Presbyterian Homes-presby
Inspection history, citations, penalties and survey trends for this long-term care facility in Hollidaysburg, Pennsylvania.
- Location
- 220 Newry Street, Hollidaysburg, Pennsylvania 16648
- CMS Provider Number
- 395530
- Inspections on file
- 30
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Presbyterian Homes-presby during CMS and state inspections, most recent first.
The facility failed to accurately code MDS assessments for five residents, resulting in omissions or incorrect entries regarding the administration of anticonvulsants, antidepressants, and antibiotics. Medication records showed that several residents received these medications during the required look-back periods, but the MDS assessments did not reflect this, as confirmed by staff interviews and record reviews.
Surveyors found that food items, including decorative sprinkles, powder, lettuce, hot dogs, and hamburgers, were improperly stored open to the air and that expired food was present in both kitchenettes. The Dietary Manager confirmed that food should be sealed and expired items removed, but these standards were not met.
An LPN was observed administering medications to multiple residents consecutively without sanitizing hands between residents or after glove removal, contrary to facility policy. Both the LPN and the Infection Control Nurse confirmed that proper hand hygiene procedures were not followed during medication administration.
A resident with dementia and anxiety was emotionally distressed when a nurse aide repeatedly teased her by withholding a baby doll and laughing, despite the resident's visible agitation. Multiple staff witnessed the incident, confirming the aide's actions caused significant emotional upset to the resident.
The facility did not provide required written notifications to residents or their representatives regarding transfers to the hospital, nor did it notify the ombudsman as mandated. In three cases, including residents with cognitive impairment and those discharged home, there was no documentation of written notification or ombudsman contact, as confirmed by facility leadership.
A resident who was cognitively intact and frequently incontinent of bowel movements did not receive bowel medications as ordered by the physician during multiple periods of constipation. Staff failed to initiate or follow the prescribed bowel protocol, and medication administration records showed the interventions were not given as required.
A resident receiving hospice services did not have the required hospice benefit of elections form documented in either the facility or hospice provider's records, despite an agreement that this information would be provided to facilitate care coordination. Staff interviews confirmed the form was missing from the resident's hospice chart.
A resident with severe cognitive impairment and dementia experienced several changes in condition, including a missing and replaced pair of glasses, a skin blister that progressed, and the start of a new antibiotic for cellulitis. The resident's representative was not notified about the optometry consult, the new glasses, the skin alteration, or the new medication, despite facility policy requiring timely notification. The DON confirmed the lack of documentation and notification.
A resident with dementia and seizures fell and sustained multiple fractures due to the facility's failure to ensure hipsters were worn as per the care plan. The oversight was due to a process error, as the intervention was not visible to the nurse aide responsible for the resident's care.
The facility failed to follow physician's orders for bowel management protocols for three residents, resulting in a deficiency in quality of care. Despite the absence of documented bowel movements, the prescribed interventions were not administered as per the medical administration records. An interview with the Assistant DON confirmed the non-compliance with the bowel protocol.
A resident with a history of falls experienced an unwitnessed fall resulting in a subdural hematoma due to the facility's failure to update the care plan with an intervention to call the resident's son when she was restless. Despite staff being instructed to use this calming measure, it was not documented in the care plan, contributing to the deficiency.
A facility failed to provide assistive eating devices according to a resident's care plan. The resident, who was severely cognitively impaired, was supposed to have her meals served in separate bowls, one at a time, to maintain her independence in eating. However, during a lunch observation, her meal was served on a plate, contrary to the care plan and confirmed by the Nursing Home Administrator.
A resident with cognitive impairment and sleep issues did not receive updated medication dosages due to a nurse's failure to transcribe physician-approved changes. The CRNP recommended increasing trazodone and melatonin, which was agreed upon by the resident's daughter and signed by the physician, but the orders were not updated in the MAR.
A cognitively impaired resident with an indwelling urinary catheter did not receive documented catheter care as required by facility policy. The facility's policy mandated catheter care during morning and evening routines and after incontinence or bowel movements. However, there was no evidence of such care being documented over a two-month period, as confirmed by the DON.
