Quality Life Services - Apollo
Inspection history, citations, penalties and survey trends for this long-term care facility in Apollo, Pennsylvania.
- Location
- 151 Goodview Drive, Apollo, Pennsylvania 15613
- CMS Provider Number
- 395371
- Inspections on file
- 36
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Quality Life Services - Apollo during CMS and state inspections, most recent first.
A resident with obstructive uropathy, toxic encephalopathy, and muscle weakness had a physician order for an RN to flush a left nephrostomy tube with 10 mL NSS every morning and as needed to maintain patency. Review of the MAR/TAR showed that the ordered morning flushes were missed on three separate days, and progress notes contained no explanation for the missed treatments or any indication that staff attempted to complete the flushes later in the day. The DON was informed that this failure to follow nephrostomy care orders did not comply with facility policy and applicable state nursing service regulations.
A resident with a history of cerebral infarction, encephalopathy, and fall risk, and who required two-person assistance for transfers, was placed in a shower chair for bathing. After the shower, a NA returned the resident to the room in the shower chair and left the resident unattended to obtain a Hoyer lift, without arranging for anyone to remain with the resident. During this unsupervised period, the resident fell from the shower chair and sustained a head laceration requiring hospital transfer. Staff witness statements indicated the NA knew residents should not be left alone in a shower chair, and other NAs reported they rely on the kardex or nursing staff for care instructions. The DON confirmed that proper supervision was not provided, resulting in the resident’s injury.
Two residents identified as high risk for wandering were able to elope from the facility due to failures in supervision, incomplete implementation of elopement interventions, and lapses in monitoring and documentation. In both cases, residents exited the building unsupervised, with staff only becoming aware after the fact, and electronic monitoring devices were either not applied or not functioning as required.
The NHA and DON failed to manage the facility effectively, resulting in the elopement of two residents and creating an immediate jeopardy situation. This deficiency was identified through review of job descriptions, clinical records, and staff interviews, which showed that essential duties to ensure regulatory compliance and resident safety were not fulfilled.
A resident with multiple diagnoses, including cancer and hypertension, was found to have incomplete medical records after ceasing to breathe, as there was no nurse progress note for the date of death. The DON confirmed the documentation was incomplete and not accurate as required.
A resident with severe cognitive impairment and a known elopement risk was able to exit the facility unsupervised after accessing an employee breakroom door that was not properly secured due to a blocked latch. The resident passed through multiple areas and exited to the parking lot before being found in a nearby building, despite having a functioning wander guard. Staff were unaware of the resident's absence until notified by personnel from another building.
Two residents experienced significant medication errors when one received multiple incorrect doses of Fosamax due to an order entry mistake, and another was given a full set of medications intended for a different resident, including narcotics and blood pressure medications. The errors led to actual harm, with one resident requiring hospital admission and emergency interventions. Staff interviews revealed lapses in following medication administration protocols and inadequate training on resident identification procedures.
The facility did not monitor or document refrigeration and freezer temperatures as required, and failed to maintain cleanliness and sanitation in kitchen areas, with observed build-up of grime and debris in multiple coolers and on shelving.
Surveyors found that three crash carts and the facility's only AED were not maintained in safe operating condition, with multiple expired supplies, empty oxygen tanks, and incomplete or missing checklists. Staff confirmed that required checks were not consistently performed, and the AED was not ready for use.
The facility did not ensure that necessary resident information was communicated to receiving health care providers during transfers for two residents, and failed to provide written notification of the bed-hold policy to three residents or their representatives at the time of hospital transfer, as confirmed by record review and staff interviews.
The facility did not complete comprehensive MDS assessments within the required time frames for multiple residents, with assessments being finalized between one and eleven days late. This was confirmed by the RN Assessment Coordinator, who acknowledged the failure to meet mandated deadlines.
Surveyors identified that MDS assessments for three residents were inaccurately coded, including errors regarding anticoagulant use, hospice care status, and physical restraint use. Staff interviews confirmed these were entry or coding errors, and clinical records did not support the information documented in the MDS.
Three residents did not receive care in accordance with physician orders and facility protocols: one resident with diabetes had repeated high blood glucose levels without physician notification; another resident with constipation did not receive timely bowel management interventions; and a third resident with a wound vac lacked an alternative dressing order in case of device failure. Staff interviews and record reviews confirmed these deficiencies.
The facility did not provide trauma-informed care for residents diagnosed with PTSD, as care plans failed to identify or address individual trauma triggers. Despite documentation of PTSD and related conditions, care plans lacked specific interventions to eliminate or mitigate triggers, and staff confirmed that individualized trauma histories and triggers were not consistently identified or addressed.
Surveyors identified multiple deficiencies in medication storage and labeling, including undated inhalers, missing refrigerator temperature logs, expired medical supplies, an expired COVID vaccine, and improperly stored insulin pens and inhalers. LPNs confirmed these issues and the facility's failure to follow its medication storage policies.
A resident with multiple medical conditions was observed with an indwelling urinary catheter bag positioned facing the room entrance and lacking a privacy cover, contrary to facility policy and the resident's care plan. An LPN confirmed the omission and acknowledged that this did not maintain the resident's dignity.
Two residents with significant care needs were found without accessible call bells, as one had the device hanging out of reach and another had it on the floor. An LPN confirmed in both cases that the call bells were not available for use, contrary to facility policy requiring such devices to be within reach at all times.
Two residents with complex medical needs had their beds placed against the wall without a physician order, individualized care plan, or documented safety evaluation. Facility policy requires these steps for any restraint use, and the DON confirmed these were not completed.
A resident's quarterly Minimum Data Set (MDS) assessment was not completed within the required timeframe, as it was signed eight days after the deadline. This delay was confirmed by the RN Assessment Coordinator.
Two residents with complex medical histories and documented tobacco use did not have care plans addressing smoking developed until after their needs were identified in assessments. The facility's failure to timely create these care plans was confirmed by the DON.
A resident with multiple diagnoses, including COPD and asthma, had documented allergies to milk and strawberries in physician orders, but these allergies were not reflected in the care plan summary used by nurse aides. The dietary manager confirmed the care plan was not revised to include this critical information.
A resident with multiple chronic conditions was given another resident's medications by an LPN who did not follow required identification and medication administration procedures. The error led to the resident experiencing hypoxia, vomiting, bradycardia, hypotension, and altered mental status, requiring emergency intervention and hospitalization. Facility investigation found that the LPN was distracted and did not use the mandated two-step identification process.
A resident with a history of cerebral infarction and dysphagia, who required direct supervision during meals per physician order, was left unattended with a meal tray in his room. This lack of supervision was confirmed by an LPN and the DON, representing a failure to follow physician orders and facility policy.
A resident with limited mobility and multiple diagnoses was observed using palm guards without a physician's order or care plan documentation. Staff confirmed the absence of required orders and care planning for the device, contrary to facility policy.
A resident with an enteral feeding tube did not receive care in accordance with facility policy when staff failed to date the feeding bottle upon opening and did not date the water bag used for flushes. An LPN confirmed the oversight, which resulted in a lack of appropriate treatment and services to prevent potential complications.
A resident with respiratory failure was observed receiving oxygen therapy with undated nasal cannula tubing and humidification bottle, and nebulizer equipment that was not stored properly or replaced as required. An LPN confirmed that facility policies and physician orders for respiratory care and equipment maintenance were not followed.
A resident with a history of constipation and other medical conditions went six days without a bowel movement and did not receive medications as ordered by the bowel protocol. The physician's progress note did not reflect these changes, and staff confirmed that the physician did not adequately review the resident's clinical record during the required visit.
