmed by the employee, who acknowledged the lapse in protocol. The Director of Nursing and the Dietary Manager confirmed the deficiencies in labeling, storage, and hygiene practices, which were not in compliance with the facility's policies and professional standards for food safety.
Failure to Document Rationale for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to provide a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident. The facility's policy on the use of psychotropic medications requires that PRN orders be limited to no more than 14 days unless there is documented justification from a physician or prescriber for an extended period. However, the clinical records for a resident, who was admitted with diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, showed a physician's order for Lunesta, a sleeping pill, initially prescribed at 1 mg and later increased to 2 mg as needed at bedtime. These orders did not include the required stop date within 14 days or a clinical rationale for continuation beyond this period. During an interview, an LPN confirmed that the orders for the resident's Lunesta lacked the necessary stop date and clinical rationale for continued use beyond 14 days. This oversight was in violation of the facility's policy and the regulatory requirement that PRN psychotropic medications should have a documented rationale and specified duration if used beyond the standard 14-day limit.
Failure to Label and Discard Expired Insulin Vials
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and timely disposal of multi-dose insulin vials. During a review, it was found that a multi-dose vial of Novolog insulin on the third-floor medication cart A was opened but not labeled with the date it was opened. Additionally, the cart contained two vials of opened Novolog insulin that were undated, despite being stored in a bag with an expiration date. The facility policy requires that multi-dose vials be labeled with the date they are opened and discarded 28 days thereafter. An LPN confirmed that the vials should be dated upon opening to ensure timely disposal and prevent usage past expiration.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by regulations effective July 1, 2024. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents overnight. This deficiency was observed over a 14-day period from January 1, 2025, to January 14, 2025. During this time, the facility was short-staffed on eight days for the day shift, two days for the evening shift, and six days for the overnight shift. The census of residents varied slightly, ranging from 82 to 86 residents, but the facility consistently failed to provide the required number of NAs to meet the staffing ratios. The specific shortages included instances where the number of NAs working was below the required number, such as on January 1, 2025, when only 7.09 NAs worked during the day shift, while 8.60 were required for a census of 86 residents. Similar shortages were noted on other days and shifts, with the most significant shortfall occurring on the overnight shift on January 4, 2025, where only 3.40 NAs worked, while 5.60 were required. The Nursing Home Administrator confirmed these staffing deficiencies during a telephone interview, acknowledging the facility's failure to meet the minimum NA ratio requirements on the specified dates and shifts.
Plan Of Correction
The facility acknowledges that, as of 1/21/2024, we are unable to change the results of the staffing ratio of nurse aides of one NA per 10 residents on the day shift for eight of 14 days reviewed (1/01/25, 1/02/25, 1/04/25, 1/05/25, 1/06/25, 1/07/25, 1/11/25, and 1/13/25); failed to ensure a minimum of one NA per 11 residents for the evening shift for two of 14 days reviewed (1/05/25, and 1/06/25); and failed to ensure a minimum of one NA per 15 residents for the overnight shift for six of 14 days reviewed (1/04/25, 1/05/25, 1/07/25, 1/09/25, 1/12/25 and 1/14/25). The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval. Instruction has been provided to the DON, Scheduler, and Nursing Supervisors to ensure that they know how staffing ratios are met in creating schedules and deal with call-offs. Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime. The Administrator performs a spot audit of schedules versus actual hours of care to track adherence to regulations. This will be applied to at least three days a week to ensure that staffing ratios are within prescribed parameters. The results of the audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on six specific days within a two-week period. The review of nursing staffing documents revealed that the facility provided less than the required hours of care on January 1st, 3rd, 4th, 5th, 6th, and 8th of 2025, with the lowest being 2.64 hours per patient per day on January 5th. This deficiency was confirmed by the Nursing Home Administrator during a telephone interview, acknowledging the shortfall in meeting the mandated care hours on the specified dates.
Plan Of Correction
The facility acknowledges that, as of 1/21/2025, the facility failed to provide the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a twenty-four-hour period for six of 14 days reviewed (1/01/25, 1/03/25, 1/04/25, 1/05/25, 1/06/25 and 1/08/25). The upcoming schedules are created by the scheduler and reviewed with the Director of Nursing (DON) and Administrator for approval. Instruction has been provided to the DON, Scheduler, and Nursing Supervisors to ensure that they know how to achieve a 3.2 hours PPD in creating schedules and deal with call-offs. Oakwood has advanced a recruitment and retention effort to entice additional employees to us and keep the ones that we hire. The facility has also acquired agency staff to augment our staff. Bonuses and incentives are offered to staff who pick up shifts and stay overtime. The Administrator performs a spot audit of schedules versus actual hours of care to track adherence to regulations. This will be applied to at least three days a week to ensure that staffing ratios are within prescribed parameters. The results of the audits will be provided to the Quality Assurance and Performance Improvement (QAPI) Committee for the next three meetings.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure the timely availability of medications for three residents, resulting in missed doses. Resident R1, diagnosed with epilepsy, cerebral palsy, and major depressive disorder, had a physician's order for Lacosamide, an anticonvulsant medication, which was not administered as ordered on four occasions due to delays in pharmacy delivery. Similarly, Resident R2, with diagnoses including pneumonia and chronic obstructive pulmonary disease, missed four doses of Cefazolin Sodium Injection Solution, an antibiotic, because the facility was waiting for the pharmacy to deliver the medication. Resident R3, who had an infection of an amputation stump and a malignant neoplasm, was prescribed Piperacillin Sodium Tazobactam Sodium Solution, another antibiotic, but missed six doses due to the same issue of delayed pharmacy delivery. The Director of Nursing confirmed that the medications for these residents were not provided in a timely manner, leading to the missed doses. The facility's policy on medication delivery was not adhered to, as emergency deliveries were not utilized to ensure timely administration of medications.