The facility did not discard expired food items as required by their policy. Observations revealed expired half and half creamer, sour cream, ricotta cheese, apple juice, cottage cheese, and Nutrijuice in various storage areas. Interviews with the Dietary Manager and a Kitchen Aide confirmed that these items should have been discarded.
The facility did not update care plans for two residents. One resident independently managed her colostomy care, contrary to her care plan, while another resident's care plan inaccurately indicated she was receiving Digoxin therapy, which she was no longer taking.
A facility failed to obtain physician's orders for the care and maintenance of a resident's Mediport, as required by their policy. The resident, who was cognitively intact and needed assistance with daily care, had a port flush documented in July, but no physician's order was recorded for this procedure. This deficiency was confirmed by the DON.
A facility failed to follow physician's orders for a resident's blood sugar management. The resident's blood sugar levels exceeded 350 mg/dL on multiple occasions without notifying the physician, as required. Additionally, the hypoglycemia protocol was not initiated when the resident's blood sugar dropped below 70 mg/dL. These actions led to a deficiency under nursing services regulations.
A resident with respiratory failure was ordered to receive continuous oxygen at 3 liters per minute via nasal cannula. However, observations showed the resident receiving oxygen at 4.5 liters per minute. Interviews with a nurse and the DON confirmed the incorrect administration, leading to a deficiency.
A facility failed to document the disposition of controlled medications for a resident who had orders for morphine sulfate and oxycodone. Despite the resident's discharge summary indicating cessation of breathing, there was no evidence of the required documentation for the disposition of these medications. The Assistant DON confirmed the absence of such documentation.
The facility failed to label an opened vial of Lispro Insulin with the date it was opened and did not ensure the narcotic box in the medication room refrigerator was permanently affixed and locked. These deficiencies were confirmed by both an LPN and the DON, indicating non-compliance with the facility's medication storage policies.
The facility's QAPI committee failed to address recurring deficiencies effectively, as identified in a recent survey. These included failures in revising care plans, providing quality care, maintaining accountability for controlled medications, and ensuring proper food storage and service. Despite previous plans of correction involving audits and QAPI review, the committee did not successfully implement these plans, leading to repeated deficiencies.
A facility failed to create a comprehensive care plan for a resident with aphasia, stroke, and dementia, neglecting to include specific interventions for notifying the resident's daughter in case of incidents or significant changes. The Nursing Home Administrator confirmed the oversight, acknowledging the lack of a care plan addressing these needs.
A resident with Parkinson's disease suffered burns after spilling coffee served at 164.1°F, above the facility's safe limit of 140°F. Dietary staff failed to temp the coffee before service, leading to the incident. The resident sustained burns on her thigh and abdomen, and the facility's investigation confirmed neglect due to non-compliance with the hot beverage policy.
A resident with Parkinson's disease was burned by hot coffee served without a lid and at a temperature exceeding facility policy. The coffee, brewed earlier and not temperature-checked, was served by a dietary server who forgot to verify its temperature, resulting in third-degree burns when spilled.
Inaccurate MDS Medication Coding for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, the facility did not correctly code Section N of the MDS, which documents medications received in the seven days prior to assessment. For one resident, Gabapentin, an anticonvulsant, was administered nightly, but the corresponding section on the MDS was not coded to reflect this. Another resident, who had all medications discontinued upon starting hospice, was incorrectly coded as having received both antidepressant and anticonvulsant medications during the look-back period, despite the Medication Administration Record (MAR) showing otherwise. Additional deficiencies included a resident who received Divalproex, an anticonvulsant, nightly, but whose admission MDS did not indicate receipt of this medication. Another resident was administered Cephalexin, an antibiotic, twice daily, but the quarterly MDS did not reflect this. Lastly, a resident received Gabapentin both in the morning and evening, but the significant change MDS assessment failed to indicate the administration of this anticonvulsant. These discrepancies were confirmed by review of clinical records, MARs, and staff interviews, including confirmation from the Regional Registered Nurse Assessment Coordinator.
