Pinecrest Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in St Marys, Pennsylvania.
- Location
- 763 Johnsonburg Rd, St Marys, Pennsylvania 15857
- CMS Provider Number
- 395279
- Inspections on file
- 19
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pinecrest Manor during CMS and state inspections, most recent first.
The facility failed to properly store Schedule II-V medications in locked, permanently affixed compartments in three medication rooms, and did not prevent unauthorized access to medications on two medication carts. Additionally, an open pen of Lantus insulin lacked an 'opened on' date, leading to improper medication management. LPNs confirmed these deficiencies during interviews.
Pinecrest Manor failed to develop a baseline care plan for a resident within 48 hours of admission, as required by federal regulations. The resident, who had multiple diagnoses including diabetes and acute kidney injury, did not have a baseline care plan documented in their clinical record. This deficiency was confirmed by the Nursing Home Administrator during an interview.
The facility failed to provide sufficient nursing staff, resulting in delayed care for residents. A resident reported waiting an hour for assistance on the toilet, while others noted long call bell wait times, especially during off shifts. Residents have adapted by managing their own needs due to staff shortages. Restorative aides are often reassigned to cover nursing duties, impacting their ability to perform restorative care.
A facility failed to prevent cross-contamination during wound care for a resident with Alzheimer's, venous stasis, and CHF. An LPN changed gloves multiple times without performing hand hygiene, and an RN handled a garbage can without washing hands before continuing care. Both staff members acknowledged the lapse in hand hygiene.
The facility did not meet the required NA staffing ratios for the evening and overnight shifts. On a specific day, with a census of 101 residents, the evening shift had 8.05 NAs instead of the required 9.18, and the overnight shift had 6.37 NAs instead of the required 6.73. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day, providing only 2.94 hours on a specific day. This deficiency was confirmed by the Nursing Home Administrator during an interview.
The facility failed to initiate a baseline care plan for a resident with diabetes, high blood pressure, and peripheral arterial disease within 48 hours of admission. Additionally, another resident with a history of stroke, cardiovascular disease, history of falling, and anxiety did not receive a written summary of the baseline care plan and order summary.
The facility failed to develop a comprehensive care plan for a resident with Alzheimer's Dementia, Seizures, and High Blood Pressure. Despite a physician's order for a Wanderguard bracelet to prevent elopement, the clinical record lacked a care plan addressing the resident's risk for wandering or elopement. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner. An opened vial of Tubersol PPD in the Unit A/B medication storage room lacked an open date, making it impossible for staff to determine the discard date. This was confirmed by an LPN during an interview.
Medication Storage and Access Deficiencies
Penalty
Summary
The facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in three of four medication rooms reviewed. Specifically, in the medication rooms for wings A/B, C/D, and E/F, Lorazepam, a controlled antianxiety medication, was found in clear plastic locked boxes that were not permanently affixed to the refrigerator shelves, allowing for potential removal. Licensed Practical Nurses (LPNs) confirmed during interviews that the storage did not comply with the facility's policy requiring these medications to be stored in a permanently affixed, double-locked compartment. Additionally, the facility did not prevent unauthorized access to medications on two of four medication carts observed. On the D and F wing medication carts, open bottles of medications such as MiraLAX, Pepto-Bismol, and Robitussin were left on open shelves at the back of the carts, which were positioned facing the hallway and out of the nurse's view while attending to residents. LPNs confirmed that these medications should not have been accessible and should have been locked in the medication cart. Furthermore, the facility failed to appropriately discard outdated medications. An open pen of Lantus insulin on the E wing medication cart lacked an 'opened on' date, which is required to ensure the medication is used within the manufacturer's recommended timeframe. The LPN confirmed that without an opened date, the insulin should have been discarded, as per the facility's policy and manufacturer's guidelines.
