Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quality Life Services - Markleysburg during CMS and state inspections, most recent first.
Failure to safely temperature hot water before serving it to a resident resulted in actual harm. A resident with moderate cognitive impairment and mobility weakness asked for hot water for coffee while in bed; an NA got water from the coffee machine, placed a lid on the cup, and handed it to him without checking the temperature. The resident removed the lid, spilled the water on himself, and sustained burns to the abdomen and pelvic area, with wound documentation showing multiple burn areas and treatment ordered for second-degree burns.
Residents reported fear of retaliation when raising complaints or grievances. One resident would not be interviewed unless assured their name would not be shared, while others said they did not want to upset staff, feared call bells or care would be ignored, or worried staff would be mean to them. The NHA and DON confirmed the facility failed to ensure residents did not feel retaliated against when voicing concerns.
The facility failed to employ a qualified Food Service Director to manage Dietary operations for 12 of 12 months. The Dietary Supervisor stated she was the manager and was still working on CDM certification, while the RD said she only comes to the facility about once a week and works at multiple facilities. The Dietary Supervisor and RD confirmed there was no CDM and no full-time RD, and the facility did not show evidence that any staff met the qualifications for the Food Service Director role.
A facility failed to provide menus that reflected resident preferences and were updated to avoid repeated food choices. During a resident council meeting, residents said the same foods were served over and over and that they feared retaliation if they raised concerns. Review of the menus showed repeated items, and the RD and Dietary Supervisor confirmed the menu choices were repeated and had the potential for menu fatigue.
Resident bedrooms did not meet the required square footage in 16 of 25 rooms. During a floor plan observation, surveyors found multiple 2-, 3-, and 4-bed rooms measuring only 64.92 to 78.40 square feet per resident bed, and the NHA confirmed the rooms were below the required 80 square feet.
Failure to provide dignified dining assistance: A resident with stroke, diabetes, and dementia, who had a BIMS score of 3 and was dependent on staff for meals, was served lunch in the dining room but did not receive help eating until 20 minutes after the tray was delivered. The RNS confirmed the delay, and the DON confirmed the facility failed to provide a dignified dining experience.
Failure to report neglect allegation for a second resident. A resident was found with his bed soiled in feces left by an NA, and statements during the facility’s investigation identified that the same NA had also neglected another resident. The facility submitted a report for the first resident, but the DON confirmed that the investigation and PB22 for the second resident were not reported to the DOH as required.
Failure to Thoroughly Investigate Alleged Resident Neglect: The facility did not thoroughly investigate an allegation of neglect involving two residents. One resident reported that an NA refused to help with toileting, leading him to hold urine and bowel movements until the next shift, and staff statements noted one bed was wet with urine while another was soiled with dried stool. The submitted report did not include an investigation of the second resident’s lack of care and did not substantiate the neglect allegation for either resident.
A resident with diabetes had repeated CBG readings above the ordered threshold, including several results over 400 and one result over 500. The physician order required notification if blood sugar was over 400, but the record did not show assessment, physician notification, or documentation of interventions for the elevated readings. The care plan directed staff to monitor for hyperglycemia and report to the physician, and the DON confirmed the failure to notify, assess, document, and follow the order.
Failure to document offering flu and pneumococcal immunizations to two residents. Record review showed one resident with stroke, hemiplegia, and seizures and another with stroke, diabetes, and COPD had MDS and immunization records that did not show the vaccines were offered or declined. The DON confirmed the missing documentation.
Failure to Protect Resident from Abuse and Neglect: A resident with vascular dementia, severe cognitive impairment, and incontinence requested toileting help while on the phone. A nurse aide responded rudely and sternly, including comments about not getting feces on the toilet seat and that the resident knew how to use the bathroom. The family member overheard the exchange and reported it to the facility.
