Orchard Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Grove City, Pennsylvania.
- Location
- 20 Orchard Drive, Grove City, Pennsylvania 16127
- CMS Provider Number
- 395793
- Inspections on file
- 21
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 24 (1 serious)
Citation history
Health deficiencies cited at Orchard Manor during CMS and state inspections, most recent first.
A resident with dementia and a high risk for wandering exited a secured unit and was found alone in the parking lot. Staff were unaware or confused about the incident, with some believing it was a drill and others not informed. Required documentation, care plan updates, and notifications were not completed, and the facility did not follow its own elopement response policies.
A resident with dementia and other medical conditions eloped from a secured unit, and staff failed to initiate or complete an investigation as required by facility policy. There was no documentation of the incident on the day it occurred, no staff interviews or statements were collected, and the administrator confirmed that no investigation took place, resulting in noncompliance with regulatory requirements.
The NHA did not ensure consistent supervision or maintain required safety interventions to prevent elopement, failing to meet administrative responsibilities and regulatory requirements.
A resident with dementia, repeated falls, and hypertension had a care plan intervention for a pressure sensor pad alarm, but the alarm was discontinued without updating the care plan to reflect this change. Facility leadership confirmed the care plan was not reviewed or revised after the intervention was resolved.
Three residents with dementia and other chronic conditions had incomplete and inaccurate documentation in their medical records, including missing entries for ADLs such as showers, dressing, and eating, as well as continued documentation of discontinued interventions. Facility leadership confirmed these documentation lapses, which did not meet policy standards.
A resident admitted with multiple medical conditions did not receive a summary of the baseline care plan, including physician orders and medications, within 48 hours of admission as required. The DON confirmed there was no documentation that this information was provided to the resident or their representative.
A resident with a history of heart failure and atrial fibrillation was found to be using oxygen tubing and a nasal cannula that had not been changed according to physician orders and facility policy. Observations and staff interviews confirmed that the equipment was overdue for replacement, resulting in a deficiency in providing safe and appropriate respiratory care.
Surveyors found that an opened vial of Humalog insulin on a medication cart was not labeled with an open date, preventing staff from determining when it should be discarded. The ADON and DON confirmed that insulins are required to be labeled with the date opened to ensure timely disposal.
The facility failed to maintain documentation for the semi-annual visual inspection of the fire alarm system and sensitivity testing of smoke detectors, as required by NFPA 70 and NFPA 72. Despite contacting the vendor, the facility could not provide the necessary documentation during a revisit survey.
The facility failed to document the code status for four residents, as required by policy. Despite having documents indicating a DNR status for one resident, the facility would have considered them a full code due to the lack of a physician's order. This deficiency was confirmed through staff interviews and clinical record reviews.
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents with complex medical conditions, as required by policy. The residents did not receive the necessary care plans or summaries, which was confirmed by the RN Assessment Coordinator.
A facility failed to adhere to its policy requiring urinary catheter bags to be covered. Observations showed a resident's catheter bag was visible from the hallway without a privacy cover. The resident had a dislocated hip, COPD, and neurogenic bladder. The DON confirmed the bag should have been covered, violating 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
A facility failed to administer oxygen therapy according to a physician's orders for a resident with COPD and CHF. The resident's order specified oxygen at 3 L/min via nasal cannula, but an observation found the flow meter set at 5 L/min. An LPN confirmed the discrepancy during an interview.
The facility failed to follow infection control practices for disinfecting and storing bedpans and wash basins for two residents. Observations showed an unlabeled bedpan on the floor of a shared bathroom, with a wash basin placed upside down on top. The RN IC confirmed these items should be sanitized, labeled, and stored properly, highlighting a deficiency in the facility's infection control protocols.
Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
The facility failed to implement sufficient monitoring interventions and supervision to prevent an elopement incident involving a resident with a known high risk for wandering. The resident, who had diagnoses including dementia, Parkinson's disease, and anxiety, was assessed as high risk for elopement and had a documented history of wandering behaviors. Despite these risk factors, the resident was able to exit the secured dementia unit and was found walking alone in the facility's parking lot. There was no documentation in the clinical record regarding the elopement on the day it occurred, and the resident's care plan was not updated to reflect the incident or address the increased risk. Staff interviews revealed a lack of awareness and inconsistent accounts regarding the event, with some staff believing the incident was an elopement drill and others unaware of any such drill or actual elopement. Key staff, including the DON and NHA, were not present at the time of the incident and were unaware of the event until after their return. Maintenance and housekeeping staff were not asked to check door locks or alarms following the incident, and several staff members who responded to the alarm were not asked to complete incident reports or provide documentation of their involvement. Video footage confirmed that the resident exited the building alone and was outside for several minutes before being returned by staff. The facility did not follow its own policies regarding elopement response, which required examination of the resident for injuries, notification of the attending physician and legal representative, completion of an incident report, and documentation in the medical record. There was no evidence that these steps were taken following the incident. The lack of immediate investigation, failure to update care plans, and absence of required documentation and notifications contributed to the deficiency and resulted in the identification of Immediate Jeopardy for resident safety and supervision.
Removal Plan
- All secured exit doors are checked and confirmed to be fully operational. Secured doors may not be propped open for any reason. This expectation is communicated to all departments, including housekeeping and maintenance.
- The resident involved and all residents residing on the secured unit are reassessed for elopement risk, and care plans are reviewed and updated as indicated. A head-to-toe skin assessment is completed on the resident involved. Any resident identified as high risk is subject to hourly documented supervision, with continued monitoring based on reassessment.
- The facility implements hourly documented checks following any cleaning, construction, or maintenance activity involving secured exits to ensure doors remain secured and alarms are active.
- All in-house staff are educated on the facility's elopement policy, elopement prevention, door alarm response expectations, supervision requirements, and escalation procedures for any alarm activation involving secured exits. All remaining staff are educated prior to the start of their next scheduled shift until one hundred percent of staff education is completed. Any staff member on vacation or otherwise unavailable in person is educated by telephone. No staff member is permitted to work until education has been completed. Compliance is monitored.
- Elopement risk mitigation is monitored through daily review of door alarm functionality, alarm response, and supervision compliance. Any identified concerns are addressed.
Failure to Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an elopement incident involving a resident with dementia, Parkinson's disease, anxiety, and high blood pressure. The resident was admitted to the facility on 3/28/2025 and eloped from the dementia unit on 12/9/2025. Review of the clinical record showed no documentation regarding the elopement on the day it occurred, and there was no evidence that an investigation was initiated or completed. Staff interviews and incident documentation were lacking, with no staff interviews or handwritten statements present in the clinical record. Video footage confirmed the resident was outside the facility and was later returned by staff, but the staff involved were not asked to complete incident reports. During interviews, a nursing assistant described the sequence of events, including responding to door alarms, searching for the resident, and ultimately assisting in returning the resident to the unit. Despite these actions, the facility administrator confirmed that no investigation was conducted into the elopement. The facility's policy required all accidents or incidents to be investigated and reported to the administrator, but this was not followed in this case, resulting in noncompliance with state regulations regarding management, resident rights, and nursing services.
Failure to Ensure Effective Supervision and Elopement Prevention
Penalty
Summary
The Nursing Home Administrator (NHA) failed to effectively manage the facility to ensure proper supervision and implementation of elopement prevention measures. Review of facility records, job descriptions, and staff interviews revealed that the NHA did not fulfill essential job duties related to the general administration and supervision of all departments, as required by facility policy and applicable laws. Specifically, the facility did not consistently supervise residents or maintain all safety interventions necessary to prevent elopement, resulting in noncompliance with Federal and State guidelines and regulations.
Failure to Update Care Plan After Change in Resident's Fall Prevention Intervention
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following a change in care and services. The resident, who had diagnoses including dementia, repeated falls, need for assistance with personal care, and hypertension, had a care plan intervention for a pressure sensor pad alarm to be used at all times while in bed. However, the resident's physician orders did not include the pressure sensor pad alarm, and documentation showed that the use of the alarm was discontinued on 4/10/25. Despite this change, the care plan was not updated to reflect the discontinuation of the intervention. Facility leadership confirmed that the care plan was not reviewed or revised to match the resident's current care and services.