Plan Of Correction
1. The refrigerators were fixed at the time of the survey. A medication box was installed and permanently affixed in the E/F wing medication refrigerator. The A/B and C/D wing medication boxes were permanently affixed to the refrigerator at the time of the survey so they were not able to be removed with the shelf. The open Lantus insulin pen was discarded at the time of the survey. The Miralax, milk of magnesium, and Robitussin were removed from the back of the medication cart. 2. An audit will be completed of all refrigerators to ensure that the refrigerators are in compliance with the medication boxes permanently affixed to the refrigerator and all Scheduled II-V medications. An audit will be completed of all insulin vials and pens to ensure if they are opened there is a date on the pen or vial. All medications were removed from the back of the medication carts. 3. All nursing employees will be reeducated on the following policies and procedures titled: Narcotic Policy PCM, Medication Cart: Med Pass Guidelines, and Pharmaceutical Services and Medication Storage. 4. An audit will be completed by the Quality Nurse or designee to ensure that the medication boxes are permanently affixed and Schedule II-V medications are stored in the box within the medication refrigerator. These audits will be completed monthly and then quarterly thereafter. An audit will be completed on insulin vials and pens to ensure if they are dated if opened and if expired discarded. An audit will be completed monthly and then quarterly thereafter. Audits on all medication carts to ensure that there are no medications on the back of the medication carts will be completed weekly for one month, monthly for two months, and quarterly thereafter. These results will be reported quarterly to the Quality Assurance Performance Improvement Committee. 5. Corrective action date is April 10, 2024.
Failure to Initiate Baseline Care Plan
Penalty
Summary
Pinecrest Manor was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the development and implementation of a baseline care plan for residents. The facility policy mandates that a baseline care plan should be developed for each resident within 48 hours of admission. However, it was determined that the facility failed to initiate a baseline care plan for one resident, identified as Resident R99, who was admitted on January 9, 2025. The resident's clinical record, which included diagnoses such as diabetes, high blood pressure, anemia, and acute kidney injury, lacked evidence of a baseline care plan being initiated. During an interview, the Nursing Home Administrator confirmed the absence of a baseline care plan in Resident R99's clinical record. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The failure to initiate a baseline care plan for Resident R99 indicates a lapse in adhering to the facility's policy and federal regulations, which require the development of a person-centered care plan within 48 hours of a resident's admission.
Plan Of Correction
1. Resident R99's base line care plan was developed. 2. An audit will be completed on all admissions in the last 30 days to ensure a base line care plan was developed within 48 hours and provided to the resident and/or his/his representative. Any deficient practice will be corrected. 3. All licensed nursing employees will be reeducated on the facility policy titled "Care Plan: Baseline Interdisciplinary Plan of Care." 4. An audit will be completed by the Quality Director or designee on all new admissions to ensure that the baseline care plan is developed and implemented within 48 hours of admission and given to the resident and/or his/her representative. These audits will be completed weekly for one month, monthly for two months, and quarterly thereafter. These results will be reported quarterly to the Quality Assurance Performance Improvement Committee. 5. Corrective Action date will be April 10, 2025.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by interviews and observations. Resident R51, who requires assistance with mobility and transfers, reported waiting for an hour on the toilet for help and experiencing soiling due to delayed assistance. Additionally, during a Resident Council meeting, six alert and oriented residents expressed concerns about long wait times for call bell responses, particularly during the 3-11 shift and weekends. These residents have adapted by doing what they can for themselves, as they do not expect timely assistance. Further interviews revealed that Resident R12 had to wait until late morning for a shower and has not been walked by staff for months. Resident R34 reported not receiving a shower and sleeping in a recliner to manage bathroom needs independently. Resident R80, who has a physician's order for walking three times a week, has not been walked since January due to restorative aides being reassigned to work as nurse aides. Observations confirmed that restorative staff are often pulled to cover nursing shortages, limiting their ability to perform restorative duties effectively.