The facility failed to update person-centered care plans and Kardex directions to reflect current transfer and bed mobility assistance needs for three residents. One resident with quadriplegia and total dependence documented on the MDS and in PT records had no bed mobility order or care plan entry, and the Kardex lacked bed mobility instructions; a NA, unaware of the need for assist of two, provided care during which the resident fell from bed and sustained nasal and patellar fractures. Another resident with dementia and gait instability had a physician order for transfer with assist of two, but the ADL care plan still directed assist of one, and a GNA attempted a one-person transfer, lowering the resident to the floor when the resident did not stand. A third resident with Parkinson’s disease and a recent hip fracture had a physician order for transfers with assist of two and a FWW, yet the care plan and Kardex continued for weeks to show only supervision with a rollator, reflecting outdated assistance levels.
Two residents did not receive adequate supervision and appropriate assist levels during care and transfers, contrary to facility policy and clinical assessments. One resident with quadriplegia and total dependence for mobility lacked clear bed mobility instructions in the care plan and Kardex, leading a CNA who was unaware of the required 2-person assist to perform a bed bath alone; the resident fell from bed and sustained nasal and patellar fractures, with increased PRN opioid use afterward. Another resident with dementia, muscle weakness, and unsteadiness had a physician order for 2-person assist with transfers, but the ADL care plan still reflected 1-person assist; a GNA, reportedly unaware of the correct transfer status, attempted a 1-person transfer to a WC, during which the resident was lowered to the floor. The DON acknowledged the failure to provide adequate supervision to prevent these falls.
The facility’s QAPI process failed to ensure that resident care plans and Kardex information were updated with current therapy recommendations, MDS results, and physician orders for required two-person assistance. As a result, a nurse aide provided care alone to a resident who required a two-person assist, leading to knee and nasal fractures, and another aide attempted a solo transfer of a resident ordered for two-person assistance, resulting in the resident being lowered to the floor. The DON acknowledged that the facility did not effectively correct these quality deficiencies or ensure that improvement plans addressed the identified issues.
A resident with severe cognitive impairment and high assistance needs for bed mobility sustained a femur fracture during repositioning when only one staff member assisted, despite documentation showing frequent need for two-person assistance. The facility lacked clear policies and consistent documentation regarding ADLs, transfers, and bed mobility, leading to inconsistent staff understanding and communication about required assistance levels.
Surveyors found that insulin vials and pens on a medication cart were not properly labeled with open or expiration dates, some expired vials were not disposed of, and medications were left accessible in an unattended area. An LPN and the ADON confirmed that medications were not stored or labeled according to facility policy, and insulin pens were not stored to prevent cross-contamination.
A resident with decreased mobility and a right ankle fracture immobilized with a T scope brace did not receive timely or consistent skin assessments, resulting in the development of Stage I and Stage III pressure ulcers related to the brace. The care plan was not updated to address the resident's increased risk, and staff did not implement necessary preventive interventions, leading to actual harm.
A resident with significant physical and cognitive impairments, who required staff assistance and adaptive equipment for eating, was served hot soup without a lid and left unsupervised. The resident spilled the soup, resulting in a second-degree burn to the thigh that required treatment. Staff and DON confirmed that care plan interventions for hot liquid safety and supervision were not followed at the time of the incident.
A resident with a history of stroke, lung disease, and falls inappropriately touched another resident and was prescribed medication for hypersexual behaviors. However, staff failed to monitor or document the resident's sexual behaviors, and there was no tracking of his whereabouts to prevent further incidents, as confirmed by the DON.
Surveyors identified that 16 rooms did not meet the required 80 square feet per resident, with measured space per bed ranging from 64.92 to 78.40 square feet. The NHA confirmed the deficiency during interview.
Five nurse aides did not receive the required 12 hours of annual in-service education within their respective 12-month periods, as confirmed by review of training records and the DON. Each aide received only four to nine hours of education, resulting in noncompliance with staff development regulations.
A resident with a suprapubic catheter, diagnosed with multiple sclerosis and neuromuscular bladder dysfunction, reported that a CNA failed to empty the catheter bag as ordered, resulting in excessive urine accumulation. Although the facility's policy required reporting all allegations of neglect, this incident was not reported to the appropriate authorities as required.