A review of personnel files and staff interviews revealed that annual performance evaluations were not completed for three nurse aides, with the last appraisals conducted the previous year and no current evaluations on file. Human Resources confirmed the absence of up-to-date evaluations, resulting in a deficiency citation for staff development and licensee responsibility.
A special lunch menu, adapted from a cook-off competition recipe, was served to residents without prior review and approval by a registered dietitian, as required. The menu and its nutritional substitutes were not signed off by the RD before being implemented.
A resident with multiple diagnoses was admitted to hospice care with a plan for twice-weekly visits by a hospice RN and NA. Review of records showed inconsistent documentation of these visits, and the DON confirmed the facility did not ensure proper coordination of hospice services to meet the resident's end-of-life care needs.
A resident diagnosed with influenza did not have a timely order for isolation or droplet precautions entered after hospital readmission, despite a recent positive flu test. Additionally, the facility lacked a surveillance plan to track and monitor residents who tested negative for influenza during an outbreak, as confirmed by staff and review of facility records.
The facility failed to provide adequate supervision and monitoring of elopement prevention devices, leading to an elopement incident involving a resident with dementia and other mental health issues. Another resident's Wanderguard was not monitored as required, despite a physician's order. The DON confirmed these lapses in supervision and monitoring.
The facility did not notify the Department about renovations in the Main Kitchen due to plumbing issues. The Dietary Staff used the adjacent PCH kitchen for food preparation, transporting meals back to the facility. A freezer truck was rented due to limited freezer space. The DON confirmed the lack of notification to the Department.
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program, as observed during a survey. A resident requested the Ombudsman's email, which was missing from the posted information. The Nursing Home Administrator confirmed the omission, acknowledging the lack of required details.
The facility failed to maintain confidentiality of residents' medical information on the Geriatric Rehabilitation Unit. An unattended medication cart with an open computer screen displayed identifiable resident information, violating privacy regulations. This was confirmed by an LPN and the DON.
A resident admitted with a tracheostomy and other complex medical conditions did not have a baseline care plan developed within the required timeframe. The facility's policy mandates an individualized care plan within 24 hours of admission, but this was not done, as confirmed by the DON.
A facility failed to obtain a physician's order for tracheostomy care for a resident, resulting in inadequate care. The resident's daughter was observed performing unsafe suctioning procedures, prompting staff intervention. The Director of Nursing confirmed the oversight in obtaining the necessary order upon admission.
The facility failed to update care plans for two residents, resulting in inaccuracies regarding their current status. One resident's care plan did not reflect the discontinuation of a Wanderguard, while another's lacked updates for a Wanderguard and an elopement incident. The DON confirmed these deficiencies.
A resident with cognitive impairments eloped from the facility due to a faulty wanderguard system, despite having an intact and functioning wanderguard bracelet. The resident was found outside, intending to go to the post office and looking for her daughter. The facility's policy required proper assessment and care planning to prevent such incidents, but the Director of Nursing confirmed inadequate supervision.
The facility failed to communicate necessary resident information to receiving health care providers during transfers for five residents. Despite sending a manilla envelope with some documents, there was no documented evidence of communication of care plan goals, advanced directives, or specific care instructions. This deficiency was confirmed by the ADON during an interview.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the transfer of five residents to the hospital. Despite various medical conditions, there was no documented evidence of required notifications. Staff interviews revealed a lack of awareness and compliance with notification requirements.
The facility failed to update care plans for four residents to include interventions for elopement risk and Wanderguard use. Residents with dementia and other conditions were ordered Wanderguards due to wandering behaviors, but their care plans lacked necessary updates. Discrepancies in Wanderguard serial numbers were also noted. The Assistant DON confirmed the oversight.
The facility failed to monitor and document wounds for four residents, notify a physician of abnormal glucose readings for a resident with diabetes, and follow physician orders to monitor daily weights for a resident with heart failure. These deficiencies were confirmed through clinical record reviews and staff interviews.
The facility failed to provide trauma-informed care for four residents with PTSD, as their care plans did not identify or manage triggers to prevent re-traumatization. Despite having various medical conditions, the care plans lacked strategies to address PTSD, as confirmed by the Assistant Nursing Home Administrator.
The facility failed to properly store medications in two medication carts and one medication room. Undated and expired medications were found in the Pleasant Valley Back and Buttercup Back Hall Medication Carts, including insulin vials and inhalers. The Angel Wing Medication Room contained expired protein supplements and culture swabs. These deficiencies were confirmed by staff and acknowledged by the Nursing Home Administrator.
A facility failed to ensure a resident with severe cognitive impairment was properly informed about Medicare coverage and potential liabilities. Despite a BIMS score of 4 and a designated responsible party, the resident signed a Notice of Medicare Non-Coverage (NOMNC) form. The Discharge Nurse typically seeks responsible party signatures for residents with BIMS scores below 13, but this protocol was not followed. The Nursing Home Administrator confirmed the deficiency.
The facility failed to maintain the confidentiality of residents' medical information when a medication cart was left unattended with an open computer screen displaying identifiable information. This breach was observed and confirmed by an LPN and acknowledged by the Nursing Home Administrator, violating the facility's privacy policy and HIPAA regulations.
The facility failed to assess and document seatbelt use as restraints for two residents. One resident with traumatic brain injury and muscle wasting had a seatbelt ordered for security, but it was not included in their care plan. Another resident with rib fractures and falls had an alarming seatbelt, but no assessment confirmed their ability to self-release it. The ADON acknowledged these deficiencies.
A facility failed to provide a personalized activity program for a resident with a history of stroke, aphasia, and dementia. Despite documented preferences for activities like crafts and being outdoors, the resident was often found in bed sleeping, with no follow-up. Additionally, a required quarterly Activity Review was not completed, as confirmed by the Director of Activities.
A facility failed to provide colostomy care consistent with professional standards for a resident with a colostomy. The facility's policy requires ostomy appliances to be changed as needed, but there were no physician orders for colostomy care or monitoring of the stoma site. This was confirmed by the ADON, who noted the orders were likely not reordered after the resident's hospital return.
Failure to Follow Physician Orders for Nephrostomy Tube Care
Penalty
Summary
Surveyors identified that the facility failed to provide nephrostomy care and services consistent with physician orders for one resident. Facility policy titled "Ostomy Care" dated 4/17/25 stated that ostomy care would be provided for residents with a urostomy, colostomy, or ileostomy to maintain peristomal skin integrity, monitor the stoma, manage odor, and promote self-esteem. Resident R1 was admitted on an unspecified date and had diagnoses including obstructive uropathy, other toxic encephalopathy, and muscle weakness. Physician orders dated 12/31/25 directed that the resident’s left nephrostomy tube be flushed daily in the morning with 10 mL normal saline solution (NSS) to keep the tube patent, and as needed, by an RN only. Review of the MAR/TAR for February 2026 showed that the ordered morning nephrostomy tube flushes were missed on three days (2/2/26, 2/5/26, and 2/6/26). The clinical record, including progress notes, did not contain any explanation for why the flushes were not administered as ordered, nor any documentation that staff attempted to complete the flushes later in the day if they were not done in the morning. During an interview on 2/24/26 at 3:06 p.m., the DON was informed that the facility had failed to provide nephrostomy care and services consistent with the physician’s orders for this resident, constituting noncompliance with 28 Pa. Code 211.10(c) and 211.12(d)(1)(2)(5).
