Perry Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wexford, Pennsylvania.
- Location
- 9850 Old Perry Highway, Wexford, Pennsylvania 15090
- CMS Provider Number
- 395300
- Inspections on file
- 51
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Perry Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not respond promptly to call lights for four residents who were dependent on staff for toilet hygiene and, in one case, toilet transfers, and who had diagnoses such as HTN, anxiety, depression, malnutrition, DM, PVD, and atrial fibrillation. Facility policy required prompt response to call lights, and resident council minutes and a written concern documented complaints about waiting to be changed and call lights remaining on for over an hour while staff walked past. In interviews, residents reported waiting from about an hour to an hour and a half for call lights to be answered, especially during the night shift. The NHA and DON acknowledged that the facility failed to ensure timely response to call lights, in violation of applicable Pennsylvania regulations.
Three residents experienced deficiencies in their living environment, including a prolonged ceiling leak with exposed piping, uncleaned privacy curtains, and accumulated debris and dust in a resident room. Additionally, a shower room was found with a detached shower head and visible debris. Facility leadership and staff confirmed these issues and acknowledged the failure to maintain a clean, safe, and homelike environment.
A resident with multiple medical conditions reported acute lower back pain following care by a nurse aide, and both the resident and family raised concerns about the care provided. The facility did not report or investigate the allegation of abuse according to its written policies and procedures, as confirmed by document review and staff interviews.
A resident with multiple medical conditions experienced acute lower back pain after care provided by a nurse aide, and both the resident and family reported concerns about the incident. Despite facility policy requiring immediate reporting of abuse allegations, the incident was not reported to administration or authorities as required, resulting in noncompliance with state regulations.
A resident with multiple medical conditions reported acute lower back pain after care provided by a nurse aide, and the family raised concerns about the incident. Despite facility policy requiring prompt investigation of abuse allegations, the incident was not reported to administration or thoroughly investigated until weeks later, resulting in a deficiency for failure to respond appropriately to an alleged violation.
Staff and resident interviews, along with documentation review, revealed that insufficient nursing staff led to missed showers and delayed care for three residents, including those with high blood pressure, post-polio syndrome, end stage renal disease, and heart failure. Staff reported difficulty providing care requiring two people, such as Hoyer lift transfers, and residents experienced long wait times and incomplete personal care routines. The DON confirmed the staffing shortage and inability to provide necessary services to maintain residents' well-being.
A resident admitted with multiple serious diagnoses did not receive all prescribed medications due to nursing staff failing to transcribe a physician order for Xanax and not administering Diovan as ordered. Facility procedures for handling missing medications and notifying the physician were not followed, as confirmed by the DON.
A resident who required two-person assistance for bed mobility was left unattended and assisted by only one nurse aide during care, resulting in a fall from bed and injuries including a hip fracture and head contusion. The aide was unaware of the resident's assistance requirements, despite this being documented in the care plan and Kardex. Facility policies on fall prevention and resident safety were not followed, leading to actual harm.
Surveyors found that the facility did not maintain a clean, safe, and homelike environment in the first-floor lobby coffee area, with multiple cleanliness issues such as debris, spills, and unclean surfaces confirmed by staff and administration.
Two residents who were dependent on staff for ADL care did not consistently receive scheduled showers or baths, with documentation missing for several dates and one resident reporting extended periods without bathing due to understaffing. The DON confirmed the failure to provide required ADL assistance.
The facility did not provide the required minimum number of nurse aides on certain evening and night shifts, resulting in staff being responsible for more residents than state regulations allow. A resident reported concerns about understaffing, and staffing records confirmed that the facility was below the mandated nurse aide-to-resident ratios on specific shifts.
The facility did not provide the required minimum of one LPN per 40 residents during a night shift, as confirmed by staffing schedules and resident interviews. A resident reported that nurse aides were assigned more residents than usual, highlighting concerns about understaffing.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on two reviewed days, as confirmed by staffing records and resident interviews indicating understaffing. This deficiency was communicated to facility leadership.
A resident with significant communication and cognitive impairments, identified as at risk for elopement, was able to exit the facility unsupervised after an alarm was silenced by an EVS employee who did not properly check the area or notify staff. The resident was found outside engaged in a physical altercation, and staff failed to update care plans or respond appropriately to the alarm, resulting in immediate jeopardy.
A resident with significant communication and medical needs, identified as an elopement risk, was found outside the facility without staff awareness. The facility's investigation into the incident was incomplete, as it did not include a statement from the EVS employee who silenced the alarm, and the investigation's findings were contradicted by later interviews.
The facility did not complete annual performance evaluations for five nurse aides, as required by their policy. The Wexford Employee Handbook mandates that job descriptions form the basis for these evaluations, which should occur annually. A review of personnel records showed that evaluations were missing for these staff members, a deficiency confirmed by a regional HR employee.
The facility failed to properly label and date food in the Main Kitchen and Third Floor Unit Pantry, as observed by surveyors. Unsealed, unlabeled, and undated food items were found in the Main Kitchen's walk-in freezer and the Third Floor Unit Pantry, confirmed by staff, creating a potential risk for foodborne illness.
The facility failed to maintain an effective QAPI program, as evidenced by 11 repeat deficiencies identified in a recent survey. Despite plans to forward audit results to the QAPI committee, the facility did not implement necessary improvements, as confirmed by the Nursing Home Administrator.
The facility failed to offer residents the opportunity to vote in the May 2024 election and did not provide a dignified dining experience for a resident requiring self-feeding assistance. Residents were not asked about voting, and a nurse aide was observed standing while feeding a resident, which was confirmed as undignified.
The facility failed to assess the ability of three residents to self-administer medications, as required by their policies. One resident was left unattended with medications, another had a medication found on the floor by a family member, and a third had a medication left at the bedside. The Director of Nursing confirmed the facility's failure to adhere to its policies on medication administration.
The facility did not address or resolve resident grievances reported during council meetings over six months. Issues included staff not wearing name tags, rude agency aides, linen and oxygen shortages, and the absence of credit card vending machines. Residents reported ongoing concerns without receiving resolutions, and the Activity Director confirmed no documentation of follow-up actions.
The facility failed to maintain resident confidentiality by displaying medical instructions in three resident rooms and leaving a medication cart unattended with an open computer screen, exposing confidential information. The DON confirmed these breaches of privacy protocols.
The facility failed to communicate necessary information to receiving health care providers for six residents transferred to the hospital. Despite having various medical conditions, including heart failure, anemia, and cancer, the facility did not provide required details such as care plan goals and advance directives. This deficiency was confirmed by the DON, indicating a violation of facility policy and resident rights.
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by their policy and state regulations. This deficiency was identified through a review of clinical records and staff interviews, revealing that six residents with various medical conditions were not informed in writing about the bed-hold policy at the time of their hospital transfers. The Director of Nursing confirmed this oversight, which violates residents' rights under state code.
The facility failed to provide necessary ADL assistance for four residents, as required by their care plans. A resident with multiple diagnoses, including diabetes and spinal stenosis, missed several showers in October, while another with dementia and muscle weakness also did not receive scheduled showers. A third resident with neurogenic bladder and quadriplegia reported going weeks without a shower, and a fourth resident with high blood pressure, depression, and dementia had not received any showers since admission. These failures were confirmed by the DON and violated the facility's routine care policy and state regulations.
The facility failed to provide a resident-centered activity program, impacting six residents' physical, mental, and psychosocial well-being. Despite policy requirements for diverse activities, residents reported unmet needs and unannounced schedule changes. Two residents, with specific medical conditions, lacked in-room activities, confirmed by the Activities Director, with no documentation of activities provided.