Two residents experienced incidents—one involving inappropriate contact and another involving elopement—where clinical records were not accurately or completely documented according to facility policy. The DON confirmed failures in documentation following these events.
Several residents with diabetes did not receive their prescribed insulin doses as ordered, despite blood sugar checks being performed by an RN. The missed administration of insulin was identified by supervisory staff, and the responsible RN acknowledged the oversight, which was confirmed by nursing leadership as a failure to protect residents from neglect.
Four residents with diabetes did not receive insulin as ordered, either due to missed blood sugar checks or failure to administer insulin coverage before meals. Facility leadership and nursing staff confirmed that insulin administration was not consistently managed according to policy, resulting in significant medication errors.
A resident experienced a significant delay in bowel movements, and the facility failed to follow its bowel management protocol. Despite the resident's dangerously high blood pressure and emergent symptoms, the nursing staff did not take immediate action, leading to the resident calling 911 for hospital transport. The resident was later admitted to the ICU with serious conditions.
The facility failed to notify physicians of abnormal blood glucose levels and did not assess residents for hyperglycemia and hypoglycemia, affecting four residents with diabetes. Despite facility policies requiring physician notification for clinical changes, residents with abnormal CBG levels were not assessed or reported. Interviews with LPNs revealed inconsistencies in understanding notification thresholds, and the DON confirmed the failure to notify physicians.
A resident with dementia and unsteadiness on feet experienced two falls due to improper footwear. The facility failed to update the care plan with non-skid footwear interventions until after the second fall, despite the resident's poor safety awareness. The Nursing Home Administrator and DON confirmed the oversight.
The facility failed to provide mandatory annual training on the prevention of abuse, neglect, and misappropriation for four staff members, including two NAs and two RNs. Despite the facility's policy requiring such training, records showed these employees did not receive the necessary education within the specified timeframe. This deficiency was confirmed by the Nursing Home Administrator.
A resident with mood disorder and depression exhibited increased behavioral symptoms after a medication dose reduction. The facility failed to conduct an evaluation for these symptoms and possible suicidality, and the psychiatrist decreased medications without an assessment. Staff confirmed the lack of appropriate treatment and services for the resident's mental health needs.
The facility did not provide mandatory effective communication training for four staff members, including two NAs, an LPN, and an RN, as required by their policies. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to provide mandatory annual training on residents' rights for a Nurse Aide and an RN. Despite the facility's assessment requiring such training, these staff members did not have documented training within the specified timeframe. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide mandatory QAPI training to six staff members, including NAs and RNs, as required by their policy. The absence of documented training was confirmed by the Nursing Home Administrator, indicating a deficiency in meeting training requirements.
The facility failed to provide mandatory Compliance and Ethics training for six staff members, including NAs and RNs, as required by their policies. The deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code regulations related to staff development and management.
Failure to Safely Temperature Hot Water Before Serving It to a Resident
Penalty
Summary
The facility failed to properly temperature hot water before giving it to a resident, resulting in actual harm to Resident R11. Resident R11 was admitted with diagnoses including unsteadiness on feet, difficulty walking, generalized muscle weakness, and schizoaffective disorder. The MDS dated 6/9/26 showed a BIMS score of 09, indicating moderate cognitive impairment, and the resident required set up or clean up assistance for eating. The resident also had physician orders for all hot liquids to be served in a cup with a lid and, later, for all fluids to be in a straw cup only. On 5/5/26, Resident R11 told staff he burned himself with hot water after asking for hot water for coffee while in bed. Facility documentation stated he spilled the water on himself after taking the lid off the cup, and multiple burn marks were noted on his abdomen and pelvic area. A body check documented burns on the abdomen and groin and a blister on the left hip, with approximately six burns described, including four large burns across the abdomen and one large blister on the left lower abdomen. Wound documentation on 5/6/26 measured the burn area as 20 cm wide by 32 cm long, and treatment orders were entered for burn care including Silvadene cream, cleansing with cold water and mild soap, and covering with ABD pads. The facility policy required hot beverages to be served below scalding temperature, not greater than 150 F, to sit with the lid off for at least 15 minutes, and to be checked with a food grade thermometer before being given to the resident. During interview, NA Employee E4 stated she got water from the hot water spout on the coffee machine, put a lid on the cup, and handed it to the resident without taking the temperature. She stated she assumed it was at the correct temperature because it came from the kitchen. Staff interviews showed inconsistent understanding of the required temperature, and several staff members stated they had not received re-education on hot water temperatures. The NHA and DON confirmed the facility failed to provide hot water at a safe temperature, resulting in second-degree burns to the resident's abdomen and pelvic area.