Plan Of Correction
1. Resident R80's restorative nursing care orders for ambulation were resumed. An announcement will be made at resident council to state that we were made aware that there are concerns with call bell response time, showers being completed that are related to staffing concerns. This plan of correction will be shared with the residents at resident council. Resident R12's concern regarding lack of assistance with walker use has been reviewed. The assigned staff have been re-educated on the resident's mobility needs, and restorative nursing aides are now ensuring assistance is provided per the care plan. Follow-up checks will be conducted weekly for four weeks to ensure continued compliance. Residents R12 and R34, who reported missed showers, will be interviewed, and their care plans have been reviewed to prevent recurrence. Assigned CNAs have been counseled on adherence to shower schedules, and their performance is being monitored. 2. An audit will be completed by the Director of Nursing or her designee and the Registered Nurse Assessment Coordinator or her designee on all residents with restorative nursing orders to see if they are still appropriate and if their orders are being fulfilled. An initial audit will be conducted by the Director of Nursing or her designee to see if showers are being completed. This audit will be conducted on 35% of the resident census. A revision of the current shower schedule will be revised if the audits result in ongoing issues with shower completion. 3. The restorative nursing program at Pinecrest Manor will be restructured where the current restorative nursing aides and coordinator will be training other staff members to be certified in restorative nursing to ensure that orders are fulfilled. All nursing employees will be re-educated by the Director of Nursing, Administrator or their designees on shower schedules, the importance of toileting, rounding and ambulation, shower schedules and documentation requirements, and call bell expectations and timeliness. 4. Audits will be completed by the Restorative Coordinator or her designee on all residents with restorative nursing orders to ensure that orders are completed and that their physical and mental needs are met. These audits will be completed by the Restorative Coordinator or designee weekly for 4 weeks and monthly thereafter. These results will be reported at the Quarterly Quality Assurance Meeting. Rounds will be completed by the Director of Nursing, Administrator or her designee to ensure that call bells are being answered in a timely manner. During these rounds, a resident will be interviewed to discuss any concerns. These rounds will occur every other week where 5 residents will be interviewed to make sure their needs are met. Audits on showers being completed will be completed by the Director of Nursing or her designee on 15 residents per week for 4 weeks and then monthly thereafter. These results will be reported at the Quarterly Quality Assurance Committee Meeting. The Director of Nursing and Administrator will oversee implementation and review findings to determine if additional corrective actions are necessary. 5. Corrective action date will be April 10, 2025.
Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care for a resident identified as R13. The resident, who was admitted with Alzheimer's Disease, venous stasis, and congestive heart failure, was observed receiving wound care. During the procedure, an LPN donned a clean gown and gloves, removed the resident's sock, and changed gloves multiple times without performing hand hygiene between glove changes. This occurred four times throughout the dressing change, contrary to the facility's hand hygiene policy. Additionally, an RN assisted in the procedure by positioning the resident's leg and handling the garbage can without performing hand hygiene before donning new gloves. The RN used bare hands to move the garbage can and then donned gloves to continue the procedure, failing to perform hand hygiene after touching the garbage can. Both the RN and LPN confirmed during an interview that they should have performed hand hygiene before donning clean gloves, as per the facility's policy.
Plan Of Correction
Resident R13 will be examined by the physician's assistant to ensure there were no negative outcomes. Employee El and Employee E2 have completed reeducation by the Quality Registered Nurse on proper hand hygiene practices specifically related to wound care and the need for hand hygiene after touching potentially contaminated items. Random audits will be conducted by the Quality Registered Nurse on all residents receiving wound dressing changes over a two-week period to ensure proper procedures are being followed, including handwashing and that the employees perform hand hygiene after touching potentially contaminated items. All nurses, including Licensed Practical Nurses and Registered Nurses, will undergo reeducation by the Director of Nursing or her designee on the "Handwashing and Hand Hygiene" policy as it applies to wound care and the need for hand hygiene after touching potentially contaminated items. This education will be incorporated into new employee orientation under infection control procedures for new nurses being onboarded. A weekly audit on 25% of the wound care dressing changes on all shifts and hand hygiene practices will be performed by the Quality Nurse or their designee for a four-week period, followed by monthly audits thereafter. The results will be presented at the quarterly Quality Assurance Performance Improvement (QAPI) Committee. The corrective action plan will be fully implemented by April 10, 2025.
Nurse Aide Staffing Deficiency on Evening and Overnight Shifts
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios for both the evening and overnight shifts on November 30, 2024. Specifically, during the evening shift, the facility had a census of 101 residents but only 8.05 NAs worked, whereas 9.18 were required to meet the regulation of one NA per 11 residents. Similarly, for the overnight shift, the facility had 6.37 NAs working when 6.73 were required to meet the regulation of one NA per 15 residents. This staffing shortage was confirmed by the Nursing Home Administrator during a telephone interview on December 23, 2024.