The facility failed to provide appropriate catheter care for three residents, resulting in deficiencies. A resident's Foley catheter order lacked necessary details, while another resident's catheter collection bag was improperly placed on the floor without a dignity cover, and an open irrigation syringe and sterile water were undated. Additionally, a third resident's urine collection bag lacked a dignity cover. These issues were confirmed by nursing staff and violated facility policy and state regulations.
The facility failed to store refrigerated medications at proper temperatures, secure treatment carts, and lock medication rooms. Medications were improperly labeled and stored, with some lacking resident information. These deficiencies were observed across multiple units and involved several staff members, including RNs and LPNs.
The facility failed to monitor personal refrigerators for four residents, leading to improper food storage. Two residents with indwelling catheters had collection bags on the floor, violating infection control practices. Additionally, the Third Floor Medication Room contained unlabeled ice packs, risking cross-contamination.
The facility failed to maintain an effective pest control program on the first and second floors, with reports and observations of mice presence. A resident reported a mouse in their room, and the County Ombudsman observed mouse droppings. The Director of Maintenance identified a rusted door as a potential entry point and confirmed the presence of a hole in an outside wall and mouse droppings. The last mouse sighting was in a first-floor storage room.
A resident with type II Diabetes Mellitus and end-stage renal dependence did not receive their prescribed weekly Trulicity medication due to its unavailability in-house. The facility failed to notify the physician about this omission, as confirmed by the DON.
The facility failed to provide accessible anonymous grievance forms for residents on the second floor. The grievance box was located in a locked lounge due to renovations, and other areas lacked grievance boxes or forms. Residents were unaware of the grievance process, and the Nursing Home Administrator confirmed the deficiency.
The facility failed to prevent neglect for two residents. One resident was left unchanged for nine hours despite being dependent on staff for toileting hygiene. Another resident with a critical potassium level was not transferred to the hospital immediately as instructed, resulting in a delay until the next morning. These incidents highlight deficiencies in timely care and response to medical conditions.
A resident with neurogenic bladder and quadriplegia reported not having access to their call bell and not being checked on by staff for six hours. Additionally, an aide improperly used a Hoyer lift without assistance. The facility failed to report these neglect allegations within the required timeframe, only reporting a less severe issue.
The facility failed to notify physicians of abnormal blood glucose levels for two residents, as required by physician orders. One resident had multiple instances of both hypoglycemia and hyperglycemia without physician notification or documented interventions. Another resident experienced consistently high blood glucose levels without physician notification. These deficiencies were confirmed through record reviews and staff interviews.
The facility failed to obtain necessary physician orders for wound care for two residents, leading to deficiencies in pressure ulcer management. A resident required negative pressure wound therapy, but the facility did not secure orders for the suction setting and interventions for potential issues. Another resident needed wound care for a pressure ulcer, but the facility did not obtain orders for an as-needed dressing, as confirmed by an LPN.
A resident with diabetes and peripheral vascular disease did not receive timely podiatry care as required by the facility's policy. Despite the resident's medical conditions, there was no record of routine podiatry services, and the resident was not placed on the podiatry list. Observations showed circulatory issues, and interviews confirmed the oversight, with no documented refusals of care.
A resident experienced two unwitnessed falls, and the facility failed to perform timely and accurate post-fall documentation and neurological assessments as per policy. The required Post Fall Assessment was not completed after the first fall, and only 11 out of 16 neurological checks were conducted. After the second fall, the Post Fall Assessment was delayed, and only six out of 16 neurological checks were completed. The DON confirmed these deficiencies.
A facility failed to provide appropriate care for a resident receiving tube feedings. The resident, with a history of hypertension, diabetes, and dysphagia, required tube feeding. A 60cc syringe used for the resident's care was found undated, contrary to facility policy. A nurse confirmed the syringe was used without being dated due to a lack of a marker, indicating non-compliance with care protocols.
The facility failed to provide appropriate respiratory care for two residents by not maintaining oxygen equipment as required. One resident had outdated nasal cannula tubing and an empty humidification bottle, while another had undated oxygen lines and humidifiers, with concentrators set incorrectly. These issues were confirmed by RNs and violated resident care policies.
The facility failed to dispose of or reconcile discontinued medications in a timely manner in one medication room. Medications, including Zoloft, Warfarin, and Repaglinide, were found unsecured in an unlocked room. An LPN indicated no accountability process for medication returns, and the DON confirmed the deficiency.
The facility did not complete Medication Regimen Reviews for three months despite recommendations from a consultant pharmacist. The policy requires monthly reviews by a licensed pharmacist, with irregularities reported to relevant staff. However, the facility failed to act on recommendations for a resident with high blood pressure, depression, and diabetes, as confirmed by the DON.
A facility failed to identify a diagnosed specific condition for a resident receiving psychotropic medication. The resident's care plan included antipsychotic medication for behaviors, but physician orders lacked a specific diagnosed condition. A registered nurse confirmed this oversight during an interview.
Two residents in the facility experienced significant medication errors due to the unavailability of prescribed medications. One resident with epilepsy and mastocytosis missed multiple doses of Cromolyn Sodium, while another resident with diabetes did not receive a scheduled Trulicity injection. The Director of Nursing confirmed these errors, which were due to delays in obtaining medications from the pharmacy.
A resident with multiple health conditions did not receive routine dental services as required by the facility's policy. Despite the facility's commitment to assist residents in obtaining dental care, the resident had not been seen by a dentist since admission. The oversight was confirmed by the Nursing Home Administrator and the Medical Records/Ancillary Services Coordinator.
A resident with an NPO diet order, due to conditions like dysphagia and intracerebral hemorrhage, was found with water at her bedside, contrary to her dietary restrictions. Despite the RN's belief that marking the cups was sufficient, the DON confirmed that no fluids should be left accessible, highlighting a failure to enforce the NPO order.
The facility failed to maintain essential heating equipment in three rooms on the second floor, as heaters were removed to be used in other areas with non-functioning units. This left the wall areas open to the outside, compromising the maintenance of essential equipment.
A facility failed to provide medical record access to the POA of a resident with dementia and anxiety disorder. Despite being contacted for medical decisions, the POA was denied access to the resident's clinical records, contrary to facility policy. Interviews confirmed the facility's awareness of the request and the failure to provide the records.
The facility did not display current Nurse Staffing Information for two days. A receptionist was unable to locate the updated information and confirmed it was outdated. The receptionist expressed uncertainty about updating the information, and the Nursing Home Administrator acknowledged the deficiency.
A resident with quadriplegia and other conditions reported that the walkway at the facility's entrance was unsafe due to missing stones and uneven surfaces, posing a hazard for those using wheelchairs and gurneys. The Nursing Home Administrator confirmed the deficiency, acknowledging the failure to maintain a safe and homelike environment.
Failure to Respond Promptly to Call Lights for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were answered in a timely manner for four residents who were dependent on staff for toilet hygiene and, in one case, toilet transfers. The facility’s Call Light Resident Communication System Policy dated 2/8/26 stated that staff would respond to call lights promptly. Resident Council Meeting Minutes from 2/18/26 documented a concern about residents waiting to be changed. A written concern from one resident dated 3/12/26 reported having a call light on for over an hour while staff walked past the room without stopping. Clinical records showed that these residents had multiple diagnoses, including high blood pressure, anxiety, depression, malnutrition, diabetes, peripheral vascular disease, and atrial fibrillation, and that each was assessed as dependent in Section GG0130 for toilet hygiene, with one also dependent in Section GG0170 for toilet transfers. During individual interviews, all four residents reported prolonged delays in call light response, particularly during the night shift. One resident stated that call lights take a long time to be answered at night. Another resident reported that response time is slow after midnight and that they had waited an hour. A third resident stated it sometimes takes an hour and a half for staff to answer the call bell at night. A fourth resident reported having to wait an hour to an hour and a half for staff to respond and stated that staff do not always come, especially at night. In an interview on 3/18/26 at 2:05 p.m., the Nursing Home Administrator and DON confirmed that the facility failed to ensure call lights were answered in a timely manner, in violation of 28 Pa. Code 211.10(c)(d) and 211.12(d)(1)(2)(3)(5).