Resident Left Unattended in Shower Chair Resulting in Fall and Head Laceration
Penalty
Summary
The facility failed to protect a resident from neglect by not providing adequate supervision during a transfer, resulting in a fall with injury. The resident had been admitted with diagnoses including cerebral infarction, encephalopathy, and a urinary tract infection, and had physician orders requiring the assistance of two staff members for transfers. The resident’s care plan identified a moderate risk for falls related to deconditioning and gait/balance problems. On the day of the incident, a nurse aide (Employee E1) assisted the resident with a shower, placed the resident in a shower chair, completed the shower, and returned the resident to the room in the shower chair. According to the nurse progress note and investigative documents, Employee E1 left the resident unattended in the shower chair in the room while going to obtain a Hoyer lift for transfer back to bed. During this time, the resident fell from the shower chair and sustained a head laceration that required transfer to the hospital. Witness statements from nursing staff documented that Employee E1 acknowledged he did not ask anyone to stay with the resident, that no one was with the resident while he went to get the lift, and that he knew residents should not be left unattended in a shower chair. Other nurse aides interviewed stated they knew not to leave a resident alone in a shower chair and would refer to the kardex or nurse for care instructions. The DON confirmed that the facility neglected to provide proper supervision for the resident, resulting in a fall with injury.
Failure to Prevent Elopement Due to Inadequate Supervision and Lapses in Elopement Protocol
Penalty
Summary
The facility failed to provide adequate supervision and accident hazard prevention for two residents identified as high risk for wandering, resulting in both residents eloping from the facility. For one resident with diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, the initial admission assessment identified a high risk for wandering, but there was no documented evidence that elopement or wandering interventions were developed or implemented after this determination. The resident was able to exit the building unsupervised, with staff only becoming aware after being notified by the resident's family. Staff interviews and witness statements confirmed that the resident was found outside the facility, and it was later discovered that a wander guard device had not been placed on the resident at admission, despite the high-risk assessment. Another resident, with diagnoses of high blood pressure, anxiety, and depression, also demonstrated exit-seeking behavior and was identified as an elopement risk. The care plan included interventions such as issuing a wandering device and frequent monitoring, but the resident was able to leave the building and was found outside in the parking lot by staff. Documentation revealed that the resident had previously cut off a wander guard device, and at the time of the elopement, the device was not found on the resident. Staff statements indicated confusion about the monitoring of the front entrance, and the door was found to be unlocked and unattended at the time of the incident. The facility's failure to implement and maintain effective elopement prevention measures, including the timely application of electronic monitoring devices and adequate supervision, directly resulted in both residents leaving the premises without staff knowledge. The lack of consistent communication, incomplete documentation, and lapses in monitoring procedures contributed to the residents' ability to elope, creating an immediate jeopardy situation as determined by the surveyors.
Removal Plan
- The facility Administrator, and or designee, will review current elopement policy for accuracy and update as needed.
- All residents will be evaluated for risk of elopement by the facility Director of Nursing, or designee.
- Any new identified residents as at risk of elopement will receive orders from physician for use of wanderguard bracelet and care plan will be updated accordingly by facility Director of Nursing, or designee.
- An audit of all residents identified as at risk for elopement will have their care plan reviewed to ensure resident centered interventions are in place, completed by facility Director of Nursing, or designee.
- All staff, both facility and agency, will be educated by the facility Director of Nursing, or designee, regarding elopement policy, identifying residents at risk, and implementing interventions.
- The facility Administrator and Director of Nursing will complete a root cause analysis as to what system failed allowing this elopement to occur.
- Facility Administrator and Director of Nursing will review the procedure on the front door monitoring, this to include functionality of wanderguard system, as well as the schedule of personnel monitoring front entrance.
- The front door wanderguard codes have been changed and code knowledge limited to administrative staff.
- Facility door will be secured and code use will be required for entry or exit. Compliance will be monitored through audits.
- Audits will consist of door security assessment by facility Administrator, or designee, audit of resident risk assessments will be completed by the facility Director of Nursing, or designee, and an audit of all resident care plans who were identified at risk of elopement will be completed by the Director of Nursing, or designee.
- Results will be reviewed at QAPI (Quality Assurance and Performance Improvement Committee) to be completed by NHA.
Failure to Prevent Resident Elopement Creates Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of two residents. Review of job descriptions, clinical records, and staff interviews revealed that both the NHA and DON did not fulfill their essential job duties to ensure compliance with federal and state regulations, specifically in preventing resident elopement. The incident created an immediate jeopardy situation for two of the 33 residents in the facility. The NHA and DON were notified of their failure to prevent the elopement, which was determined to be a result of inadequate management and supervision as outlined in their respective job descriptions.
Incomplete Medical Record Documentation for Deceased Resident
Penalty
Summary
The facility failed to ensure that medical records for each resident were complete and accurately documented, as required. Specifically, for one resident with diagnoses including malignant neoplasm of the kidney, major depressive disorder, and hypertension, the clinical record review showed that the resident ceased to breathe on a specified date and time. However, there was no nurse progress note documented for the date when the resident ceased to breathe. This omission was confirmed by the Director of Nursing during an interview, acknowledging that the medical record was incomplete and not accurately documented for this resident.
Failure to Prevent Elopement Due to Unsecured Exit Door
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of wandering and elopement risk was able to exit the facility without staff knowledge. The resident, who had diagnoses including dementia and age-related cognitive decline, was assessed as severely impaired on the Brief Interview for Mental Status (BIMS) and was identified as an elopement risk in the care plan. The care plan included interventions such as a functioning wander guard device, monitoring for wandering patterns, and providing structured activities. Despite these measures, the resident was able to leave the secured area. The incident took place when the resident accessed an employee breakroom door that was supposed to be locked. However, the door's latch had been blocked by a paper towel, preventing it from locking. This allowed the resident to pass through the breakroom, into a wheelchair supply room, and then out an external door that led to the parking lot and another building. Surveillance footage confirmed the resident exited the facility, walked through the parking lot, and attempted to open a parked car before entering a nearby personal care building. Staff only became aware of the resident's absence after being notified by a hospice nurse aide in the personal care building. At the time of the event, the resident's wander guard was functioning properly, but there were no sensors on the breakroom door, as it was assumed to be secured by a lock. Staff interviews and facility documentation confirmed that the resident was last seen in the dining room area shortly before the elopement and that the doors in question were not properly secured due to the obstructed latch. The facility's failure to ensure that all exit doors were secured and to provide adequate supervision resulted in the resident's unsupervised exit from the building.
Significant Medication Errors Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with osteoporosis, hip fracture, and arthritis was prescribed Fosamax 70 mg once every seven days, but due to an error in order entry by a registered nurse, the medication was administered daily for five days within a seven-day period. This error was discovered after the resident had already received multiple incorrect doses, prompting notification of the provider and the resident's family, who requested hospital evaluation. In the second incident, another resident with a history of coronary artery disease, Alzheimer's disease, and cerebrovascular accident received a full set of medications intended for a different resident. The medications included a combination of narcotics, blood pressure medications, anticoagulants, diabetic medications, and others. The error was identified after the resident exhibited symptoms such as hypoxia, vomiting, bradycardia, hypotension, and altered mental status. Emergency services were called, and the resident required administration of Narcan, atropine, and IV fluids before being transferred to the hospital for further observation and management. Interviews with staff revealed that the LPN responsible for the second incident was distracted during medication administration and was not adequately trained on using resident photos for identification or on best practices such as bringing the medication cart to each resident's room. The facility's policies required verification of the five rights of medication administration and use of two identification methods, but these procedures were not followed, resulting in significant medication errors and actual harm to the residents involved.