Incomplete and Inaccurate Documentation of ADLs and Interventions
Penalty
Summary
The facility failed to maintain complete and accurate documentation of activities of daily living (ADLs) and interventions for three residents with diagnoses including dementia, repeated falls, hypertension, and diabetes. For one resident, documentation indicated that body pillows were in place to prevent rolling out of bed even after the intervention had been discontinued and the pillows were no longer available. Additionally, there were multiple instances where documentation for showers, dressing, personal hygiene, and eating was missing for all three residents over several dates. Interviews with the Director of Nursing, Nursing Home Administrator, and Assistant Director of Nursing confirmed the inaccuracies and omissions in the clinical records. Facility policies required that all services provided to residents be documented objectively, completely, and accurately, but these requirements were not met for the residents reviewed.
Failure to Provide Baseline Care Plan Summary to Resident or Representative
Penalty
Summary
The facility failed to provide a resident and/or their representative with a summary of the baseline care plan, including physician's orders and medications, within 48 hours of admission as required by facility policy. The policy states that a baseline care plan must be developed within 48 hours to address the resident's immediate needs, and a summary of this plan, including initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable, must be provided to the resident or their representative. In the case reviewed, a resident admitted with diagnoses including Parkinson's disease, high blood pressure, orthostatic hypotension, and high cholesterol did not have evidence in their clinical record that a copy of the baseline care plan, including physician orders and medications, was provided to them or their representative. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of documentation showing that the required information was given.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders and facility policy for a resident requiring supplemental oxygen. Facility policy required nasal cannulas to be replaced every 7 days and oxygen tubing every 14 days, or sooner if visibly soiled or compromised. A review of the resident's clinical record showed physician's orders for continuous oxygen at bedtime and for oxygen tubing to be changed on the 2nd and 15th of each month during the night shift. Observations revealed that the resident was receiving oxygen via nasal cannula, but the tubing in use was dated from over a month prior, indicating it had not been changed as required. The resident involved had a history of atrial fibrillation, heart failure, and high blood pressure, and was admitted with orders for supplemental oxygen due to shortness of breath. During interviews, an LPN confirmed that the nasal cannula in use was dated from a previous month and acknowledged it should have been changed according to the schedule. This failure to follow physician's orders and facility policy resulted in a deficiency related to the provision of safe and appropriate respiratory care.
Failure to Properly Date and Discard Opened Insulin Vial
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner, as required by facility policy and manufacturer recommendations. During a review of the B Wing medication cart 2, surveyors observed an opened vial of Humalog insulin that was not labeled with an open date, making it impossible for staff to determine the appropriate discard date. The Assistant Director of Nursing confirmed that the vial lacked an open date, and the DON acknowledged that insulins should be labeled with the date opened to ensure proper discard timing. This deficiency was identified through policy review, manufacturer guidelines, direct observation, and staff interviews.
Fire Alarm System Documentation Deficiency
Penalty
Summary
The facility failed to meet the fire alarm system requirements as outlined by NFPA 70 and NFPA 72, which are essential for ensuring safety in healthcare occupancies. During a document review on October 31, 2024, it was discovered that the facility did not have documentation for the semi-annual visual inspection of the fire alarm system and the sensitivity testing of the smoke detectors. This lack of documentation was confirmed in an interview with the administrator and maintenance supervisor, indicating a lapse in maintaining the necessary records for fire safety compliance. During an onsite revisit survey on December 17, 2024, the facility still failed to provide documentation for the sensitivity testing of the smoke detectors. The facility had contacted the vendor to verify whether the test was completed or needed to be completed, but at the time of the survey, the issue remained unresolved. This was confirmed in an interview with the chief operating officer and administrator, highlighting a continued deficiency in meeting the fire alarm system requirements.