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for three residents and one shower room. Specifically, two residents' room had a water leak from a ceiling pipe, resulting in a missing ceiling tile and an exposed pipe above the bathroom entrance. Water was observed dripping into a bin placed under the leak, and staff had to sop up water to allow bathroom access. One resident was relocated when the plumber arrived to fix the pipe, but the other resident remained in the affected room. The leak persisted for several days before being repaired, and the administrator confirmed that both residents should have been relocated until the issue was resolved. Additionally, another resident reported that their privacy curtain had not been cleaned, and observations confirmed a dirty curtain with stains, debris along the walls and under the bed, and dust on the windowsill and blinds. The large shower room on the second floor was found with a detached hose/shower head lying on the floor and a brown spot on the shower stall floor. Housekeeping staff confirmed these conditions. The administrator acknowledged the facility's failure to maintain cleanliness and a homelike environment in these areas.
Failure to Implement Abuse Investigation Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of an allegation of abuse involving one resident. According to the facility's own policy, all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation, misappropriation of resident property, and injuries of unknown source are to be investigated. However, documentation and staff interviews revealed that an allegation of abuse was not reported to administration and was not investigated in accordance with these policies. The resident involved had diagnoses including cachexia, dysphagia, and hypothyroidism, and was assessed as cognitively intact. Progress notes indicated that the resident experienced acute lower back pain following care provided by a nurse aide, with the resident and family both raising concerns about the care received. Despite these complaints and the facility's policy requirements, the incident was not promptly reported or investigated by administration as an abuse allegation. The deficiency was identified through review of facility documents, clinical records, and staff interviews, which confirmed that the required procedures for investigating abuse allegations were not followed for this resident. The Director of Nursing acknowledged that the facility failed to implement its written policies and procedures in this case.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident, despite having a policy that requires immediate reporting and investigation of all allegations, suspicions, and incidents of abuse, neglect, or misappropriation of resident property. The policy mandates that such allegations be reported to the Administrator, who must then notify local and state agencies. In this case, the required reporting did not occur when a resident complained of pain following care provided by a nurse aide. The resident in question had diagnoses including cachexia, dysphagia, and hypothyroidism, and was assessed as cognitively intact. Progress notes documented that the resident experienced acute lower back pain after being turned during incontinence care by a nurse aide. The resident and their family reported the incident, stating that the pain began when the aide elevated the resident's legs during care. Medical evaluations, including x-rays and a CT scan, were performed, with findings that did not confirm an acute injury but did note an indeterminate compression fracture. Despite these reports and the facility's policy, the allegation of abuse was not reported to administration or to the appropriate authorities in a timely manner. The Director of Nursing later confirmed that the required reporting did not occur for this incident, resulting in noncompliance with state regulations regarding the reporting of alleged violations.
Failure to Investigate Alleged Abuse Following Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse involving one resident. The resident, who was cognitively intact and had diagnoses including cachexia, dysphagia, and hypothyroidism, reported experiencing acute lower back pain after being turned by a nurse aide during incontinence care. The resident's family later inquired about the incident after receiving a phone call from the resident describing the care provided by the aide. Progress notes documented the resident's complaints of pain originating during care, and subsequent medical evaluations noted persistent lower back pain, with imaging revealing an indeterminate L4 compression fracture. Despite these reports and the facility's policy requiring investigation of all allegations and incidents of abuse, the allegation was not reported to administration, and a thorough investigation was not initiated until weeks after the incident, when the DON became aware through communication with the resident's family. The delay in reporting and investigating the allegation constituted a failure to respond appropriately to an alleged violation, as required by facility policy and regulatory standards.
Insufficient Nursing Staff Resulting in Missed Care and Delayed Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by staff and resident interviews, documentation review, and direct observations. Nurse aides and licensed nurses reported that staffing levels were inadequate, particularly on the second and third floors, resulting in residents not receiving routine care such as showers and timely assistance with activities of daily living. Staff described working twelve-hour shifts with only three aides for 37 residents, making it difficult to provide care that required two staff members, such as Hoyer lift transfers, and leading to residents waiting longer than appropriate for care. Three residents were specifically affected by the staffing shortage. One resident with high blood pressure, post-polio syndrome, and vitamin D deficiency reported not receiving scheduled showers and described an incident where an aide attempted a transfer without proper equipment or assistance, resulting in discomfort and feelings of disrespect. Documentation confirmed that this resident received only three showers in the past 30 days, with the last one occurring over two weeks prior to the interview. Another resident with end stage renal disease, heart failure, and high blood pressure stated they had not received a shower in over a month, despite a scheduled shower routine, and documentation showed only one shower in the past 30 days. A third resident with similar diagnoses also reported not receiving showers as scheduled, with records indicating only three showers in the same period. Interviews with registered nurses and the Director of Nursing confirmed the lack of sufficient staff to provide necessary care, with staff acknowledging that residents had to wait for assistance and that it was often difficult to find a second person for required two-person transfers. The Director of Nursing was unable to locate complete shower documentation for the affected residents and confirmed the facility's failure to provide adequate nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being for the residents involved.
Failure to Transcribe and Administer Admission Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received the correct medications upon admission, as required by physician orders and facility policy. Upon review, it was found that the resident, who had diagnoses including respiratory failure, abdominal aortic aneurysm without rupture, and high blood pressure, was admitted with hospital discharge orders for Xanax 0.25mg four times a day for five days and Diovan 80mg every evening. However, the nursing staff did not transcribe the Xanax order into the facility's physician orders or Medication Administration Record (MAR), resulting in the medication not being administered as prescribed. Additionally, the Diovan was not administered on the evening of admission because it was not available from the pharmacy, and the nursing staff did not follow facility procedures for handling a missing medication. Specifically, the staff failed to notify the physician regarding the missed dose of Diovan. The Director of Nursing confirmed these omissions, acknowledging that the required procedures for medication transcription and notification were not followed.
Failure to Provide Required Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was identified as being at risk for falls and required the assistance of two persons for bed mobility, was left unattended and assisted by only one nurse aide during a routine care activity. The resident's care plan and assessment tools clearly indicated the need for two-person assistance and the use of a mechanical lift for all transfers due to the resident being non-ambulatory and on bedrest. Despite these documented requirements, the nurse aide proceeded to provide care alone and left the resident on their side while reaching for linens, resulting in the resident rolling off the bed and falling to the floor. The incident led to the resident sustaining significant injuries, including a right hip fracture, a head contusion, and multiple skin tears. The resident was sent to the emergency department, where further evaluation confirmed a right lateral impacted sub capital fracture of the hip, a temporal laceration, and additional abrasions. The resident experienced new pain following the fall, and the injuries required medical intervention, including sutures and hospital assessment. Interviews with staff revealed that the nurse aide involved was unaware of the resident's requirement for two-person assistance, despite this information being available in the resident's Kardex and care plan. Other staff members confirmed that the standard protocol is to always use two people for residents requiring such assistance and to never leave them unattended on their side. The facility's policies on fall prevention, incident management, and routine care all emphasized the importance of providing care according to individualized resident needs and minimizing accident hazards, but these protocols were not followed in this instance.