Failure to Monitor Food Storage Temperatures and Maintain Kitchen Sanitation
Penalty
Summary
The facility failed to monitor and maintain records of refrigeration and freezer temperature logs, which are necessary to ensure that refrigeration and freezers function properly. During an observation of the portable freezer, it was found that the facility did not document freezer temperatures twice daily as required. The Dietary Manager confirmed that proper monitoring and documentation of freezer temperatures had not been conducted. Additionally, the facility did not properly maintain cleanliness and sanitation in the kitchen areas. Observations revealed a build-up of dust, grime, and dark debris on the cold air condenser fan covers in the walk-in cooler, as well as grime and dried food debris on the floor beneath shelving racks. In the Cook's Prep reach-in cooler, there was a build-up of black, fuzzy debris on the top coated wire shelving. The Dietary Manager confirmed these sanitation and cleanliness failures.
Failure to Maintain Emergency Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that essential emergency equipment, including three crash carts and one AED, were maintained in safe operating condition. Observations revealed that the GRU, Angel Wing, and Buttercup crash carts contained multiple expired supplies such as nebulizer kits, non-rebreather masks, suction canisters, IV catheters, and distilled water. Additionally, the oxygen tanks on the Angel Wing and Buttercup crash carts were found to be empty. Documentation reviews showed that required daily and monthly checks of the crash carts were not consistently performed or recorded, with several dates missing from the checklists. In some cases, the crash cart checklists were not present on the carts as required by facility policy. The facility's only AED was observed to display a red X, indicating it was not ready for use. Staff interviews confirmed the findings and acknowledged that the AED and crash carts were not in safe operating condition. The facility policy required that emergency carts be stocked, locked, and checked regularly, with documentation maintained, but these procedures were not followed as evidenced by the expired supplies, empty oxygen tanks, and lack of proper documentation.
Failure to Communicate Resident Information and Bed-Hold Policy During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. Specifically, for these residents, there was no documented evidence that information such as care plan goals, advanced directive details, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' needs at the receiving facility was provided at the time of transfer. This was confirmed through clinical record review and staff interviews, which indicated that the required transfer documentation was not completed or sent as per facility policy. Additionally, the facility did not provide written notification of the bed-hold policy to residents or their representatives at the time of hospital transfer for three residents. Clinical record reviews showed no evidence that the required bed-hold policy notice was given or mailed within the specified timeframe outlined in facility policy. Staff interviews further confirmed that this notification was not completed for any of the sampled residents who were transferred to the hospital.
Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed within the required time frames for five of six residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed within 14 calendar days of admission, and an annual MDS assessment must be completed no later than 14 days after the Assessment Reference Date (ARD). Review of clinical records showed that several MDS assessments were completed past these required deadlines. Specifically, one resident's annual MDS was completed two days late, another's admission MDS was completed seven days late, and additional residents had MDS assessments completed between one and eleven days after the required due dates. These findings were confirmed by the Registered Nurse Assessment Coordinator during a staff interview, who acknowledged that the facility did not complete the required MDS assessments within the mandated time frames.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For one resident with diagnoses including anemia and paraplegia, the MDS indicated anticoagulant use during the 7-day look-back period, but the clinical record did not contain a physician order for any anticoagulant medication. This was confirmed as a coding error by the Registered Nurse Assessment Coordinator. Another resident, with diagnoses of epilepsy, diabetes mellitus, and major depressive disorder, was admitted to hospice services per physician order, but the MDS assessment did not reflect hospice care during the 14-day assessment period. The Licensed Practical Nurse Assessment Coordinator acknowledged this as an entry error. A third resident, diagnosed with anemia and hemiplegia, had their MDS coded to indicate daily use of a physical restraint (chair prevents rising), but the clinical record lacked any physician order or assessment for restraint use. The Director of Nursing stated that the facility is restraint-free and believed the resident used a regular wheelchair. The LPN Assessment Coordinator confirmed the MDS was incorrectly coded for restraint use. The Nursing Home Administrator and Director of Nursing confirmed that the MDS assessments for these three residents did not accurately reflect their status.
Failure to Provide Care per Physician Orders and Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for three residents. For one resident with diabetes, there were multiple instances of significantly elevated blood glucose levels, as documented in the clinical record, but there was no evidence that the physician was notified as required by the sliding scale insulin order. The Director of Nursing confirmed that the facility did not document physician notification for these high blood glucose readings, indicating a failure to follow the prescribed protocol for managing hyperglycemia. Another resident with a history of constipation and on scheduled narcotics did not receive bowel management interventions as outlined in the facility's bowel protocol. Despite several days without a bowel movement, the medication administration record did not show that the required medications were given according to the protocol. Staff interviews confirmed that the bowel protocol should have been initiated and that the clinical record would alert staff to the need for intervention, but this was not done in a timely manner for this resident. A third resident with a wound vac for a pressure ulcer had physician orders for wound vac management but did not have orders for an alternative dressing method, such as wet-to-dry, in the event the wound vac became inoperable. Staff confirmed that there was no such order in place. The lack of an alternative treatment order meant that appropriate care could not be ensured if the wound vac failed, as required by the resident's care plan and physician orders.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to four residents diagnosed with Post Traumatic Stress Disorder (PTSD). Review of the residents' clinical records and care plans revealed that the facility did not identify or address individual trauma triggers for these residents. Specifically, the care plans for each resident with a PTSD diagnosis did not include information on their specific triggers or strategies to avoid them. In one case, a resident's care plan included general interventions such as asking about trauma and involving the social worker, but still failed to identify individualized triggers. Additionally, inconsistencies were found in the documentation, such as a social service assessment indicating no history of PTSD despite other records confirming the diagnosis. Interviews with the Director of Social Services confirmed that the process for identifying trauma history and triggers was not consistently followed, resulting in the lack of individualized care planning for trauma survivors. The deficiency was identified for all four residents reviewed, each with a documented history of PTSD and other medical conditions such as high blood pressure, chronic pain, depression, anxiety, and anoxic brain injury. The failure to provide trauma-informed care was confirmed by facility staff and supported by the review of clinical records and care plans.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals in multiple medication rooms and carts. Observations revealed that several inhalers belonging to different residents were not dated upon opening on the Angel Wing Back Hall Medication Cart. Additionally, the temperature log for the Angel Wing Medication Room refrigerator had several dates with missing temperature recordings, and expired medical supplies, including IV catheters and syringes, were found stored in the same room. In the GRU Medication Room, a COVID vaccine was observed in the refrigerator past its expiration date. Furthermore, on the GRU Back Hall Medication Cart, an insulin pen and an inhaler were not stored in bags as required. Staff interviews with LPNs confirmed these findings and acknowledged the facility's failure to adhere to its own medication storage policies. The deficiencies were identified through direct observation and review of facility records, including temperature logs and medication labeling, and were corroborated by staff at the time of the survey.
Failure to Maintain Resident Dignity with Catheter Bag Privacy
Penalty
Summary
The facility failed to maintain resident dignity by not ensuring that a privacy cover was applied to a resident's indwelling urinary catheter bag, as required by facility policy. The resident, who had diagnoses including high blood pressure, diabetes, and respiratory failure, was observed with the catheter bag hanging on the right side of the bed, facing the entrance to the room, and without a privacy cover. The resident's care plan specified that the catheter bag should be positioned away from the entrance and secured with a leg strap, but this was not followed. During staff interview, an LPN confirmed that the catheter bag did not have a privacy cover and acknowledged the failure to provide care in a manner that maintained the resident's dignity.