Plan Of Correction
Corrective Action Taken: 1. The semi-annual visual inspection of the fire alarm system was completed on December 13, 2024. 2. The sensitivity testing of the smoke detectors has been scheduled for January 8, 2024. Systemic Changes: 1. The facility has implemented a tracking system to ensure timely scheduling and documentation of all fire alarm system inspections and testing. 2. The maintenance supervisor will review the schedule monthly to verify compliance with inspection and testing requirements.
Failure to Document Code Status for Residents
Penalty
Summary
The facility failed to ensure that a physician's order was completed to indicate the code status for four residents. The facility policy required the attending physician to write an order for any valid advanced directive on the physician order sheet and document it in the progress notes. However, the clinical records of four residents lacked a physician's order to indicate whether they were Full Code or Do Not Resuscitate (DNR). This deficiency was confirmed through staff interviews and a review of clinical records. Resident R56's clinical record did not have a physician's order for code status, and although documents in the Admissions Director's office indicated a DNR status, the facility would have considered the resident a full code. Similarly, the clinical records of Residents R58, R65, and R225 also lacked a physician's order for code status. Interviews with the Director of Nursing and other staff confirmed these omissions, indicating a failure to document and honor the residents' code status preferences as per facility policy.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for three residents, as required by their policy. The policy mandates that a baseline care plan, which includes necessary instructions for effective and person-centered care, be developed within 48 hours of a resident's admission. Additionally, a written copy of this care plan should be provided to the resident and their representative in an understandable language. However, for three residents reviewed, there was no evidence that such a care plan was developed or provided within the stipulated timeframe. The residents involved had various medical conditions requiring specific care plans. One resident had a dislocated left hip, COPD, and neurogenic bladder; another had a fractured left arm, acute kidney failure, morbid obesity, and osteoarthritis; and the third had diabetes mellitus, dementia, protein-calorie malnutrition, and cerebral infarction. Despite these complex medical needs, the facility did not provide the necessary baseline care plans or summaries to the residents or their representatives. This deficiency was confirmed by the Registered Nurse Assessment Coordinator during an interview.
Failure to Cover Urinary Catheter Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, as observed during a survey. The facility's policy, dated 10/1/24, required that catheter bags be covered. However, observations on two separate occasions revealed that the urinary drainage bag of a resident with a dislocated left hip, COPD, and neurogenic bladder was hanging from the bed and visible from the hallway without a privacy cover. This was confirmed by the Director of Nursing during an interview, acknowledging that the catheter drainage bag should have been covered. The deficiency was noted under 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide oxygen therapy according to physician's orders for a resident with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and high blood pressure. The resident's clinical record included a physician's order for oxygen at 3 liters per minute (L/min) via nasal cannula continuously every shift for shortness of breath. However, an observation revealed that the resident's oxygen flow meter was set at 5 L/min, contrary to the prescribed order. During an interview, an LPN confirmed that the oxygen administration level was incorrectly set at 5 L/min, not following the physician's orders.
Infection Control Deficiency in Bedpan and Wash Basin Storage
Penalty
Summary
The facility failed to adhere to appropriate infection control practices concerning the disinfection and storage of bedpans and wash basins for two residents. The facility's policy, dated 10/01/24, outlines specific procedures for disinfecting bedpans and urinals, including wearing gloves, covering the items before transport, emptying contents into a toilet or hopper, rinsing with cool water, applying disinfectant, and ensuring items are stored properly. However, observations revealed that an unlabeled bedpan was found on the floor of a shared bathroom used by two residents, with a wash basin placed upside down on top of it. The wash basin was labeled with one resident's name, indicating improper storage and potential cross-contamination. Resident R29 had a medical history that included a head injury, concussion, and facial fractures, while Resident R58 had a history of colon cancer, cardiac heart failure, weakness, and repeated falls. The Registered Nurse Infection Control (RN IC) confirmed the improper storage and labeling of the bedpan and wash basin, acknowledging that these items should be sanitized, labeled, and stored in a clean bag in the resident's bedside stand after use. This failure to follow established infection control protocols was noted as a deficiency in the facility's practices.
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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