Plan Of Correction
1. Review and Revise Staffing Plans: - Daily Staffing Assessment: A daily staffing review will be scheduled to assess daily census levels, staffing requirements, and any gaps. This will ensure sufficient staffing is planned each day based on the census. - Shift Adjustments: Shift adjustments or additional NA staff will be scheduled proactively, especially during peak times, holidays, or any days expected to have higher resident needs. 2. Training & Education: - Staff Education and Staffing Protocols: Educate all managerial and supervisory staff on how to monitor staffing levels and staff ratios throughout the day and night shifts and to take appropriate action to prevent shortfalls and adhere to state-required staffing ratios. 3. Monitoring and Audits: - Weekly Audits: The facility will implement a weekly audit of staffing records to ensure that staffing ratios are met. The Nursing Home Administrator will review staffing ratios against census levels to monitor compliance. - Audit Reviews: The audit findings will be discussed in the quarterly quality assurance meetings. 4. Corrective Action Plan Implementation & Monitoring: - The Nursing Home Administrator and Director of Nursing will be responsible for overseeing the implementation of the corrective actions. 5. Completion Date: - All corrective actions will be implemented immediately, with a review and audit completed by 2/23/2025 to ensure compliance.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's nursing staffing documents for the period from November 21, 2024, to December 4, 2024. Specifically, on November 30, 2024, the facility provided only 2.94 hours of direct nursing care per resident, falling short of the mandated minimum. This shortfall was confirmed during a telephone interview with the Nursing Home Administrator on December 23, 2024.
Plan Of Correction
1. Review and Revise Staffing Plans: - Daily Staffing Assessment: A daily staffing review will be scheduled to assess daily census levels. This will ensure sufficient staffing is planned each day based on the census. - Shift Adjustments: Shift adjustments or additional staff will be scheduled proactively on days expected to have higher resident needs. 2. Training & Education: - Staff Education and Staffing Protocols: Educate all managerial and supervisory staff on how to monitor staffing levels, staff ratios throughout the day and night shifts, and to meet a minimum of 3.2 hours of direct resident care hours and to take appropriate action to prevent shortfalls and adhere to state-required staffing ratios. 3. Monitoring and Audits: - Weekly Audits: The facility will implement a weekly audit of staffing records to ensure that the 3.2 minimum hours of direct resident care for each resident are met. The Nursing Home Administrator will review staffing ratios and resident care hours are met against census levels to monitor compliance. - Audit Reviews: The audit findings will be discussed in the quarterly quality assurance meetings. 4. Corrective Action Plan Implementation & Monitoring: - The Nursing Home Administrator and Director of Nursing will be responsible for overseeing the implementation of the corrective actions. 5. Completion Date: - All corrective actions will be implemented immediately, with a review and audit completed by 2/23/2025 to ensure compliance.
Failure to Initiate Baseline Care Plan and Provide Written Summary
Penalty
Summary
The facility failed to initiate a baseline care plan for one resident and did not provide a written summary of the baseline care plan and order summary to another resident or their representative. Resident R201, who was admitted with diagnoses including diabetes, high blood pressure, and peripheral arterial disease, did not have a baseline care plan initiated within the required 48-hour timeframe. This was confirmed by the Nursing Home Administrator. Additionally, Resident R99, admitted with a history of stroke, cardiovascular disease, history of falling, and anxiety, did not receive a written summary of the baseline care plan and order summary. This was confirmed by the Director of Nursing.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for one of the residents reviewed, identified as Resident R7. The facility's policy requires a comprehensive care plan that includes measurable objectives and timetables to meet the medical, nursing, mental, and psychosocial needs of residents. Resident R7, who was admitted with diagnoses including Alzheimer's Dementia, Seizures, and High Blood Pressure, had a physician's order for a Wanderguard bracelet to prevent elopement. However, the clinical record lacked evidence of a care plan addressing Resident R7's risk for wandering or elopement and the use of the Wanderguard bracelet. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Properly Date and Discard Medications
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner. Specifically, in the Unit A/B medication storage room, an opened vial of Tubersol PPD was found without an open date, making it impossible for staff to determine the discard date. This was confirmed during an interview with an LPN, who acknowledged the missing open date on the vial. The facility policy and manufacturer's recommendations both require that vials be discarded 30 days after being opened, but this protocol was not followed in this instance.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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