Failure to Ensure Call Bell Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the call bell needs for two residents, as required by its own policy and state regulations. For one resident with diagnoses including high blood pressure, dementia, and a need for assistance with personal care, the call bell was observed hanging from the wall unit at the head of the bed, out of the resident's reach. This was confirmed by an LPN, who acknowledged that the call bell was not accessible or available for the resident's use. A second resident, who had diagnoses of anemia, hemiplegia, and muscle weakness, was observed with their call bell on the floor, also out of reach. This was similarly confirmed by the same LPN, who stated that the call bell was not accessible or available for use. These findings demonstrate that the facility did not ensure that call bells or alternative communication devices were within reach for residents when unattended, as required by facility policy.
Failure to Obtain Physician Order and Care Plan for Bed Placement Against Wall
Penalty
Summary
The facility failed to obtain a physician order, develop a resident-centered care plan, and assess resident safety for the placement of beds against the wall for two residents. For one resident with dementia, repeated falls, and difficulty walking, the bed was observed pushed against the wall without documentation of a safety evaluation, physician order, or care plan addressing this arrangement. Similarly, another resident with high blood pressure, difficulty swallowing, and chronic pain was found with the bed against the wall, and stated that this placement was not requested. The clinical record for this resident also lacked evidence of a safety evaluation, physician order, or care plan for the bed placement. Facility policy prohibits the use of restraints for discipline or convenience and requires that restraints only be used as a last resort when medically necessary. The Director of Nursing confirmed that the required steps—physician order, individualized care plan, and safety assessment—were not completed for either resident regarding the bed placement against the wall.
Late Completion of Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for one resident. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly MDS assessments must be completed no later than 14 calendar days after the Assessment Reference Date (ARD). For one resident, the quarterly ARD was set, and the assessment was due by a specific date, but the MDS was not signed as completed until eight days after the required deadline. This failure was confirmed by the Registered Nurse Assessment Coordinator during an interview.
Failure to Timely Develop Comprehensive Care Plans for Tobacco Use
Penalty
Summary
The facility failed to develop comprehensive care plans to address the needs of two residents who used tobacco products or vaping devices. For both residents, clinical records and assessments indicated tobacco use, but there was no documentation of a care plan related to smoking until a specific date. This gap in care planning meant that the residents' needs and choices regarding tobacco use were not addressed in a timely manner, as required by facility policy and state regulations. Both residents had significant medical histories, including diagnoses such as high blood pressure, PTSD, anemia, paraplegia, and muscle weakness. Despite these conditions and the identified tobacco use, the care plans for smoking were not developed until after the initial assessments and documentation. The Director of Nursing confirmed that the facility did not create comprehensive care plans to meet the care needs of these residents prior to the identified date.
Failure to Update Care Plan for Resident Food Allergies
Penalty
Summary
The facility failed to revise the care plan for a resident to accurately reflect current food allergies. The resident was admitted with diagnoses including adult failure to thrive, chronic obstructive pulmonary disease, and asthma. Physician orders documented that the resident had allergies to milk and strawberries and required a regular, easy-to-chew diet. However, review of the resident's care plan summary report did not list any allergies. This omission was confirmed by the dietary manager during staff interview, indicating that the care plan was not updated as required to include the resident's food allergies.
Medication Administration Error Due to Failure in Resident Identification
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to administer medications according to professional standards, resulting in a resident receiving another resident's medications. Facility policy required staff to verify the '5 Rights' of medication administration and use two identification methods before giving medications. However, the LPN did not follow these procedures, and instead, administered a full set of medications intended for a different resident to the affected individual. The resident who received the incorrect medications had a medical history including coronary artery disease, Alzheimer's disease, and a previous stroke. After receiving the wrong medications, the resident exhibited symptoms such as hypoxia, vomiting, bradycardia, hypotension, and altered mental status. Emergency services were called, and the resident was treated with Narcan, atropine, and IV fluids before being transported to the hospital for further evaluation and management. The medications administered in error included a combination of narcotics, blood pressure medications, anticoagulants, diabetic medications, and other drugs, totaling 18 different medications. Interviews and facility investigation revealed that the LPN became distracted during the medication pass and did not use the required identification checks. The LPN was unaware of the best practices for medication administration, such as bringing the medication cart to each resident's room and verifying resident identity with photos in the electronic medical record. The Director of Nursing confirmed that the facility failed to provide care and services in accordance with accepted standards of practice by not ensuring medications were administered to the correct resident.
Failure to Provide Ordered Meal Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dysphagia, and abnormal posture was not provided with the required supervision during meals as ordered by the physician. The resident's care plan indicated a need for assistance with meals, noting resistance to help, and the physician order specified direct supervision for feeding. Despite these documented needs, the resident was observed alone in his room with his lunch tray, without any staff supervision. This lack of supervision was confirmed by both an LPN and the Director of Nursing, indicating a failure to follow physician orders and facility policy regarding meal supervision for this resident.
Failure to Document and Manage Use of Palm Guards for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Specifically, a resident with diagnoses including difficulty swallowing, anoxic brain injury, and muscle weakness was observed wearing palm guards on both hands. However, a review of the clinical record did not reveal a physician's order for the palm guards, nor was there documentation in the care plan regarding their use and management. Further investigation, including staff interviews, confirmed that the facility did not obtain a physician's order for the palm guards and failed to include their care and management in the resident's care plan. This lack of documentation and oversight was in violation of the facility's own Restorative Nursing policy, which requires physician orders and care plan documentation for restorative devices such as splints or braces.
Failure to Date Enteral Feeding Supplies for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services to prevent potential complications. According to the facility's policy, all staff are required to follow basic guidelines for enteral feeding. Clinical record review showed that the resident had diagnoses including anemia, hemiplegia, and muscle weakness, and had a physician's order for Jevity 1.5 tube feeding via gastric tube. During an observation, the enteral feeding bottle in use for the resident was found to be labeled with an expiration date but did not have the date it was opened, and the water bag used for flushes was not dated at all. In an interview, an LPN confirmed that the bottle should have been dated when opened and acknowledged the failure to follow proper procedures, resulting in the resident not receiving care in accordance with facility policy and standards.
Failure to Provide Appropriate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with diagnoses including high blood pressure, diabetes, and respiratory failure. Facility policy required that nasal cannulas and nebulizer equipment be dated, stored properly, and replaced every seven days. Physician orders also specified weekly changes for nebulizer cups, tubing, hand-held nebulizers, nasal cannulas, and protective covers, as well as proper storage and dating of equipment. During observation, the resident was found receiving oxygen via nasal cannula with no date on the tubing or humidification bottle. The nebulizer machine was present on the bedside table, with the mouthpiece left out and not stored in a bag as required. The connecting tubing was dated nearly a month prior, indicating it had not been replaced according to policy. An LPN confirmed these findings, acknowledging that the required respiratory care procedures were not followed for this resident.
Physician Failed to Review Resident's Total Program of Care
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care as required. Specifically, a resident with diagnoses including high blood pressure, phantom limb pain syndrome, and constipation experienced a period of six days without a bowel movement. The clinical record showed that the resident did not receive medications as ordered per the bowel protocol during this time. Despite this, the physician's progress note indicated there were no changes in bowel habits, and the resident was described as tending toward constipation with a fair appetite. Further review revealed that the registered nurse documented the absence of bowel movements for six days and noted hyperactive bowel sounds and decreased appetite. Interviews with facility staff, including a certified registered nurse practitioner and the director of nursing, confirmed that the physician did not adequately review the resident's clinical record, including bowel and eating patterns, during the required visit. This failure was identified for one of five residents reviewed.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of five nurse aides, as determined by a review of personnel records and staff interviews. Specifically, the personnel files for three nurse aides showed that their last performance evaluations were completed during the previous year, with no up-to-date appraisals available for the current year. During an interview, the Human Resources staff confirmed that the facility did not have current performance evaluations for these nurse aides. This deficiency was cited under 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development and 28 Pa Code: 201.14 (a) Responsibility of licensee.