Failure to Maintain Clean and Homelike Environment in Coffee Area
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean, safe, and homelike environment in the first-floor lobby coffee area. During an observation, multiple cleanliness issues were noted, including a white substance on the ice machine catch tray and counter, brown splatter debris inside the microwave, and yellow and brown substances on the sink's plastic shield. Additional findings included a basket, washcloth, and debris under the sink, a white fuzzy substance and a grape under the coffee machine, a step stool with a brownish tan substance, and tan debris, paper wrappers, and coffee stirrers on the floor. The windowsill also had leaf debris under a plant. Staff interviews confirmed these observations. The receptionist acknowledged the unclean conditions and indicated that housekeeping had not yet attended to the area that morning. The Nursing Home Administrator also confirmed the findings and acknowledged the failure to maintain a clean, safe, and homelike environment in the coffee area. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
F 0584 1. Following the surveyor's feedback, facility housekeeping initiated a thorough cleaning of the main lobby coffee bar. 2. The Director of Environmental Services will educate housekeeping staff on the cleaning processes and procedures for the main lobby coffee bar. 3. The main lobby coffee bar cleanliness will be audited by the Director of Environmental Services or designee daily, 7 days a week, for the next three weeks, then weekly for the next three weeks, then monthly for the next two months. 4. Results of the findings will be reviewed during the Monthly QAPI for the next two months for any recommendations.
Failure to Provide Consistent ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide consistent assistance with activities of daily living (ADLs), specifically showers or baths, for two residents who were dependent on staff for these services. One resident, admitted with diagnoses including anemia, gastroesophageal reflux disease, and anxiety, was scheduled to receive showers on specific days but did not have documentation indicating receipt or refusal of a shower or bed bath on one of the scheduled days. The Director of Nursing confirmed that the resident did not receive the required care on that date. Another resident, diagnosed with quadriplegia, neuromuscular dysfunction of the bladder, and anxiety disorder, was also dependent on staff for bathing. Documentation for this resident failed to show that showers or bed baths were provided or refused on multiple scheduled dates. The resident reported significant delays in receiving showers, citing understaffing as a contributing factor. The Director of Nursing confirmed the lack of consistent ADL assistance for this resident as well.
Plan Of Correction
1. Resident R1 has been discharged, and Resident R3 has received a shower as of 07/11/2025. 2. All residents have the potential to be affected by the alleged deficient practice. 15 residents on each unit have been interviewed regarding if they are receiving showers. 3. The Director of Nursing or Designee will in-service nursing staff on residents receiving showers at least twice weekly. The Director of Nursing or Designee will audit 10 residents' shower documentation 5 times weekly for 2 weeks and 3 times weekly for 2 weeks. 4. The Director of Nursing or Designee will report in monthly QAPI meetings the results of findings monthly for the next three months and randomly thereafter.
Failure to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet state-mandated minimum nurse aide staffing levels on specific evening and night shifts, as evidenced by a review of three weeks of nurse staffing schedules. On one evening shift, the number of nurse aides present did not meet the required ratio of one nurse aide per 11 residents, and on one night shift, the number of nurse aides did not meet the required ratio of one nurse aide per 15 residents. The census and required staffing numbers were documented, showing that the facility was understaffed on these particular shifts. Additionally, during interviews, a resident reported that nurse aides were responsible for more residents than the expected ratio, specifically noting that there were more residents per aide than the standard of 10-12 residents per nurse aide. This concern was communicated to the Nursing Home Administrator and the Director of Nursing during the exit interview, confirming the facility's failure to provide the required minimum nurse aide staffing on the identified shifts.
Plan Of Correction
1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the minimum state ratio requirements for CNAs. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum ratio of CNAs are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate CNA coverage is scheduled to meet the minimum ratio of CNAs. 4. Facility recruitment/retention efforts include utilizing job postings on company's career website, Indeed, and LinkedIn. Company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met. --- 1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the minimum state ratio requirements for LPNs. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum ratio of LPNs are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate LPN coverage is scheduled to meet the minimum ratio of LPNs. 4. Facility recruitment/retention efforts include utilizing job postings on company's career website, Indeed, and LinkedIn. Company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met.
Failure to Meet Minimum LPN Staffing Requirement on Night Shift
Penalty
Summary
The facility failed to meet the state-required minimum staffing level of one licensed practical nurse (LPN) per 40 residents during the night shift on one of 21 reviewed days. Review of three weeks of nurse staffing schedules revealed that on 5/31/25, the facility did not have the required number of LPNs scheduled for the night shift, with a census of 124 residents and only 3.00 LPNs present instead of the required 3.10. During interviews, a resident reported that nurse aides were responsible for more residents than expected, indicating concerns about understaffing on the hallway. This deficiency was communicated to the Nursing Home Administrator and Director of Nursing during the exit interview.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum of 3.2 hours of direct nursing care per resident per day on two out of twenty-one days reviewed. Specifically, staffing documents and nurse schedules showed that on 5/30/25 and 6/30/25, the provided hours of care were 3.15 and 3.14 PPD, respectively, which is below the required threshold. During interviews, a resident reported that nurse aides were responsible for more residents than expected, indicating issues with understaffing on the affected days. These findings were confirmed and communicated to the Nursing Home Administrator and Director of Nursing during the exit interview.
Plan Of Correction
P 5640 1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the state-required minimum staffing levels of 3.2 hours per patient day. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum number of general nursing care hours are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate nursing coverage is scheduled to meet the minimum number of general nursing care hours. 4. Facility recruitment/retention efforts include utilizing job postings on the company's career website, Indeed, and LinkedIn. The company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for elopement or unsafe wandering. The resident, who had diagnoses including aphasia, heart failure, and a history of stroke, was noted to rarely understand or be understood and had been assessed as at risk for elopement on multiple nursing admission evaluations. However, a wandering observation tool completed shortly before the incident indicated no history of wandering, and physician orders did not include interventions related to wandering or elopement risk. On the day of the incident, the resident was observed to be agitated, pacing the halls, and not at his baseline. Staff last saw the resident at the nurses' station, and shortly thereafter, the resident exited the facility through a side door. The stairwell alarm sounded but was silenced by an Environmental Services employee who did not properly check the stairwell or notify other staff. The resident was later found outside the building on the road, engaged in a physical altercation with a passerby. Staff intervened and escorted the resident back into the facility, where a small open area was found on his wrist. Interviews and documentation revealed that staff did not respond appropriately to the alarm, and the resident was able to leave the premises without supervision. The facility's investigation confirmed that the alarm was silenced without ensuring resident safety, and the resident's care plan and risk assessments were not updated in a timely manner to reflect his increased agitation and risk of elopement. This failure resulted in an immediate jeopardy situation for the resident.
Removal Plan
- Affected Resident was escorted back into the facility. Wanderguard was then placed on resident. Physician was notified. Body assessment completed and skin tear to resident's right wrist was discovered. Treatment applied. Resident was transferred to ED for evaluation and treatment. Resident returned with a positive UA but not being treated.
- Facility Wide Headcount was conducted by nursing department and all residents were accounted for.
- All Alarming Doors were audited to ensure functionality.
- After return from hospital immediate intervention of 1:1 was placed on resident and will be until adjustment to new medications is accomplished.
- Elopement Books were updated to include affected resident.
- Elopement Care plan and Orders were updated on all like residents.
- Whole House Education was completed on Elopement Policy, Responding to Alarms, Code [NAME] and inspecting any stairwells or any exit path by Nurse Educator/designee.
- Pharmacist Consultant reviewed medications, no medication changes.
- Psychiatric consultation was made, and medication adjustments were made. Resident was prescribed Lexapro.
- Newly admitted residents are screened for elopement risk upon admission, quarterly and as needed and care plans and assessments done accordingly. Any resident deemed at risk for elopement will have a Wanderguard placed.
- Facility Medical Director was notified of the Immediate Jeopardy and Abatement Plan.
- Daily Door Alarm Audits will continue by Maintenance Department or designee.
- Elopement Drills will be conducting weekly for two months, alternating shifts for two months.
