Oxford Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oxford, Pennsylvania.
- Location
- 7 East Locust Street, Oxford, Pennsylvania 19363
- CMS Provider Number
- 395367
- Inspections on file
- 23
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Oxford Health Center during CMS and state inspections, most recent first.
The facility failed to follow its infection surveillance and outbreak policies for residents with GI symptoms. Policy required nursing staff to report residents with multiple loose stools or other infection indicators so the DON or IC coordinator could enter them on a surveillance line list and monitor for trends, and to initiate an outbreak investigation when an emerging infectious disease was suspected. Several residents on one unit with more than one loose bowel movement in 24 hours were entered on an outbreak line list, but two additional residents with documented multiple loose stools and vomiting were not added. The IC nurse, who worked part-time and had the line list handed off from a prior DON, could not explain the omission of these residents and confirmed that no investigation was completed to determine the source of the GI symptoms.
A resident with Alzheimer's disease, osteoarthritis, and a history of falls sustained a skin tear during a transfer using a stand-up lift when staff, unaware of her updated transfer requirements, did not provide the necessary assistance and cues. The assignment sheet used by CNAs was not updated to reflect her need for a two-person transfer and specific precautions, resulting in inadequate supervision and an accident.
The facility did not maintain the smoke resistance of smoke barrier walls, as observed in the basement Linen Storage Room where two unprotected penetrations were found after pipe removal. This issue, confirmed by the Maintenance Manager, affected two of the 14 smoke compartments, compromising the smoke barrier's integrity.
The facility did not maintain the fire resistance of common walls, affecting one smoke compartment. Observations revealed four unprotected penetrations in the wall separating the 01 and 02 Components, located above the ceiling and doors. Three penetrations were around wires, and one was empty. The Maintenance Manager confirmed these findings.
The facility did not maintain the fire resistance of an exit stairtower enclosure, affecting one smoke compartment. The fire exit hardware on the 1st floor Rosewood East Stairwell door was missing an end cap, compromising its fire resistance. This was confirmed by the Maintenance Manager.
The facility failed to maintain smoke resistance in a hazardous area enclosure, affecting one of 14 smoke compartments. The basement door to the Maintenance Storage Room, over 100 square feet, lacked an automatic closure. This was confirmed by the Maintenance Manager.
A portable fire extinguisher in the basement Elevator Machine Room was found unsecured on the floor, having been removed from its wall bracket. This was confirmed by the Maintenance Manager during a survey.
The facility failed to monitor the use of surge suppressors and extension cords, leading to a deficiency. Observations revealed a surge suppressor powering an extension cord for communications equipment in the basement and a receptacle multiplying power tap supplying a surge suppressor in the Chapelwood Communications Closet. These setups were confirmed by the Maintenance Manager.
The facility failed to ensure accurate MDS assessments for three residents, with errors in documenting insulin administration and pressure ulcers. Staff interviews confirmed discrepancies between MDS entries and clinical records, highlighting inaccuracies in resident status documentation.
The facility failed to ensure timely responses to call bells on two floors, with an average response time of 28.07 minutes and some extending up to 111.05 minutes. Residents and a family member reported concerns about prolonged waits, with one resident experiencing delays of 45 to over 60 minutes. The NHA confirmed these findings, noting that response times over 40 minutes are investigated.
Failure to Accurately Track and Investigate GI Symptoms Under Infection Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control surveillance policies for residents with gastrointestinal (GI) symptoms. The written policy "Surveillance for Infection/Infectious Disease" required nursing staff to notify the charge nurse when residents had a temperature of 100°F or greater, two or more loose watery stools in 24 hours, skin inflammation or purulent drainage, or a hospital transfer due to infection, and required the DON or Infection Control (IC) Coordinator to enter such data on a Weekly Surveillance Line Listing Report to monitor trends. The "Outbreak Plan" policy required an outbreak investigation when there was evidence of a possible outbreak of an emerging infectious disease. Facility records showed that one resident had more than one loose bowel movement (LBM) in 24 hours on January 30, 2026, and seven additional residents on the Transitional Care Unit (TCU) had more than one LBM in 24 hours between February 1 and February 2, 2026, and these residents were listed on the Outbreak Case-Patient Line List. However, nursing progress notes documented that another resident had two episodes of loose stools on two separate dates in early February 2026, and a different resident had multiple episodes of vomiting and multiple episodes of loose bowel movements, but these two residents were not included on the facility’s Outbreak Case-Patient Line List. During an interview, the IC nurse reported that residents with potential infectious symptoms were communicated to the DON during daily morning meetings or by verbal reporting and stated they only worked three days per week. The IC nurse explained that the previous DON initiated the GI symptom line list and then handed it off on February 2, 2026, but could not explain why the two additional symptomatic residents were not captured on the surveillance report and confirmed that no investigation was conducted to determine the source of the residents’ GI symptoms. The surveyors concluded that the facility failed to ensure appropriate surveillance, monitoring, and tracking for residents showing GI symptoms, citing 28 Pa. Code 201.18(b)(1), 211.5(f), and 211.12(d)(1)(3)(5).