Improper Food Storage and Expired Items in Kitchenettes
Penalty
Summary
Surveyors determined that the facility failed to store food in accordance with professional standards for food service safety in both the first and second floor kitchenettes. During observations, an open bag of decorative sprinkles and expired powder were found in the kitchen's dry storage room. In the second floor kitchenette's refrigerator and freezer, a head of lettuce and multiple bags of frozen hot dogs and hamburgers were found open to the air. Similar findings were observed in the first-floor kitchenette freezer, where additional bags of frozen hot dogs and a platter of frozen hamburgers were also left open. The Dietary Manager confirmed that all food items should be sealed to prevent air exposure and that expired food should be removed, but these practices were not followed.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed during medication administration for six of nine residents observed. According to facility policy, staff are required to sanitize their hands before preparing or handling medications and after glove removal. During a medication pass, an LPN was observed preparing and administering medications to multiple residents consecutively without sanitizing his hands between residents or after removing gloves. This included preparing and administering medications to several residents in succession without following hand hygiene protocols. Interviews with the LPN and the Infection Control Nurse confirmed that the required hand sanitizing procedures were not followed during these medication passes.
Resident Subjected to Emotional Abuse by Staff Member
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with dementia, anxiety, and agitation was subjected to emotional distress by a staff member. The incident involved a nurse aide who was observed holding a baby doll, which belonged to another resident, in front of the affected resident and repeatedly pulling it away as the resident reached for it. The nurse aide laughed at the resident during this interaction, despite the resident's visible distress, yelling, and anxiety. Multiple staff witnesses confirmed that the nurse aide prolonged the episode, teased the resident, and caused the resident to become visibly upset, with one staff member noting the resident had a red face and tears in her eyes. The facility's policy required that residents be protected from all forms of abuse, including mental and emotional abuse. Documentation and staff interviews indicated that the nurse aide was aware the doll did not belong to the resident and continued the behavior despite the resident's agitation. The incident was substantiated through investigation reports, clinical records, and multiple witness statements, all of which described the resident's emotional distress as a direct result of the nurse aide's actions.
Failure to Provide Required Written Notifications for Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for transfer to the hospital, and did not notify the ombudsman as required by policy and regulation. Specifically, for three residents reviewed, there was no documented evidence that written notifications were given to the residents or their legal guardians when the residents were transferred to the hospital or discharged home. For one resident with moderate cognitive impairment and a history of stroke, there was no written notification to the resident or legal guardian, nor was the ombudsman notified when the resident was transferred to the hospital for chest pain. Another resident, who was cognitively intact, was sent to the emergency room for evaluation of tremors, weakness, and stiff neck, but again, there was no documentation of written notification to the resident or representative, or notification to the ombudsman. Additionally, a third resident, also cognitively intact, was discharged home with his wife, but there was no evidence that the ombudsman was notified of the discharge as required. These findings were confirmed by the Assistant Director of Nursing, who acknowledged the lack of documentation and notifications for the residents involved. The facility's policy required written notification to both the resident/representative and the ombudsman upon transfer or discharge, but this was not followed in these cases.
Failure to Follow Physician-Ordered Bowel Protocol
Penalty
Summary
A review of clinical records and staff interviews revealed that the facility failed to follow physician-ordered bowel protocols for a cognitively intact resident who was frequently incontinent of bowel movements. The physician's orders specified a stepwise administration of Milk of Magnesia, dulcolax suppository, and Fleets enema based on the number of days without a bowel movement. Documentation showed multiple periods in August and September 2025 where the resident did not have a bowel movement for several consecutive days, yet there was no evidence that the prescribed bowel protocol was initiated or followed. Medication administration records confirmed that staff did not administer the ordered interventions during these periods of constipation. The Nursing Home Administrator confirmed that the physician's orders for bowel medications were not followed for this resident.
Failure to Obtain Required Hospice Election Form
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required hospice benefit of elections form from the contracted hospice provider for one of five hospice residents reviewed. The agreement between the facility and the hospice provider specified that the hospice provider would supply information, including the benefit of elections form, to facilitate coordination of care. Physician's orders indicated that the resident was to receive hospice services, but as of the date of review, there was no documented evidence in either the facility's or the hospice provider's clinical records that the form had been obtained. Interviews with the Social Service Manager and the Hospice Representative confirmed the absence of the required documentation in the resident's hospice chart.