Plan Of Correction
Intervention with regard to R1, R2 and R3: We have reviewed the case files of these residents and have determined that there were no adverse effects experienced due to the events cited. Interventions for all residents: 1. All residents' medications were reviewed by the pharmacist to ensure medications were present in the facility and made an urgent request to pharmacy in the event that medications that were not available. 2. New Admissions will be reviewed by Director of Nursing (DON) or designee to ensure medications were delivered as per order on next business day. 3. Review of the in-house medication storage and distribution vault (aka Cubex) was completed on January 15, 2025 and medication Cefazolin was added to the Cubex. 4. All licensed staff will be educated by the DON or designee on admission process for new medications to include medication in Cubex, calling pharmacy for late admissions, printing orders and faxing to pharmacy for controlled substances. They will also be trained on the medication re-ordering process in order to mitigate lapsed medication orders. Monitoring of the change to sustain system compliance ongoing: The DON/designee will monitor medication orders 5 times a week for 4 weeks to ensure medications are available to administer then monthly for 2 months and ongoing. Findings will be reported to Quality Assurance and Performance Improvement (QAPI) committee for review and recommendations.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to provide the highest practicable care regarding correct medication administration for a resident, identified as Resident R1. Resident R1 was admitted with diagnoses including diabetes, kidney disease, and high blood pressure. On June 25, 2024, Resident R1 was observed to be clammy and sweaty with a low blood glucose level. A review of the facility's investigation into the medication error revealed that Resident R1 was supposed to receive Novolog 70/30 mix insulin, which they had been using at home. However, upon admission to the facility, they were incorrectly administered Novolog insulin instead. This error persisted from the admission date of June 5, 2024, until June 26, 2024, when the mistake was discovered and corrected. A registered nurse confirmed that the incorrect insulin type was ordered and administered during this period.
Failure to Provide Adequate Social Interaction for Resident
Penalty
Summary
The facility failed to provide an environment that enhances the quality of life for Resident R37, who has a history of dementia, Type 2 Diabetes, heart failure, post-traumatic seizures, bipolar disorder, and traumatic brain injury. Despite enjoying watching TV and spending time in common areas, Resident R37 was observed multiple times sitting alone in his/her room, often yelling for help and expressing a desire for social interaction. On 3/26/24, Resident R37 was found alone in his/her room yelling for help and expressed a desire to visit the lounge, but a nurse aide indicated that the resident's yelling often disturbed others. Subsequent observations on 3/27/24 and 3/28/24 revealed that Resident R37 spent extended periods alone in his/her room without personal interactions, except for brief periods in the beauty shop, near the nurse's station, and during lunch in the lounge. On 3/29/24, the resident was again observed eating breakfast alone in his/her room with the door ajar. Interviews with the Director of Nursing and the Director of Activities confirmed that Resident R37 should not be left alone in his/her room for extended periods and should be brought out to common areas to interact with other residents and staff. The facility's failure to ensure that Resident R37 had adequate social interaction and engagement in common areas constitutes a deficiency in honoring the resident's right to a dignified existence, self-determination, and communication, as required by 28 Pa. Code 201.29 (a) and 28 Pa. Code 211.12 (d)(1)(3)(5).
Failure to Follow Safety Measures Resulting in Resident Falls
Penalty
Summary
The facility failed to ensure essential resident safety measures were followed to prevent falls for two residents. For Resident R26, the facility's policy required the use of footrests when transporting residents in wheelchairs. However, on 2/21/24, a CNA pushed Resident R26 down the hallway without the leg rests attached. As a result, the resident's feet dropped and got stuck under the wheelchair, causing the resident to be thrown to the floor and land face down. The Director of Nursing (DON) confirmed that the leg rests should have been in place to prevent such an incident, and Resident R26 expressed that the fall could have been prevented if the leg rests were used, as they made the resident feel safer. For Resident R37, the clinical record indicated that the resident required transfer assistance from two staff members using a wheeled walker. However, on 1/17/24, the resident was transferred by only one staff member, leading to the resident's knees giving out and a subsequent fall. The DON confirmed that the staff failed to follow the physician's order for a two-person transfer, which compromised the resident's safety during the transfer process.
Failure to Maintain Proper Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter. The facility's policy required that urinary drainage bags and tubing be kept off the floor at all times. However, observations revealed that the urinary drainage bag of a resident with an indwelling urinary catheter was lying flat on the floor with the drainage spout facing down and touching the floor. This was observed twice within an hour. During an interview, an LPN confirmed that the urinary drainage bag should not be on the floor and that a privacy cover should be in place. The resident had a history of urinary tract infection, hypertension, and hyperlipidemia.
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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