Failure to Update Assignment Sheet Leads to Resident Injury During Transfer
Penalty
Summary
The facility failed to prevent accidents by not ensuring that the assignment sheet accurately reflected the care needs of a resident with Alzheimer's disease, osteoarthritis, and a history of repeated falls. The resident was involved in an incident where, while being transferred using a stand-up lift, she moved her left arm and did not hold onto the bar, resulting in a skin tear to her left forearm. Occupational therapy notes indicated that the resident had limited standing tolerance and required significant assistance and constant cues to keep her feet on the lift platform. It was also documented that transfers using the sit-to-stand lift should only be performed by CNAs familiar with her behavior and who had been educated on her specific needs. Despite these documented requirements, staff involved in the transfer were not fully aware of the resident's current transfer status, with one employee stating they believed the resident was cleared for the sit-to-stand lift based on previous information. The assignment sheet, which is used by CNAs to determine transfer statuses, was not updated to reflect the resident's need for a two-person transfer and the specific precautions required. Although competency evaluations and orientation for mechanical lift use were in place, the lack of accurate and updated information on the assignment sheet contributed to the incident.
Failure to Maintain Smoke Barrier Wall Integrity
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier walls, which is a requirement for ensuring fire safety within the building. During an observation, it was noted that there were two unprotected penetrations in the basement Linen Storage Room wall, where two pipes had been removed. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the smoke barrier wall. This issue affected two out of the 14 smoke compartments within the component, compromising the smoke resistance of the barrier walls.
Plan Of Correction
The two penetrations of the basement Linen Storage Room will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month, then bi-weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place and ensure that the facility is maintaining the rating of the smoke barrier wall. Deficient findings will be reported to DES and QAPI meeting.
Failure to Maintain Fire Resistance of Common Walls
Penalty
Summary
The facility failed to maintain the fire resistance of building separating common walls, which affected one of the 14 smoke compartments within the component. During an observation, it was noted that there were four unprotected penetrations in the common wall separating the 01 and 02 Components. These penetrations were located above the suspended ceiling, above the double doors, on the 01 Component side. Specifically, three penetrations were found around groups of wires, and one penetration was empty. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the unprotected penetrations of the fire wall.
Plan Of Correction
The four penetrations of the common wall, separating the 01 and 02 components above the suspended ceiling above the double doors will be corrected by the Maintenance Manager using an approved through penetration fire stop system. The Maintenance Manager or designee will conduct an audit of corridor walls weekly for one month. Monthly fire walls inspections will be added to PM schedule to check for penetrations and caulking in place to ensure the facility maintains the rating of the common wall. Deficient findings will be reported to DES and QAPI meeting.
Fire Resistance Deficiency in Stairwell Enclosure
Penalty
Summary
The facility failed to maintain the fire resistance of exit stairtower enclosures, specifically affecting one of the 14 smoke compartments. During an observation, it was noted that the fire exit hardware on the 1st floor Rosewood East Stairwell door was missing an end cap. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged the compromised fire resistance of the fire exit hardware.
Plan Of Correction
1. The end cap on the fire exit hardware for Rosewood east stairwell door will be replaced. 2. The Maintenance Manager or designee will conduct an audit of the fire exit hardware weekly for one month. 3. Fire door hardware inspection will be added to the PM checklist to ensure all parts are on the fire doors. 4. Deficient findings will be reported to DES and QAPI meeting.
Deficiency in Smoke Resistance of Hazardous Area Enclosure
Penalty
Summary
The facility failed to maintain the smoke resistance of hazardous area enclosures, specifically affecting one of the 14 smoke compartments within the component. During an observation on January 28, 2025, at 12:30 PM, it was noted that the basement door to the Maintenance Storage Room, which is over 100 square feet, lacked an automatic closure. This deficiency was confirmed through an interview with the Maintenance Manager at the same time, who acknowledged that the door did not automatically close.
Plan Of Correction
A door closure will be installed on the basement maintenance storage. The Maintenance Manager or designee will conduct a facility wide audit on hazardous doors, and then random doors on a quarterly basis. Education will be provided to all staff on when to report doors missing hardware. Deficient findings will be reported to DES and QAPI meeting.
Unsecured Portable Fire Extinguisher in Facility
Penalty
Summary
The facility failed to secure a portable fire extinguisher, which was observed during a survey. The deficiency was identified in one of the 14 smoke compartments within the facility. Specifically, on January 28, 2025, at 12:20 PM, a portable fire extinguisher located in the basement Elevator Machine Room, near the vending machines, was found removed from its wall bracket and placed unsecured on the floor. This observation was confirmed through an interview with the Maintenance Manager at the same time.