- The Plan of Correction will be monitored at the Monthly QAPI Committee Meetings monthly for the next three months. Reviewing all door audits, elopement drills, new admissions for elopement assessments and reviewing the Elopement Policy as needed.
- Results will be submitted to QAPI.
Failure to Fully Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to fully investigate an incident involving a resident who was at risk for elopement and was found outside the facility without staff awareness. The resident, who had diagnoses including aphasia, heart failure, and a history of stroke, was rarely able to understand or be understood and had been identified as an elopement risk in the care plan. Despite this, there were no physician orders related to wandering or elopement risk, and documentation of the resident's wandering history was inconsistent. On the day of the incident, the resident was discovered outside the building on the road, interacting with a passerby, and was subsequently returned to the facility and sent to the emergency department for evaluation. The facility's investigation into the incident was incomplete, as it failed to gather a statement from the Environmental Services (EVS) employee who had silenced the alarm without ensuring no residents were present in the stairwell. The DON and Nursing Home Administrator later confirmed that the investigation did not include an interview with this key employee, and the surveyor's interview with the EVS employee contradicted the facility's initial findings. This lack of a thorough investigation prevented the facility from eliminating possible neglect in the incident.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides, as required by their policy. The Wexford Employee Handbook specifies that job descriptions form the basis for annual performance evaluations, which should be conducted at least once a year. However, a review of personnel records for Nurse Aides E26, E27, E30, E31, and E33 revealed that these evaluations were not completed based on their respective hire dates. This deficiency was confirmed during an interview with Regional Human Resource Employee E12, who acknowledged the facility's failure to conduct the required evaluations for these staff members.
Failure to Properly Label and Date Food
Penalty
Summary
The facility failed to adhere to its policy on food storage, which requires all foods to be wrapped or stored in covered containers, labeled, and dated to prevent cross-contamination. During an observation in the Main Kitchen's walk-in freezer, an open bag of chicken breast and an open package of ravioli were found unsealed, unlabeled, and undated. This was confirmed by the Assistant Food Service Supervisor, indicating a failure to properly store, label, and date opened food packages, which could lead to foodborne illness. Additionally, in the Third Floor Unit Pantry, several food items were found without proper labeling or dating. These included two containers of vanilla reduced sugar Med pass 2.0, a container of thickened lemon water, a container of Panera broccoli cheddar soup, and a box of cheddar biscuits in the freezer. An LPN confirmed these observations, further highlighting the facility's failure to properly label and date food in the nursing unit pantry, creating a potential risk for foodborne illness.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to maintain and implement an effective Quality Assurance and Performance Improvement (QAPI) program, which is essential for focusing on outcomes. This deficiency was identified through a review of facility documentation and staff interviews, revealing that the facility did not implement a QAPI for 11 previously cited citations. These citations were identified during a Full Health Survey ending on October 27, 2023, and included issues such as resident rights, quality of care, and infection control, among others. Despite the facility's indication that audit results would be forwarded to the QAPI committee for further review and recommendation, the Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies and failed to maintain an effective QAPI program.
Failure to Facilitate Voting and Provide Dignified Dining Experience
Penalty
Summary
The facility failed to uphold residents' rights to participate in the electoral process and to have a dignified dining experience. The review of facility documentation, observations, and interviews revealed that the facility did not offer residents the opportunity to vote in the May 2024 election. The resident council meeting minutes for six months did not include any information about the facility asking residents about voting. During a resident group meeting, residents indicated they were not offered the ability to vote in the November 2024 election, and four residents expressed a desire to vote. The Activity Director confirmed the lack of documentation showing that all residents were asked about voting and acknowledged the facility's failure to offer voting to all residents. Additionally, the facility did not provide a dignified dining experience for one resident, identified as Resident R43. The resident, who has diagnoses of high blood pressure, dementia, and muscle weakness, requires self-feeding assistance during meals. An observation noted that Resident R43 was being fed by a nurse aide who was standing beside her, which was confirmed by the nurse aide as not providing a dignified dining experience. This incident highlights the facility's failure to adhere to its policy of providing care in a safe and respectful manner.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess and determine the ability of three residents to self-administer medications, as required by their policies. Resident R17 was observed holding a medication cup full of medications without any nursing staff present, and there was no physician's order or care plan for self-administration of medications. Additionally, there was no Self-Administration of Medication assessment in Resident R17's clinical record. Similarly, Resident R50's physician orders and care plan did not include self-administration of medications, and there was no assessment for this ability. An incident occurred where Resident R50's granddaughter found an Ativan pill on the floor, raising concerns about whether the resident was receiving her medication properly. The nurse had left the medication with the resident while she was visiting with her granddaughter, contrary to the facility's policy. Resident R71 also did not have a physician's order or care plan for self-administration of medications, nor was there an assessment for this ability. A bottle of Biofreeze was left on Resident R71's bedside table, which was confirmed by a nurse. The Director of Nursing acknowledged that the facility failed to determine the ability to self-administer medications for these three residents. The facility's policies emphasize the importance of remaining with residents during medication administration to ensure safety and avoid adverse effects, which was not adhered to in these cases.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve resident concerns and grievances raised during resident council meetings over a six-month period from May 2024 to October 2024. The resident council minutes documented recurring issues such as staff not wearing name tags, agency aides being unfamiliar and rude to residents, shortages in linens and oxygen, and the lack of vending machines that accept credit cards. Despite these concerns being consistently reported, residents expressed during a group meeting that they did not receive answers or resolutions, only being told that the facility was working on their concerns. The Activity Director confirmed the absence of documentation for follow-up actions on these grievances, indicating a lack of response from the facility to the residents' issues.
Breach of Resident Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information, as observed during a tour and interviews. In three out of six resident rooms, signs were posted that disclosed specific medical instructions for the residents. For instance, one resident had a sign indicating the need to float heels when in bed, while another had instructions for food intake and assistance during meals. These signs were visible to anyone entering the rooms, thus compromising the residents' privacy. The Licensed Practical Nurse interviewed was unaware of who placed the signs, and the Director of Nursing confirmed the breach of confidentiality. Additionally, during a medication administration observation, a Registered Nurse left a medication cart unattended with the computer screen open, exposing confidential information to passersby. This occurred with one out of four medication carts, further indicating a lapse in maintaining the confidentiality of residents' medical records. The Director of Nursing acknowledged this failure, confirming the breach of privacy protocols as per the facility's HIPAA policy.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for six residents who were transferred from the facility. The facility's policy required that specific information, including the contact information of the practitioner responsible for the resident's care, resident representative information, advance directive information, care plan goals, and any special instructions or precautions for ongoing care, be provided to the receiving provider. However, the clinical records for these residents showed no documented evidence that such information was communicated. The residents involved in this deficiency had various medical conditions. One resident had high blood pressure, depression, and heart failure, while another had high blood pressure, hyponatremia, and unsteadiness on feet. Other residents had conditions such as peripheral vascular disease, dependence on supplemental oxygen, anemia, atrial fibrillation, neurogenic bladder, quadriplegia, depression, muscle weakness, and cancer. Despite these complex medical needs, the facility did not provide the necessary information to ensure a safe and effective transition of care when these residents were transferred to the hospital. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that there was no evidence of the required communication to the receiving health care institution or provider for the six residents with facility-initiated transfers. This lack of communication violated the facility's policy and the residents' rights as outlined in the applicable regulations.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by their own policy and state regulations. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, last reviewed on 10/24/24, mandates that residents or their representatives be informed in writing about the bed-hold policy within 24 hours of a hospital transfer, or the next business day if the transfer occurs on a weekend or holiday. However, this procedure was not followed for six residents who were transferred to the hospital. The clinical records of six residents, identified as R20, R36, R41, R42, R48, and R101, were reviewed, and it was found that none of them contained documented evidence that the residents or their representatives were provided with written information about the facility's bed-hold policy at the time of their hospital transfers. These residents had various medical conditions, including high blood pressure, depression, heart failure, hyponatremia, peripheral vascular disease, anemia, atrial fibrillation, neurogenic bladder, quadriplegia, muscle weakness, and cancer. Despite these conditions, the facility did not comply with its policy to inform them about the bed-hold arrangements. The Director of Nursing confirmed during an interview that the facility did not notify the residents or their representatives about the bed-hold policy for any of the six hospital transfers. This lack of notification is a violation of the residents' rights as outlined in 28 Pa. Code 201.29 (a) (c.3) (2). The failure to provide this information could potentially impact the residents' understanding of their rights and the financial implications of their hospital stays.