Menu Served Without Dietitian Approval
Penalty
Summary
The facility failed to ensure that a registered dietitian reviewed and approved a special lunch menu and its nutritional substitutes prior to serving it to residents. On the date in question, the Dietary Manager prepared a special meal, Braised Beef Tips, for a cook-off competition and subsequently adapted the recipe to serve to residents for lunch. Review of the four-week menu cycle showed that this meal did not have a registered dietitian's signature of approval. The registered dietitian later confirmed that approval for the special menu was not obtained prior to serving.
Failure to Coordinate Hospice Services for End-of-Life Care
Penalty
Summary
The facility failed to ensure proper coordination of hospice services with facility services for a resident requiring end-of-life care. According to facility policy, hospice referrals should be initiated in accordance with resident and family wishes, with care coordinated among the resident's physician, pharmacy, and responsible party. The clinical record for a resident admitted with diagnoses including epilepsy, diabetes mellitus, and major depressive disorder indicated an order for hospice services, with a plan for a hospice RN and NA to visit twice weekly as part of contracted services. However, a review of both the clinical and hospice records did not show consistent documentation of hospice RN or NA visits at the frequency specified in the care plan from the start of hospice services through the review period. This lack of documentation and coordination was confirmed by the DON during an interview, indicating the facility did not meet the needs of the resident for end-of-life care as required.
Failure to Timely Enter Isolation Order and Incomplete Influenza Surveillance During Outbreak
Penalty
Summary
The facility failed to timely enter an order for isolation for a resident who had been diagnosed with influenza. The resident was admitted and later readmitted with diagnoses including influenza, anxiety, and depression. After returning from the hospital, the resident's physician orders did not include an order for isolation or droplet precautions on the days immediately following readmission, despite a recent positive flu test. This omission was confirmed through review of clinical records and staff interviews. Additionally, the facility did not have a surveillance plan in place to track and monitor residents who tested negative for influenza during an outbreak over a two-month period. The facility's line listing for respiratory illnesses only included residents who tested positive, and failed to document those who tested negative. Staff interviews confirmed that negative results were not being tracked as required by the facility's outbreak toolkit and policies.
Failure in Supervision and Monitoring of Elopement Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of elopement prevention devices, resulting in an elopement incident involving a resident with a history of wandering and dementia. The resident, who also had diagnoses of schizophrenia and PTSD, was found in the parking lot by a nurse who was leaving the facility. Despite having a care plan that included interventions for elopement risk, the resident managed to exit the building through the front door. The Director of Nursing confirmed that the facility did not provide adequate supervision, which led to the resident being outside the facility for approximately two to three minutes before being assisted back inside. Additionally, the facility did not adequately monitor the elopement prevention device for another resident who had a physician's order for a Wanderguard to be worn at all times. The clinical record for this resident, who was admitted with dementia and other health issues, did not show any documentation of staff checking the placement of the Wanderguard since its application. The Director of Nursing confirmed this lapse in monitoring, indicating a failure to adhere to the prescribed safety measures for residents at risk of elopement.
Plan Of Correction
0689-R 2 was transferred to a secure facility the following day. R 2 was not seen leaving the facility by the receptionist. Elopement binder available and up to date. Facility has wander guard system but R2 would not wear the wander guard bracelet. R 2's order has been fixed so that it is now visible on the treatment record and function and placement can be signed off as being verified. All residents who are identified as at risk for elopement will have their orders checked to ensure supplemental documentation is present and placement and function can be verified and documented on each resident's treatment record. Education to be provided to licensed nurses by the Director of Nursing, or designee, on the importance of ensuring supplemental documentation is completed in Point Click Care so that placement and function can be verified on each resident's treatment record. Each resident who has been identified as at risk of elopement will be audited for the next 60 days to ensure supplemental documentation is completed in Point Click Care so that placement and function can be verified on each resident's treatment record. Results of audits will be reviewed at the month QAPI meeting for tracking and trending purposes. The facility Director of Nursing shall ensure compliance.
Failure to Notify Department of Kitchen Renovations
Penalty
Summary
The facility failed to notify the Department of renovations made to the Main Kitchen, as required by regulations. Observations and staff interviews revealed that the facility had been experiencing plumbing issues in the Main Kitchen, with corroded sewer pipes causing sewage to leak back into the ground. As a result, the floor was removed, and plumbing repairs were initiated, which were still ongoing at the time of the survey. Despite these significant alterations, the facility did not inform the Department prior to commencing the renovations. During the renovation period, the Dietary Staff utilized the kitchen in the adjacent Personal Care Home (PCH) to prepare food for the facility's residents. The food was then transported back to the facility's Main Dining Room for tray line service. Due to limited freezer space in the PCH kitchen, a freezer truck was rented and placed in the facility's parking lot to accommodate the food supply. The Director of Nursing confirmed that the facility did not report these renovations to the Department, as required.
Plan Of Correction
2590 - Facility Administrator, or designee shall notify the Department of Health of replacement of sewer line and removed flooring above sewer lines in kitchen. The facility Administrator will be educated by the corporate manager, or designee, on proper notifications to the Department of Health. The facility Administrator will audit the nursing facility operations for possible notification requirements to the Department of Health for one month then weekly for two months. Results of audits will be reviewed at the month QAPI meeting for tracking and trending purposes. The facility Administrator shall ensure compliance.
Incomplete Ombudsman Contact Information Posted
Penalty
Summary
The facility was found to be non-compliant with the federal requirement to post complete contact information for the State Long-Term Care Ombudsman program. During an interview, a resident requested the email address of the Ombudsman, which was not available on the posted information in the hallway. The observation confirmed that the poster only included a phone number, lacking the name, address, and email address of the Ombudsman. The Nursing Home Administrator acknowledged the omission during an interview and observation, confirming that the facility failed to meet the requirement to post the Ombudsman's complete contact information. This deficiency was identified during an abbreviated survey conducted in response to a complaint, highlighting the facility's failure to provide residents with accessible and comprehensive contact details for pertinent state agencies and advocacy groups.
Plan Of Correction
F 575 - The Ombudsman's email address was added to the poster. Education will be provided to the Nursing Home Administrator by the Clinical consultant on what is required on the Ombudsman posting. An audit will be completed by the Nursing Home Administrator, or designee, on all mandatory postings to ensure all required information is present. An audit will be completed by the Nursing Home Administrator, or designee, weekly for two months to ensure all required information is present on the postings. Results of the audits will be reviewed at the monthly QAPI meeting for tracking and trending purposes. The Nursing Home Administrator shall ensure compliance.
Breach of Resident Confidentiality on Geriatric Rehabilitation Unit
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on the Geriatric Rehabilitation Unit. During an observation, it was noted that the medication cart beside the nurse's station was left unattended with the computer screen open, displaying identifiable resident information. This lapse in security allowed any passerby to view personal and confidential information, violating the residents' right to privacy. The incident was confirmed by a Licensed Practical Nurse and the Director of Nursing, who acknowledged the failure to protect residents' medical information as required by HIPAA and HITECH regulations. The facility's policy, dated 6/3/24, mandates the protection of residents' privacy rights and individually identifiable health information, which was not adhered to in this instance.