Failure to Notify Resident Representative of Changes in Condition and Care
Penalty
Summary
The facility failed to ensure timely notification of a resident representative regarding significant changes in a resident's condition and care. Specifically, for a resident with severe cognitive impairment and a diagnosis of dementia, there was no documented evidence that the resident's representative was informed about an in-house optometry consult, the ordering of new glasses, the development and progression of a skin blister, or the initiation of a new antibiotic medication for cellulitis. The facility's policy required timely notification to families and representatives about changes in medical condition and care, but this was not followed in these instances. A grievance was filed by the resident's representative after the resident's glasses went missing and were replaced, but the representative had not been notified of the optometry visit or the order for new glasses. Additionally, clinical documentation showed the resident developed a blister that later became non-intact, and a new antibiotic was ordered, yet there was no evidence of family notification. The DON confirmed that there was no documentation of notification and acknowledged that the family should have been informed of these events.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for a resident who was at risk for falls. This resident, who had a history of dementia and seizures, was found on the floor with a head laceration and was unresponsive for a period of time. The incident occurred after the resident experienced a seizure, leading to a fall that resulted in multiple fractures. The resident's care plan included the use of hipsters to be worn at all times, except during personal hygiene, to prevent injury from falls. However, during a subsequent fall, it was discovered that the resident was not wearing the hipsters as required by the care plan. This oversight was attributed to a facility process error, as the intervention was not visible to the nurse aide responsible for the resident's care. Interviews with staff confirmed that the hipsters were not applied to the resident, and the care plan intervention was not properly communicated or documented. This failure to implement the care-planned intervention contributed to the resident's fall and subsequent injuries, highlighting a lapse in the facility's adherence to its fall management policy.
Failure to Follow Bowel Management Protocols
Penalty
Summary
The facility failed to adhere to physician's orders for bowel management protocols for three residents, leading to a deficiency in quality of care. Resident 1, who was severely cognitively impaired and had diagnoses including kidney failure, anemia, and dementia, did not receive the prescribed bowel management interventions despite not having a bowel movement from January 18 through 24, 2025. The medical administration records (MARs) for January 2025 showed that the staff did not initiate or follow the bowel protocol as ordered by the physician. Similarly, Resident 2, who was cognitively impaired with a diagnosis of dementia, did not have a documented bowel movement from November 1 through 6, 2024, and the MARs for November 2024 indicated that the bowel protocol was not followed. Resident 3, who was cognitively intact and occasionally incontinent of bowel, also did not receive the prescribed bowel management interventions during periods in January 2025 when there was no documented bowel movement. An interview with the Assistant Director of Nursing confirmed that the bowel protocol was not followed for these residents on the specified dates.
Plan Of Correction
1. Residents 1, 2, and 3 had no ill-effects from this deficient practice. 2. An audit was completed by Director of Nursing, or designee, on currently admitted residents who should have received bowel protocol in the past 7 days to ensure that the resident's bowel protocol orders were followed as per the physician's orders. 3. An education was completed with licensed nursing staff on following bowel protocol orders as per the physician's orders. 4. An audit will be conducted on 5 active residents who should have received bowel protocol to ensure that the resident's bowel protocol orders were followed as per the physician's orders weekly x 4 weeks, then monthly x 2 months. The results of these audits will be brought to the Quality Assurance Performance Improvement (QAPI) committee for review.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect specific care needs, leading to a deficiency. Resident 3, who was cognitively intact and had a history of falls, was admitted with a comprehensive care plan that included various interventions to prevent falls. Despite these measures, the resident experienced an unwitnessed fall in her room, resulting in a subdural hematoma and subsequent hospitalization. The care plan did not include the intervention of calling the resident's son when she was restless, which was identified as a calming measure after a previous fall. Interviews with the Assistant Director of Nursing and the Nursing Home Administrator revealed that staff were instructed to call the resident's son to help prevent further falls, but this intervention was not documented in the care plan following the fall on February 1, 2025. The lack of documentation and update to the care plan contributed to the deficiency, as the facility did not adequately revise the care plan to address the resident's specific needs and prevent further incidents.