Failure to Provide ADL Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for four residents, as required by their care plans. Resident R27, who has multiple diagnoses including diabetes and spinal stenosis, was dependent on staff for bathing. However, documentation showed missed showers on several dates in October 2024, and the resident reported not receiving a shower or beard trim as needed. Similarly, Resident R46, diagnosed with dementia and muscle weakness, required assistance for bathing but did not receive showers on multiple occasions in October 2024. Resident R48, with neurogenic bladder and quadriplegia, was also dependent on staff for bathing. The resident reported going weeks without a shower, despite being scheduled for showers twice a week, and documentation confirmed missed showers on several dates. Resident R87, who has high blood pressure, depression, and dementia, was admitted in September 2024 and had not received any showers since admission, as confirmed by the Director of Nursing. These failures were in violation of the facility's routine care policy and state regulations.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and support the physical, mental, and psychosocial well-being of six residents. The facility's policy requires a resident-centered care approach, including a variety of activities such as social, indoor, outdoor, religious, creative, intellectual, educational, exercise, individualized, in-room, and community activities. However, during a resident group interview, several residents expressed dissatisfaction, stating that activities often do not meet their needs, and changes to the activity calendar occur without prior notice. Specific cases highlighted include Resident R1, who was admitted with high blood pressure, muscle weakness, and dependence on a wheelchair, and Resident R112, diagnosed with cerebral palsy and epilepsy. Both residents reported a lack of in-room activities despite their preferences and needs. The Activities Director confirmed that activities were not consistently offered to these residents, and there was no documentation to support that activities were provided during the specified months. This lack of adherence to the activity program policy resulted in a deficiency in meeting the residents' psychosocial, physical, and emotional needs.
Deficiencies in Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with indwelling urinary catheters, as evidenced by deficiencies found in the care of three residents. Resident R42 had a physician order for a Foley catheter that lacked essential details, such as the amount of fluid needed for balloon inflation and a diagnosis for the catheter. This omission was confirmed by a registered nurse during an interview. Resident R48's care was compromised by the improper placement of the catheter collection bag on the floor without a dignity cover, and the use of an open, undated irrigation syringe and bottle of sterile water. These issues were observed and confirmed by a registered nurse. Resident R107 was also found to have inadequate catheter care, as her urine collection bag lacked a dignity cover while she was resting in bed. This was confirmed by a registered nurse during an interview. The facility's failure to adhere to its catheter care policy, which mandates twice-daily care and proper placement of collection bags, resulted in these deficiencies. The report cites violations of several Pennsylvania codes related to the responsibility of the licensee, resident rights, resident care policies, and nursing services.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that refrigerated medications were stored at proper temperatures in one of the four medication rooms, specifically the Third Floor Medication Room. The temperature logs for the medication refrigerator were found to be incomplete for several dates, and a vial of Tuberculin was not labeled with the date it was opened. Additionally, the facility did not properly label open medications with a date on one of the medication carts and in the medication refrigerator. The facility also failed to secure medications and treatment carts properly. On the C1 nursing unit and the Second Floor D Unit, treatment carts were observed to be unlocked. Furthermore, the Second Floor D Wing Medication Room was found propped open with a garbage can, allowing unauthorized access. Medications and biologicals were not stored securely, as evidenced by the presence of a white jar of nystatin/Silvadene cream on a resident's nightstand and multiple used tubes of treatments on medication carts. The facility did not adhere to its policy of storing medications and biologicals safely and securely. Medications were found improperly stored on medication carts, with some lacking resident information. The Director of Nursing confirmed these deficiencies, acknowledging the failure to secure medication rooms and carts, and to prevent cross-contamination of treatments. These lapses in protocol were observed across multiple units and involved several staff members, including RNs and LPNs.
Deficiencies in Food Storage, Catheter Care, and Medication Room Sanitation
Penalty
Summary
The facility failed to properly monitor and maintain the personal refrigerators of four residents, leading to improper storage of food items. Observations revealed that residents had personal refrigerators with food items that were not dated or labeled, and there was no evidence of daily temperature monitoring. This lack of monitoring was confirmed by staff interviews, indicating a failure to adhere to the facility's policy on safe food storage. Additionally, the facility did not maintain proper infection control practices for residents with indwelling urinary catheters. Two residents were observed with catheter collection bags placed on the floor, which is against the facility's policy. Staff interviews confirmed these observations, highlighting a failure to ensure that catheter care was conducted in a manner that prevents infection. The facility also failed to provide a safe and sanitary environment in one of its medication rooms. Observations in the Third Floor Medication Room revealed the presence of ice packs without proper labeling or identification, which could lead to cross-contamination. Staff interviews confirmed the lack of awareness and proper management of these items, indicating a breach in maintaining a sanitary environment.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on the first and second floors, as evidenced by multiple reports and observations of mice presence. A resident reported having a mouse in their room in June 2024, and the County Ombudsman observed mouse droppings in the same room. Facility documentation revealed multiple concerns from residents on the second floor about seeing mice. During an inspection, the Director of Maintenance identified a rusted-out corner of an outside door as a potential entry point for mice and confirmed the presence of a hole in an outside wall and mouse droppings in the resident's room. The last reported sighting of a mouse was in a storage room on the first floor the previous week. The Director of Maintenance acknowledged the facility's failure to maintain an effective pest control program.
Failure to Notify Physician of Medication Omission
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident diagnosed with type II Diabetes Mellitus and end-stage renal dependence. The resident was prescribed Trulicity, a medication for diabetes, to be administered weekly. However, the medication was not available in-house, and there is no documentation in the clinical record indicating that the medication was administered or that the physician was notified of this issue. This deficiency was confirmed during an interview with the Director of Nursing.
Inaccessible Grievance Forms on Second Floor
Penalty
Summary
The facility failed to ensure that anonymous grievance forms were readily accessible for resident use on the second floor. According to the facility's grievance policy, dated February 20, 2024, a secure box should be maintained in an area accessible to residents and visitors for reporting grievances anonymously. However, during a resident group interview, residents expressed that they were unaware of the location of the grievance box, the concern forms, or the identity of the grievance officer. Observations on October 31, 2024, revealed that the grievance box was located in the second floor D-wing lounge, which was locked and inaccessible due to renovations. Additionally, other areas on the second floor, such as the lounge across from a specified room and the Savor lounge, were observed to lack grievance boxes or forms. The Nursing Home Administrator confirmed during an interview that the facility did not have a private grievance box available to residents on the second floor, as the existing box was in an inaccessible area. This deficiency was communicated to the Nursing Home Administrator and the Director of Nursing during an exit interview. The report cites violations of 28 Pa. Code 201.29(l) regarding resident rights and 28 Pa. Code 201.18e(4) concerning management, indicating a failure to uphold the residents' right to voice grievances without discrimination or reprisal.