Plan Of Correction
F 583 - Employee 1 was educated by the Director of Nursing on the importance of closing the computer screen when walking away from the computer. Education will be provided by the Director of Nursing, or designee, to nursing staff on the importance of maintaining resident privacy and confidentiality while passing medications. A random audit will be completed by the Director of Nursing, or designee, to observe at least three medication carts three times a week for one month, then weekly for one month to ensure confidentiality and privacy is maintained during medication pass. Results of the audits will be reviewed at the monthly QAPI meeting for tracking and trending purposes. The Director of Nursing shall ensure compliance.
Failure to Develop Baseline Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to develop a baseline care plan for a resident, identified as Resident R1, who was admitted with significant medical needs. According to the facility's policy, an individualized, interdisciplinary care plan should be initiated within 24 hours of admission. However, upon review of Resident R1's clinical records, it was found that no baseline care plan was developed for the resident's tracheostomy care. This oversight was confirmed during an interview with the Director of Nursing. Resident R1 was admitted to the facility with a tracheostomy and had a physician's order for supplemental oxygen via trach mask. The resident's Minimum Data Set indicated diagnoses of cancer, malnutrition, and muscle weakness. Despite these complex medical conditions, the facility did not create a baseline care plan within the required timeframe, which is a violation of the regulatory standards for comprehensive person-centered care planning.
Plan Of Correction
F 655 - Resident 1 has been discharged from the facility. No corrective action can be completed. An audit of the last ten admissions will be completed by the Director of Nursing, or designee, to ensure baseline care planning is completed accurately. Education will be provided to the nursing staff by the Director of Nursing, or designee, on the expectation of baseline care planning to be completed at the time of the resident's admission. New admissions will be audited by the Director of Nursing, or designee, for two months to ensure the baseline care plan is completed accurately. Results of the audits will be reviewed at the monthly QAPI meeting for tracking and trending purposes. The Director of Nursing shall ensure compliance.
Failure to Obtain Physician's Order for Tracheostomy Care
Penalty
Summary
The facility failed to obtain a physician's order for tracheostomy care and suctioning for a resident with a tracheostomy, leading to inadequate care. The facility's policy required tracheostomy care to be performed at least once per shift, but this was not documented for the resident. The resident was admitted with a tracheostomy, as noted in hospital documentation, but the facility did not have an order for tracheostomy care or suctioning until several days after admission. The deficiency was further highlighted when the resident's daughter was observed performing unsafe suctioning procedures, including using saline and tweezers to remove secretions. The nursing staff intervened and informed the daughter that such procedures were unsafe. It was confirmed by the Director of Nursing that the facility did not obtain the necessary physician's order upon the resident's admission, resulting in a failure to provide the required tracheostomy care and suctioning.
Plan Of Correction
F 695 - Resident 1 has been discharged from the facility. No corrective action can be completed. All residents with a tracheostomy will be reviewed by the Director of Nursing, or designee, to ensure orders are present for both suctioning and tracheostomy care as appropriate. Education to be provided to licensed nursing staff by the Director of Nursing, or designee, on the importance of ensuring appropriate suctioning orders and tracheostomy care orders are present for residents with a tracheostomy. Each new admission of a resident with a tracheostomy will be reviewed by the Director of Nursing, or designee, to ensure appropriate suctioning orders and tracheostomy care orders are present for residents with a tracheostomy. Results of the audits will be reviewed at the monthly QAPI meeting for tracking and trending purposes. The Director of Nursing shall ensure compliance.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, resulting in deficiencies in accurately reflecting their current status. Resident R2, who was admitted with diagnoses including adult failure to thrive, Parkinson's disease, and neurocognitive disorder, had a Minimum Data Set (MDS) assessment indicating that these diagnoses remained current. However, the physician orders for Resident R2 dated 12/5/24 showed that the use of a Wanderguard safety device was discontinued on 11/4/24, yet the Resident Care Plan Summary Report still listed the resident as an elopement risk with an outdated wandering device intervention. Similarly, Resident R1, admitted with diagnoses such as encephalopathy, cognitive communication mood disorder, and dysphagia, had a physician order dated 11/15/24 for a Wanderguard to be used at all times. Despite this, the Resident Care Plan Summary Report dated 11/26/24 did not include the Wanderguard or any updates regarding an elopement incident. The Director of Nursing confirmed that the facility did not revise the care plans for these residents as required, leading to the identified deficiencies.
Resident Elopement Due to Faulty Wanderguard System
Penalty
Summary
The facility failed to provide adequate supervision for a resident, resulting in an elopement incident. The resident, who had diagnoses including encephalopathy, cognitive communication mood disorder, and dysphagia, was found sitting in the grass outside the facility, claiming to be headed to the post office and looking for her daughter. The facility's Resident Elopement policy, dated 6/3/24, indicated that residents should be properly assessed and their care planned to prevent accidents related to wandering behavior or elopement. However, the wanderguard system on the front entrance was found to be faulty, although the resident's wanderguard bracelet was intact and functioning properly when tested at another proximity sensor. The Director of Nursing confirmed that the facility did not properly supervise the resident as required.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five out of seven residents who were transferred from the facility to a hospital. The facility's policy, dated 6/3/24, required that a transfer form and appropriate documentation accompany the resident during a transfer. However, upon review of the clinical records, it was found that there was no documented evidence that specific information, such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information, was communicated for Residents R41, R49, R68, R116, and Closed Resident Record CR134. Resident R41, who had diagnoses of high blood pressure, heart failure, and depression, was transferred to a hospital on 2/22/24. Similarly, Resident R49, with high blood pressure, heart failure, and diabetes, was transferred on 6/12/24. Resident R68, diagnosed with high blood pressure, unsteadiness on feet, and depression, was transferred on 5/5/24. Resident R116, with high blood pressure, atrial fibrillation, and end-stage renal disease, was transferred on 12/8/23. Closed Resident Record CR134, who had high blood pressure, hyperlipidemia, and muscle weakness, was transferred on 5/26/24 and did not return to the facility. In each case, there was no evidence that the necessary information was communicated to the receiving facility. During an interview, the Assistant Director of Nursing (ADON) confirmed that the facility sent a manilla envelope with residents to the hospital, which included a POLST form, two copies of the face sheet, and a copy of the MAR. However, the ADON acknowledged that there was probably no documentation about what was sent unless it was noted in a progress note. This lack of documentation and communication was confirmed as a failure to meet the requirements for facility-initiated transfers.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of five residents to the hospital. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The residents involved had various medical conditions, including high blood pressure, heart failure, depression, diabetes, unsteadiness on feet, atrial fibrillation, end-stage renal disease, hyperlipidemia, and muscle weakness. Despite these transfers, there was no documented evidence that the required written transportation notifications were sent to the Ombudsman for these hospitalizations. Interviews with facility staff, including the Social Services Director, revealed a lack of awareness and compliance with the requirement to notify the Ombudsman of such transfers. The Social Services Director admitted to not sending notifications for hospital transfers and discharges, as they were not requested monthly. This oversight affected five out of seven residents reviewed, indicating a systemic issue in the facility's notification process, as required by 28 Pa. Code 201.29 (a) (c.3) (2) regarding resident rights.
Failure to Update Care Plans for Elopement Risk and Wanderguard Use
Penalty
Summary
The facility failed to ensure that the care plans for four residents were updated and revised to reflect their specific care needs. Resident R23, who was diagnosed with dementia, repeated falls, and diabetes, exhibited wandering behavior and was ordered to have a Wanderguard. However, the care plan did not include goals and interventions for elopement risk and Wanderguard implementation. Similarly, Resident R38, with high blood pressure and dementia, was also ordered to have a Wanderguard due to exit-seeking behavior, but the care plan lacked the necessary updates for elopement risk and Wanderguard use. Resident R78, diagnosed with high blood pressure, dementia, and muscle weakness, had a discrepancy in the Wanderguard serial number in the care plan, which was not updated to reflect the current device. Resident R337, with dementia and muscle weakness, was also ordered to have a Wanderguard, but the care plan did not include interventions for elopement risk. The Assistant Director of Nursing confirmed that the facility did not update the care plans as required, leading to the deficiency.