Plan Of Correction
1. Resident 3's care plan was updated on 2/5/2025 with the intervention to call her son when she is restless to help prevent future falls. 2. An audit was completed by Director of Nursing, or designee, on currently admitted residents with falls occurring in the last 30 days to ensure that interventions put into place were added to the resident's care plan. 3. An education was completed with licensed nursing staff and interdisciplinary team members who edit care plans on the appropriate entering of interventions in the resident's care plan following falls. 4. An audit will be conducted on 5 active residents who have had 1 or more falls to ensure that care plan interventions were added to the resident's care plan appropriately following a fall weekly x 4 weeks, then monthly x 2 months. The results of these audits will be brought to the Quality Assurance Performance Improvement (QAPI) committee for review.
Failure to Provide Assistive Eating Devices as Per Care Plan
Penalty
Summary
The facility failed to provide assistive devices for eating in accordance with the care plan for one resident. The resident, who was severely cognitively impaired, was assessed to be independent with eating after setup and required her food to be served in bowls, one at a time, as per her care plan and speech therapy notes. However, during an observation of the lunch meal, the resident was served pork, mashed potatoes, and sauerkraut on a plate instead of in separate bowls. This was confirmed by the Nursing Home Administrator, who acknowledged that the resident's food should have been served in separate bowls, one at a time, as care planned.
Plan Of Correction
1. Resident 1 experienced no ill-effects from this deficient practice. 2. An audit was completed by the Director of Dining Services, or designee, to ensure that current residents requiring adaptive feeding devices had their care-planned assistive feeding devices in place before the residents began eating their meal. 3. An education was completed with all nursing staff and dining services staff members on the policy for adaptive feeding devices and ensuring that residents receive their care-planned assistive feeding devices before the residents begin eating their meal. 4. An audit will be conducted on 5 currently active residents requiring adaptive feeding devices to ensure that they have their care-planned assistive feeding devices in place before the residents begin eating their meal weekly x 4 weeks, then monthly x 2 months. The results of these audits will be forwarded to the Quality Assurance Performance Improvement (QAPI) committee for review.
Failure to Transcribe Medication Changes
Penalty
Summary
The facility failed to transcribe physician's orders related to medication changes for a resident, leading to a deficiency in meeting professional standards of quality. The resident, who was cognitively impaired and had a history of falls, anxiety, and depression, was reviewed by a Certified Registered Nurse Practitioner (CRNP) with Psychogeriatric Services. The CRNP recommended increasing the resident's trazodone and melatonin to help with sleep issues, and these recommendations were agreed upon by the resident's daughter and signed off by the physician. Despite the physician's approval, the nurse did not transcribe the increased dosages into the physician's orders, resulting in the resident continuing to receive the original lower dosages. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the nurse failed to update the medication orders as per the psychogeriatric consult recommendations. The deficiency was identified through a review of the resident's Medication Administration Record (MAR) and clinical records.
Failure to Document Catheter Care
Penalty
Summary
The facility failed to provide proper care for an indwelling urinary catheter for a resident who was cognitively impaired and required extensive assistance for all care. The facility's policy required catheter care to be performed with morning and evening care and as needed after incontinence or bowel movements. However, there was no documented evidence in the resident's clinical record indicating that staff provided the necessary catheter care from July 6, 2024, to September 4, 2024. This deficiency was confirmed through an interview with the Director of Nursing, who acknowledged the lack of documentation for the required catheter care during this period.