Neglect in Timely Care and Response to Medical Condition
Penalty
Summary
The facility failed to prevent physical neglect for two residents, R87 and R107. For Resident R87, the facility's neglect was evident when the resident was not provided timely incontinent care, remaining unchanged for nine hours. This incident was reported by a resident representative and confirmed by the facility's investigation, which substantiated the neglect allegation. The resident was dependent on staff for toileting hygiene, as indicated in the care plan and Minimum Data Set (MDS), and the neglect occurred during the evening shift, which was noted as problematic by the resident representative. For Resident R107, the deficiency involved a failure to address a critical medical condition in a timely manner. The resident, who had a history of high blood pressure, intracerebral hemorrhage, and dysphagia, had a dangerously high potassium level that required immediate hospital transfer. Despite instructions from a Physician Assistant (PA) to send the resident to the hospital immediately, the facility delayed the transfer until the following morning. This delay was confirmed by the Director of Nursing (DON), who acknowledged that the facility neglected to respond promptly to the resident's change in condition.
Failure to Timely Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect involving a resident, identified as Resident R48, within the required timeframe. According to the facility's policy on abuse, neglect, and misappropriation, any alleged violations of neglect must be reported within 24 hours if they do not result in serious bodily injury. Resident R48, who has a neurogenic bladder and quadriplegia, reported that they did not have access to their call bell from 11 p.m. to 5 a.m. and were not checked on by staff during this period. Additionally, the resident stated that an aide used a Hoyer lift to transfer them to bed without assistance from another staff member, which is against protocol. The Nursing Home Administrator and Director of Nursing were informed of these allegations by the State Agency during an interview. However, when the facility submitted an incident report to the State, it only included the allegation that an aide failed to shave the resident and omitted the more serious allegations of neglect regarding the call bell and the improper use of the Hoyer lift. The Director of Nursing confirmed that the facility did not report these allegations within the required timeframe, which constitutes a failure to comply with state regulations.
Failure to Notify Physicians of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal Capillary Blood Glucose (CBG) levels as per physician orders for two residents, identified as R5 and R88. Resident R5 had several instances of abnormal blood glucose levels recorded between June and July 2024, including hypoglycemic readings of 64 mg/dL and hyperglycemic readings exceeding 400 mg/dL. Despite these critical readings, there was no documentation indicating that the physician was notified as required by the orders. Additionally, there were no documented interventions for a hypoglycemic event on October 7, 2024. Resident R88 also experienced multiple instances of elevated blood glucose levels in October 2024, with readings consistently above the threshold of 250 mg/dL, as specified in the physician's orders. However, the facility's records did not show any notifications to the physician regarding these abnormal readings. This lack of communication with the physician was confirmed during an interview with the Director of Nursing. The facility's failure to adhere to physician orders regarding the notification of abnormal blood glucose levels and the lack of documented interventions for hypoglycemia represent significant deficiencies in the care provided to these residents. These actions, or lack thereof, were identified through a review of clinical records, facility policies, and staff interviews, highlighting a breach in the management and execution of resident care policies.
Deficiencies in Pressure Ulcer Care Due to Lack of Physician Orders
Penalty
Summary
The facility failed to obtain necessary physician orders for wound care for two residents, leading to deficiencies in pressure ulcer management. Resident R107, who was readmitted with conditions including hypertension, anemia, and neurogenic bladder, required negative pressure wound therapy (NPWT) for pressure ulcer care. However, the facility did not secure physician orders specifying the frequency of the suction setting and interventions for potential displacement or malfunction of the wound vac. This oversight was confirmed by a registered nurse during an interview. Similarly, Resident R64, who was readmitted with hypertension, anemia, and diabetes, required wound care for a pressure ulcer on the right lateral malleolus. The facility failed to obtain physician treatment orders for an as-needed dressing, as confirmed by a licensed practical nurse who reported administering the dressing two days in a row without proper orders. These deficiencies were noted in the context of the facility's policies on skin care, wound management, and physician orders, which emphasize the need for resident-centered care that addresses the psychosocial, physical, and emotional needs of residents.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide adequate and timely podiatry care for Resident R27, who had significant medical conditions including diabetes, peripheral vascular disease, hypertensive heart disease, anxiety disorder, and spinal stenosis. The facility's foot care policy, dated 9/19/23, required that diabetic residents and those with chronic circulatory problems receive care from licensed professionals. However, a review of Resident R27's clinical records and consultation visits revealed a lack of routine podiatry services, despite his medical conditions necessitating such care. Observations on 10/27/24 noted that Resident R27's left leg was purple below the knee and around the calf, indicating potential circulatory issues. Interviews with the resident and staff, including the Receptionist/Ancillary Services Coordinator and the Director of Nursing, confirmed that Resident R27 was never placed on the podiatry list, and there were no documented refusals of podiatry services from him. The podiatrist confirmed that Resident R27 had never been seen, highlighting a failure in the facility's process to ensure necessary podiatry care was provided.
Failure in Post-Fall Documentation and Neurological Assessments
Penalty
Summary
The facility failed to perform timely and accurate post-fall documentation and ensure neurological assessments were conducted following incidents involving a fall for Resident R50. The facility's policy on Fall Prevention and Management required a Post Fall Assessment and Neuro Checks if a resident's fall was unwitnessed or involved a head injury. However, after Resident R50's unwitnessed fall on 9/16/24, the clinical record did not indicate that a Post Fall Assessment was completed. Additionally, only 11 out of the required 16 neurological checks were performed. A subsequent fall on 9/23/24 also revealed deficiencies in post-fall procedures. The Post Fall Assessment and Fall Follow Up were not completed until 10/5/24, despite the fall occurring on 9/23/24. Furthermore, only six out of the required 16 neurological checks were completed. The Director of Nursing confirmed these failures in documentation and adherence to the facility's policy during an interview on 10/31/24.
Failure to Date Syringe for Tube Feeding
Penalty
Summary
The facility failed to provide appropriate care and services to a resident receiving tube feedings, as identified during a survey. The deficiency was noted in the care of a resident with a history of hypertension, diabetes, and dysphagia, who required tube feeding. The facility's policy for medication administration via enteral tube required the use of a 60cc piston syringe, which should be dated upon opening and changed daily. However, during an observation, a syringe was found undated and sitting in an opened package on the resident's dresser, indicating non-compliance with the facility's policy. During an interview, a registered nurse confirmed that the flush syringe used for the resident's tube feeding was not labeled with the date it was opened, as required. The nurse admitted to using the syringe that morning without dating it due to the absence of a marker. This oversight was acknowledged as a failure to provide appropriate care and services to the resident, as per the facility's established protocols and state regulations.
Failure to Maintain Oxygen Equipment for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for two residents, Resident R71 and Resident R113. For Resident R71, the facility's policy required weekly cleaning of oxygen concentrators and a physician's order to change oxygen tubing every week. However, during an observation, it was found that Resident R71's nasal cannula tubing was dated nearly a month prior, and the humidification bottle was empty and undated. This was confirmed by RN Employee E1, indicating a failure to adhere to the facility's respiratory care policy. Similarly, Resident R113's care plan required oxygen administration at ten liters via nasal cannula, with weekly cleaning of the oxygen concentrator and changing of the oxygen tubing and humidifier. Observations revealed that two concentrators in Resident R113's room were set to five liters each, with no dates on the oxygen line or humidifier water-containers. RN Employee E2 confirmed the facility's failure to maintain the oxygen equipment as required. These deficiencies were noted under the Pennsylvania Code sections related to resident rights, care policies, and nursing services.