Failure to Monitor Wounds, Notify Physician, and Document Weights
Penalty
Summary
The facility failed to monitor and document the wounds of four residents, as well as complete weekly skin assessments as required by their policy. Resident R52 had a wound on the right foot second toe, which was not documented for the week of 8/12/24, and there was no care plan for this wound. Similarly, Resident R66's right above knee amputation site was not documented for the weeks of 8/5/24 and 8/12/24. Resident R88's wound on the right side of the head/neck was not documented for the weeks of 7/29/24, 8/5/24, and 8/12/24, and there was no care plan for this wound. Resident R96's left buttock wound was not documented for the weeks of 8/5/24 and 8/12/24, and there was no care plan for this wound. The facility also failed to notify a physician of abnormal glucose readings for Resident R49, who had multiple blood glucose levels above 401 mg/dl, as per the physician's order. The blood glucose levels recorded on 7/7/24, 7/13/24, 7/23/24, 7/25/24, 8/6/24, and 8/10/24 were all above the threshold, yet there was no documentation of physician notification. This oversight was confirmed by the Assistant Director of Nursing (ADON) during an interview. Additionally, the facility did not follow physician orders to monitor daily weights for Resident R116, who had a physician order to document daily weights and notify the physician of any significant weight changes. The weight records from 8/11/24 to 8/20/24 showed multiple days where no weight was obtained, and there was no indication that the resident refused to have their weight taken. This failure to document and monitor was also confirmed by the ADON.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to four residents diagnosed with PTSD, as evidenced by the lack of identification and management of triggers in their care plans. The facility's social worker was responsible for conducting social evaluations and planning interventions, but the care plans for these residents did not address PTSD or strategies to avoid potential triggers. This oversight was confirmed during an interview with the Assistant Nursing Home Administrator. The residents involved had various medical conditions alongside PTSD, including high blood pressure, malnutrition, difficulty walking, and unsteadiness on feet. Despite these diagnoses, the care plans reviewed on a specific date did not include any measures to mitigate or eliminate triggers that could lead to re-traumatization. This deficiency was identified through a review of facility policies, resident records, and staff interviews, highlighting a failure to comply with federal, state, and local regulations regarding trauma-informed care.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to properly store medications in two out of three medication carts and one of three medication rooms. Specifically, the Pleasant Valley Back Medication Cart contained Resident R88's Novolog insulin multi-dose vial, Novolog insulin pen, and Lantus insulin pen, all of which were not dated upon opening. This was confirmed by LPN Employee E4 during an observation. Additionally, the Buttercup Back Hall Medication Cart had expired or undated medications, including Resident R60's expired Ellipta inhaler, Resident R98's undated Ellipta inhaler, and Resident R110's expired Brimonidine eye drops. A drawer in this cart was also found to have liquid and powder residue, as confirmed by LPN Employee E7. In the Angel Wing Medication Room, two bottles of ProSource protein supplement and several culture swabs were found to be expired. These observations were confirmed by RN Employee E8. The Nursing Home Administrator acknowledged the facility's failure to properly store medications in the specified carts and medication room. The deficiencies were noted to be in violation of specific Pennsylvania Code regulations related to pharmacy and nursing services.
Failure to Ensure Informed Consent for Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that residents were properly informed about their Medicare coverage and potential liabilities for services not covered, specifically in the case of one resident. The deficiency was identified through a review of facility admission documents and staff interviews. The resident in question, who was admitted to the facility with severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 4, signed a Notice of Medicare Non-Coverage (NOMNC) form. This was despite the fact that the resident was not oriented to time or location, as noted in a physician's report, and had a designated responsible party, his son, who should have been involved in the decision-making process. During interviews, the Discharge Nurse responsible for issuing the NOMNC forms stated that she typically has residents sign the form if their BIMS score is 13 or above, and otherwise seeks the signature of the responsible party unless a doctor confirms the resident's decisional capacity. However, in this case, the facility did not ensure that the NOMNC was explained in a manner understandable to the resident or his representative, leading to a failure in upholding the resident's rights to make informed decisions. This was confirmed by the Nursing Home Administrator and the Assistant Nursing Home Administrator.
Failure to Maintain Confidentiality of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of its units, specifically the Pleasant Valley Back Medication Cart. During an observation, it was noted that the medication cart was left unattended with the computer screen open, displaying identifiable resident information that could be seen by any passerby. This incident was confirmed by a Licensed Practical Nurse and later acknowledged by the Nursing Home Administrator. The facility's policy, dated 6/3/24, mandates the protection of residents' privacy rights and compliance with HIPAA and HITECH regulations, which was not adhered to in this instance.
Failure to Assess and Document Seatbelt Use as Restraints
Penalty
Summary
The facility failed to properly assess and document the use of seatbelts as potential restraints for two residents, leading to deficiencies in compliance with restraint policies. Resident R2, who has a history of traumatic brain injury, difficulty swallowing, and muscle wasting, was noted to have a trunk restraint when in a chair or out of bed, used less than daily. Despite a physician's order for a seatbelt for security during transport and position changes, the facility did not include the use of a seatbelt in Resident R2's care plan. Similarly, Resident R99, who has multiple rib fractures, repeated falls, and malnutrition, was ordered to have an alarming seatbelt at all times while out of bed to chair. Although the Assistant Director of Nursing (ADON) stated that Resident R99 could remove the seatbelt independently, there was no documented assessment to confirm this ability. The ADON confirmed that the facility failed to assess Resident R99 for the use of a seatbelt to rule out its classification as a restraint and did not develop a resident-centered care plan for Resident R2's seatbelt use.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and support the physical, mental, and psychosocial well-being of Resident R90. This resident, who has a history of cerebrovascular accident, aphasia, and dementia, was noted to have specific preferences for activities, including enjoying crafts, country music, and being outside. Despite these documented preferences, the facility did not ensure that Resident R90 participated in activities, as evidenced by the resident being in bed sleeping 19 times in July and 16 times in August, with no follow-up documented. Additionally, the facility did not complete a quarterly Activity Review for Resident R90 from April through June 2024, which is a requirement to assess and adjust the activity program to better meet the resident's needs. The Director of Activities confirmed these deficiencies, acknowledging the failure to provide a consistent and personalized activity program for Resident R90, which is necessary to support the resident's overall well-being.
Failure to Provide Colostomy Care Consistent with Standards
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for a resident identified as R76. The facility's policy on ostomy care, dated 6/3/24, requires that ostomy appliances be changed as needed to maintain the integrity of the peristomal skin, manage odor, and promote the resident's self-esteem. However, upon review of Resident R76's current physician orders, there were no orders for colostomy care, monitoring of the stoma site, or specifications for the size and type of appliances used. This oversight was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged the absence of necessary orders, suggesting they were not reordered following the resident's return from the hospital. Resident R76, who was admitted with diagnoses including high blood pressure, depression, and heart failure, was observed to have a colostomy. The resident's care plan, dated 3/28/24, included instructions to monitor the skin around the stoma site with each change and report any abnormal findings. Despite these care plan directives, the lack of physician orders for colostomy care indicates a failure to adhere to the facility's policy and professional standards, as confirmed by the ADON during the surveyor's investigation.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