Failure to Discard Expired Food
Penalty
Summary
The facility failed to ensure that food was discarded after it was outdated, as required by their policy on labeling and dating food. During observations in the kitchen, surveyors found three half-gallons of half and half creamer, two large containers of sour cream, and two large containers of ricotta cheese that were expired. Additionally, in the dry storage room, there were two cartons of expired apple juice and five cartons of apple juice with no manufacturer's expiration date. An interview with the Dietary Manager confirmed that expired items should be discarded and not used. Further observations in the first-floor kitchenette revealed a large container of cottage cheese that was opened and in use, despite being expired. There were also 10 cartons of frozen Nutrijuice in the freezer that were expired. A Kitchen Aide confirmed that these expired items should have been thrown away and not used.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to update care plans to reflect changes in residents' care needs for two residents. For one resident, a significant change Minimum Data Set (MDS) assessment indicated that she was cognitively intact and dependent on staff for activities of daily living, with a colostomy requiring care. However, both the resident and a Licensed Practical Nurse confirmed that the resident independently managed her colostomy care, including emptying and changing the bag. Despite this, the care plan was not revised to reflect her independence in managing her colostomy. Another resident, who was cognitively intact and dependent on staff for activities of daily living, had a care plan indicating she was receiving Digoxin therapy for atrial fibrillation. However, a review of the Medication Administration Record showed no evidence of Digoxin administration. The Assistant Director of Nursing confirmed that the resident was no longer taking Digoxin, but the care plan had not been updated to reflect this change.
Failure to Obtain Physician's Orders for IV Device Care
Penalty
Summary
The facility failed to ensure that physician's orders were obtained for the care and maintenance of an intravenous access device for one of the residents reviewed. The facility's policy, dated February 8, 2024, required that orders for flushing and care of intravenous devices be obtained to maintain the device and prevent obstruction. An annual Minimum Data Set (MDS) assessment for the resident, dated June 21, 2024, indicated that the resident was cognitively intact and required assistance for daily care needs. A nurse's note from July 24, 2024, documented a port flush with good blood return, with the next flush scheduled in three months. However, there was no documented evidence in the resident's clinical record of a physician's order for the Mediport care, as confirmed by the Director of Nursing during an interview.
Failure to Follow Physician's Orders for Blood Sugar Management
Penalty
Summary
The facility failed to follow physician's orders for a resident, identified as Resident 38, regarding the management of blood sugar levels. According to the facility's policy for hyperglycemia and hypoglycemia, if a resident's blood glucose reading is 350 mg/dL or greater, the physician must be notified. Resident 38, who is cognitively intact and dependent on staff for daily care, had physician's orders to have her blood sugar checked four times a day and to notify the doctor if her blood sugar exceeded 350 mg/dL. However, on three occasions in July and August 2024, the resident's blood sugar levels were recorded as 360 mg/dL, 371 mg/dL, and 361 mg/dL, respectively, without any documented evidence that the physician was notified as required. Additionally, the facility did not initiate the hypoglycemia protocol for Resident 38 when her blood sugar level dropped to 69 mg/dL on September 1, 2024. The physician's orders specified that the hypoglycemia protocol should be initiated if the resident's blood sugar was less than 70 mg/dL. An interview with the Director of Nursing confirmed the lack of documentation for notifying the physician about the elevated blood sugars and the failure to initiate the hypoglycemia protocol. These actions and inactions led to the deficiency cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Oxygen Therapy Not Administered as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for a resident, leading to a deficiency. The facility's policy required a physician's order for oxygen to specify the liter flow and method of administration. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact, required substantial assistance, used supplemental oxygen, and had a diagnosis of respiratory failure. The physician's order specified continuous oxygen at a flow rate of 3 liters per minute via nasal cannula for hypoxia. However, observations on two separate days revealed that the resident was receiving oxygen at a flow rate of 4.5 liters per minute. Interviews with a registered nurse and the Director of Nursing confirmed that the oxygen was not administered at the correct flow rate.
Failure to Document Disposition of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for one resident. According to the facility's policy, controlled substances require special handling, storage, disposal, and record-keeping in compliance with federal and state laws. Physician's orders for the resident included morphine sulfate and oxycodone, both controlled narcotic pain medications. The resident's discharge summary indicated that the resident ceased to breathe, but there was no documented evidence of the disposition of these medications. An interview with the Assistant Director of Nursing confirmed the lack of documentation regarding the disposition of the controlled substances as required.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policies, resulting in deficiencies related to the labeling and securing of medications. During a review, it was observed that a medication cart did not have medications labeled with the date they were opened. Specifically, an opened vial of Lispro Insulin was found without a date opened sticker, contrary to the facility's policy that requires such labeling. This was confirmed by both a Licensed Practical Nurse and the Director of Nursing, who acknowledged that the vial should have been properly labeled. Additionally, the facility did not ensure that the narcotic box in the medication room refrigerator was permanently affixed and locked as required. A clear, unlocked box containing a schedule IV medication, lorazepam, was found secured to a removable shelf, which does not comply with the policy that mandates schedule II-V medications to be stored in a permanently affixed and double-locked compartment. This oversight was also confirmed by the nursing staff and the Director of Nursing.