Failure to Dispose or Reconcile Discontinued Medications
Penalty
Summary
The facility failed to properly dispose of or reconcile discontinued medications in a timely manner in one of the two medication rooms reviewed, specifically the Second floor D Wing Medication room. During a review, it was observed that four blister packs of medications, including Zoloft, Warfarin, and Repaglinide, were left in an opened tote in an unlocked medication room. This is contrary to the facility's policy, which requires medications to be stored safely, securely, and properly, and accessible only to authorized personnel. Interviews with staff revealed a lack of adherence to the facility's policy for returning medications to the pharmacy. An LPN stated that there was no paperwork or accountability process for tracking the disposition of medications before sending them back to the pharmacy. The Director of Nursing confirmed the facility's failure to dispose of or reconcile discontinued medications in a timely manner, as required by their policies.
Failure to Complete Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews were completed by the facility after the consultant pharmacist made recommendations for three months: November 2023, March 2024, and April 2024. According to the facility's Medication Regimen Review policy, a licensed pharmacist is required to perform a monthly medication review and report any irregularities to the attending physician, medical director, and director of nursing. These reports must be acted upon in a timely manner to meet the needs of the residents. However, the facility did not adhere to this policy for the specified months, as confirmed by the Director of Nursing (DON) during an interview. The deficiency was identified through a review of clinical records, facility policy, and staff interviews. Resident R47's clinical pharmacy review notes indicated that recommendations were made in November 2023, March 2024, and April 2024, but the facility failed to produce these pharmacy recommendations. The DON confirmed the absence of these records, indicating a lapse in the facility's responsibility to ensure that the medication regimen reviews were completed and acted upon as required by their policy and state regulations.
Failure to Identify Diagnosed Condition for Psychotropic Medication Use
Penalty
Summary
The facility failed to identify a diagnosed specific condition for treatment for a resident receiving psychotropic medication. The facility's policy on resident rights emphasizes providing resident-centered care that meets psychosocial, physical, and emotional needs. However, a review of the clinical records for a resident, who was admitted to the facility and had a care plan indicating the use of antipsychotic medication for behaviors such as verbal outbursts and violent actions, revealed a lack of a specific diagnosed condition for the use of these medications. The resident's Minimum Data Set (MDS) included diagnoses of hypertension, viral hepatitis, and anxiety disorder, but the physician orders for antipsychotic medications did not specify a condition warranting their use. The physician orders dated in October indicated the use of trazadone and risperdal for mood, yet failed to identify a diagnosed specific condition for treatment. During an interview, a registered nurse confirmed the facility's failure to specify a diagnosed condition for the treatment of the resident with psychotropic medication. This deficiency was identified for one of three residents reviewed who were receiving psychotropic medications, indicating a lapse in adherence to the facility's policies and regulatory requirements.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the cases of two residents. Resident R73, who has a diagnosis of epilepsy, psychotic disorder, and mastocytosis, did not receive Cromolyn Sodium as prescribed for mastocytosis on multiple occasions. The medication was not available in-house, and there were delays in obtaining it from the pharmacy, leading to missed doses. Resident R73 reported feeling unwell due to the missed medications, which were documented as unavailable on several dates. Similarly, Resident R173, diagnosed with type II diabetes mellitus and end-stage renal dependence, did not receive the prescribed Trulicity injection for diabetes management. The medication was not available in-house, and there was no documentation indicating that the physician was notified of the missed dose. The Director of Nursing confirmed that both residents experienced significant medication errors due to the facility's failure to provide the medications as ordered.
Failure to Provide Routine and Emergency Dental Services
Penalty
Summary
The facility failed to provide routine and emergency dental services to Resident R27, as required by their policy. The facility's dental services policy, dated 9/19/23, stated that they would assist residents in obtaining routine and 24-hour emergency dental services. However, a review of Resident R27's clinical records and consultation visits revealed that he had not received any routine dental services since his admission on 6/11/24. This was confirmed during an interview with the Nursing Home Administrator on 10/30/24. Resident R27, who has multiple diagnoses including diabetes, peripheral vascular disease, hypertensive heart disease, anxiety disorder, and spinal stenosis, expressed during an interview on 10/27/24 that he had not seen a dentist and needed two teeth extracted. The Medical Records/Ancillary Services Coordinator, Employee E14, also confirmed that Resident R27 was not on the list for dental services and had not been seen for dental care. This oversight was acknowledged by the Nursing Home Administrator, indicating a failure to adhere to the facility's dental services policy.
Failure to Enforce NPO Diet Order
Penalty
Summary
The facility failed to provide food in a form that met the individual needs of a resident who was ordered an NPO (nothing by mouth) diet. The resident, identified as R107, had a medical history that included high blood pressure, intracerebral hemorrhage, and dysphagia, and was receiving nutrition through a feeding tube. Despite the NPO order, an observation on 10/27/24 revealed that Resident R107 had a large Styrofoam cup full of ice water marked 'Oral Care' and another cup full of water marked 'G-tube flush' on her bedside table. During interviews, RN Employee E18 confirmed that Resident R107 was not allowed to drink anything by mouth but believed it was permissible to leave water at the bedside since the cups were marked. The Director of Nursing later confirmed that no fluids should be left at the bedside for a resident with an NPO order, as it could lead to the resident, staff, visitors, or other residents providing the resident with a drink. This oversight indicated a failure to enforce the NPO diet order as prescribed.
Failure to Maintain Essential Heating Equipment
Penalty
Summary
The facility failed to maintain essential heating equipment in three resident rooms on the second floor, specifically rooms 238, 239, and 251. During observations, it was noted that the heaters had been removed from these rooms, leaving the wall areas open to the outside. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the heaters were removed from these rooms to be used in other areas of the facility where heating units were not functioning. This action resulted in the failure to maintain essential equipment in the affected rooms, as required by regulations.
Failure to Provide Medical Record Access to POA
Penalty
Summary
The facility failed to provide medical record access to the Power of Attorney (POA) for a resident, identified as Closed Resident Record R177. The resident had a diagnosis of unspecified dementia, anxiety disorder, and cognitive communication deficiency. Despite the facility's policy stating that residents and their legal guardians have the right to access all resident records promptly, the POA was denied access to the resident's clinical records. The POA, who had been the financial POA since 2013, was contacted by the facility to make medical and financial decisions, including decisions about hospital transfers and weight changes. Interviews with the POA and a corporate employee confirmed that the facility used the financial POA as the responsible party for medical decisions. However, the facility did not assist the POA in obtaining the medical POA and failed to provide the requested medical records. This deficiency was identified during a phone interview with the POA and an interview with a corporate employee, who acknowledged the facility's awareness of the request and the failure to provide the records.
Failure to Display Current Nurse Staffing Information
Penalty
Summary
The facility failed to prominently display the required Nurse Staffing Information for two out of five days, specifically on 10/30/24 and 10/31/24. During an observation on 10/31/24 at 11:05 a.m., the receptionist, identified as Employee E19, was unable to locate the current nurse staffing information at the receptionist desk. In an interview conducted shortly after, Employee E19 confirmed that the displayed nurse staffing information was outdated, showing data from 10/29/24. Employee E19 expressed uncertainty about the responsibility and process for updating the information, indicating a lack of training or instruction. The Nursing Home Administrator confirmed the deficiency, acknowledging the failure to display the current nurse staffing information as required by regulations.
Unsafe Walkway Poses Hazard in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the resident public areas, specifically the front entrance outside walkways. This deficiency was identified through observations and interviews conducted by surveyors. The walkway adjacent to the driveway was found to be constructed with small stones, with some stones missing, creating holes and an uneven surface. This condition poses a safety hazard to individuals walking or using wheelchairs and gurneys to access transportation. A resident, who is cognitively intact and has a history of traumatic spinal cord dysfunction, quadriplegia, and depression, expressed concerns about the walkway's condition. The resident is permitted to get out of bed into a wheelchair, and the unsafe walkway presents a significant risk to their safety and comfort. The Nursing Home Administrator confirmed the facility's failure to maintain a safe environment during an interview, acknowledging the hazardous condition of the walkway.
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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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