Plan Of Correction
Fire extinguisher located within the elevator Machine Room was reinstalled onto the wall bracket. The Maintenance Manager, or designee will audit fire extinguisher placement for one month. Add to our monthly Fire Extinguishers checklist to ensure extinguisher is in mounting bracket. Education will be provided to all staff on the proper mounting of fire extinguishers, and the reporting when a bracket or cabinet is damaged. Deficient findings will be reported to DES and QAPI meeting.
Improper Use of Surge Suppressors and Extension Cords
Penalty
Summary
The facility failed to properly monitor the use of surge suppressors and extension cords, which led to a deficiency in one of the 14 smoke compartments. During an observation on January 28, 2025, at 12:45 PM, it was found that a surge suppressor was supplying electrical power to an extension cord, which then powered communications equipment in the basement Communications Room. This setup was confirmed by the Maintenance Manager during an interview at the same time. Additionally, another observation on the same day at 1:09 PM revealed a receptacle multiplying power tap supplying electrical power to a surge suppressor within the Chapelwood Communications Closet. This was also confirmed by the Maintenance Manager during an interview. These findings indicate a failure to adhere to the proper use of electrical equipment as per the NFPA standards, contributing to the deficiency noted in the report.
Plan Of Correction
An additional electrical outlet will be installed to supply electricity to the communication equipment. The multiplying power tap in the Chaplewood Communication closet has been removed. The Maintenance Manager or designee will conduct an audit for unauthorized electrical equipment not less than quarterly, and more frequently during high decoration holidays such as Christmas and Easter. Deficient findings will be reported to DES and QAPI meeting.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments, as evidenced by discrepancies in the Minimum Data Set (MDS) for three residents. For Resident 18, the quarterly MDS inaccurately indicated that the resident was receiving insulin, despite the absence of physician orders or documentation in the Medication Administration Record (MAR) confirming insulin administration. Similarly, Resident 31's MDS incorrectly noted insulin administration, which was not supported by physician orders or the MAR. These inaccuracies were confirmed through staff interviews. Additionally, Resident 52's MDS failed to reflect the presence of an unstageable pressure ulcer on the right heel, as documented in the resident's wound and skin records. The MDS inaccurately reported no unhealed pressure ulcers, contradicting the clinical documentation. These errors in the MDS assessments were confirmed by staff interviews, indicating a failure to accurately document and assess the residents' medical conditions.
Plan Of Correction
The following Resident Assessments were resubmitted for accuracy: Resident 18 Quarterly MDS 12/17/2024 was modified and resubmitted on 1/21/2025. Resident 31 Quarterly MDS 12/6/2024 was modified and resubmitted on 1/21/2025. Resident 52 Quarterly MDS 10/11/2024 was modified and resubmitted on 1/21/2025. An MDS audit for current residents' last assessment will be completed for resident assessments coded as receiving insulin and resident assessments coded as having wounds to ensure accuracy. Any identified modifications resulting in resubmission will occur. MDS staff received re-education on MDS completion by Nursing Home Administrator on 1/21/2025, accuracy and RAI guidelines. A weekly audit of 3 quarterly resident assessments for MDS accuracy will be completed by the NHA or designee x one-month. Random audits of 3 quarterly resident assessments for MDS accuracy x 2 months will be completed by NHA or designee. Findings will be reported to Quality Assurance for review and recommendations as appropriate.
Delayed Call Bell Response Times
Penalty
Summary
The facility failed to ensure that call bells were answered in a timely manner on both the first and second floors, as evidenced by a review of facility records and interviews with staff and residents. The facility's 'Call Bell Response' policy, which was undated, stated that call lights should be responded to promptly to promote a secure atmosphere for residents. However, a call bell response time report from November 1 to November 30, 2024, revealed an average response time of 28.07 minutes for 283 call alarms, with some response times extending up to 111.05 minutes. Interviews with several residents and a visiting family member confirmed concerns about prolonged call bell response times. One resident reported experiencing response times of more than 10 minutes but less than 60 minutes, while another reported waiting 20 minutes or more. Another resident experienced response times ranging from 45 minutes to over 60 minutes, corroborated by a family member who noted a 45-minute wait the previous night. The Nursing Home Administrator confirmed the lengthy response times and stated that response times over 40 minutes are investigated, often finding that staff were assisting other residents at the time.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Based upon the 2567, the facility is unable to determine which residents provided statements to the surveyor. An audit was conducted of the call bell response report for the entire month of November 2024. There was a total of 6,112 events with an average response time of 6.58 mins for all of them. An audit of Incident reports and the Grievance log for November 2024 did not indicate any incidents or complaints about prolonged wait for call bell response and no harm or injury was identified. 2. To prevent this from reoccurring, re-education for Nursing staff on the call bell policy and the importance of properly clearing call bell devices. 3. Ongoing monitoring for compliance, DON/designee will review call bell response time reports daily x 2 weeks than weekly x 2 months and investigate any prolonged wait times to ensure proper staff response to call bells. 4. Results will be presented at QAPI for review and revision.
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.