Repeated Deficiencies in Care Plans, Quality Care, Medication Accountability, and Food Service
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as identified in the current survey ending September 5, 2024. These deficiencies included the failure to revise care plans, provide quality care, maintain accountability for controlled medications, and ensure proper food storage and service. Despite having developed plans of correction following a previous survey ending November 1, 2023, which included quality assurance systems and audits, the facility did not maintain compliance with nursing home regulations. The specific deficiencies cited in the current survey were under F657 for care plan revisions, F684 for quality care, F755 for controlled medication accountability, and F812 for food storage and service. The facility's plans of correction from the previous survey involved completing audits and reporting results to the QAPI committee for review. However, the committee failed to implement these plans successfully, resulting in repeated deficiencies in the same areas.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan that included specific and individualized interventions for a resident with significant medical conditions, including aphasia, stroke, and dementia. The care plan, dated May 15, 2024, noted the resident's impaired decision-making and functional status, requiring staff to notify the resident's daughter when the resident refused showers. However, there was no documented evidence of a care plan addressing the need to notify the resident's daughter first in the event of an accident, significant changes in the resident's status, or decisions regarding treatment alterations or transfers. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that a care plan should have been developed to ensure the resident's daughter was notified first. The facility's policies required consultation with competent residents and notification of designated individuals following significant changes or incidents, but these procedures were not followed for this resident, leading to the deficiency.
Resident Burned Due to Hot Beverage Neglect
Penalty
Summary
The facility failed to ensure that residents were free from neglect, specifically in the case of a resident who suffered burns from spilling hot coffee. The facility's policy required that hot beverages be served at a maximum temperature of 140 degrees Fahrenheit. However, the coffee served to the resident was not temped before service and was found to be at 164.1 degrees Fahrenheit, significantly above the safe temperature limit. This oversight led to the resident spilling the coffee and sustaining burns on her right upper thigh and abdomen. The resident, who had a diagnosis of Parkinson's disease and was on a mechanically altered diet, was observed by a visitor to spill the coffee into her lap. The incident resulted in the resident suffering from burns, with areas of redness and blisters developing on her skin. The facility's investigation revealed that the coffee was brewed during lunch and served at dinner without being temped, contrary to the facility's policy. Dietary staff involved admitted to not temping the coffee due to being busy and forgetting, which directly contributed to the incident. The investigation confirmed that the dietary staff did not follow the procedure for temping coffee prior to meal service, leading to the resident's injury. The facility's policy clearly outlined the need for hot beverages to be served at a safe temperature, and the failure to adhere to this policy resulted in neglect. The staff involved were placed on administrative leave, and the incident was substantiated as neglect due to the failure to follow established procedures.
Resident Burned by Hot Coffee Due to Policy Violation
Penalty
Summary
The facility failed to provide an environment free from accident hazards by serving hot coffee to a resident without ensuring the temperature was not greater than 140 degrees Fahrenheit. The coffee was served in a cup without a lid, and the temperature was not checked before serving. This resulted in the resident spilling the coffee and sustaining third-degree burns on her right upper thigh and abdomen. The resident involved had a diagnosis of Parkinson's disease and was on a mechanically altered diet. She required assistance with feeding at times, as noted in her care plan. On the day of the incident, a dietary server provided the resident with coffee brewed earlier in the day, which had not been temperature-checked. The coffee was later found to be at 164.1 degrees Fahrenheit, significantly above the facility's policy limit. Statements from staff revealed that the dietary server forgot to check the coffee temperature before serving it to the resident. The coffee had been brewed during lunch and was served during dinner without being reheated or checked. The failure to adhere to the facility's policy on hot beverage temperatures directly led to the resident's injuries.
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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