Residents Afraid to Voice Grievances Without Retaliation
Penalty
Summary
The facility failed to uphold residents’ rights to voice grievances without fear of retaliation for ten residents reviewed, including R800 through R809. The facility policy on Resident Rights stated that residents have the right to file complaints with any individual or agency and recommend changes in policies, home rules, and services without intimidation, retaliation, or threat of discharge. During a group meeting, R804 said they did not want to be interviewed until they confirmed their name would not be mentioned when the state surveyor discussed issues with the facility, stating they were afraid to speak up against staff for fear of retaliation. R802 stated, “we don't want to bite the hand that feeds us.” R805, R807, R803, and R806 said they did not want staff to come back and not take care of them. R809 expressed concern that their call bell would be ignored, resident care would not be given, or staff would be mean to them, and said they did not want to get staff in trouble. These residents requested to remain anonymous. The NHA and DON later confirmed that the facility failed to ensure residents did not feel retaliated against when voicing complaints or grievances.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months, from July 2025 through June 25, 2026. During an interview on 6/23/26, the Dietary Supervisor stated that she was the manager and was currently working on her certification to become a CDM. During an interview on 6/24/26, the RD stated that she comes to the facility usually once a week and works at a few facilities. The Dietary Supervisor and RD later confirmed that the facility did not have a Certified Dietary Manager and that the RD was not employed by the facility full time. The facility failed to show evidence that any staff met the qualifications for the position of Food Service Director.
Repeated Menu Choices and Failure to Reflect Resident Preferences
Penalty
Summary
The facility failed to provide food in accordance with resident preferences and failed to provide menus that were followed, updated periodically, and reflective of resident input and national guidelines. During the resident council meeting, residents stated that menu choices repeat and that they get the same foods over and over; they also reported having a food committee but being fearful to raise concerns because of retaliation. Review of the food committee minutes did not include concerns about menu choices. Review of the Spring/Summer menus showed repeated items, including white rice three times in one week and chicken four times in one week, with chicken served three times at lunch and once at dinner. The Registered Dietician and Dietary Supervisor confirmed that the menu choices were repeated and had the potential for menu fatigue.
Resident Bedrooms Below Required Square Footage
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident in 16 of 25 resident rooms. During an observation of the facility floor plan on 6/22/26 at 2:15 p.m., surveyors found multiple rooms with less than the required space per resident bed, including rooms with 2, 3, and 4 beds measuring between 64.92 and 78.40 square feet per resident bed. Specific findings included rooms measuring 72.69, 73.40, 71.37, 69.52, 70.67, 73.70, 74.61, 71.61, 76.52, 77.06, 70.91, 71.90, 66.12, 64.92, 78.40, and 71.56 square feet per resident bed. During an interview on 6/25/26 at 12:02 p.m., the Nursing Home Administrator confirmed that the room sizes were less than 80 square feet as required.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident during lunch meal service in the main dining room. Resident R3 was admitted with diagnoses including stroke with left side weakness, diabetes, and dementia. The resident’s MDS indicated a BIMS score of 3, and Section GG showed the resident was dependent on staff for meals. The care plan also indicated the resident needed assistance with eating. During observation, 16 residents were seated for lunch and the first tray was served at 11:35 a.m. Resident R3’s tray was served at 11:45 a.m. At 11:55 a.m., the resident stated, “Can you help me?” Staff did not assist the resident to eat until 12:05 p.m., 20 minutes after the meal tray was delivered. The RNS confirmed the tray delivery time and the delay in assistance, and the DON later confirmed the facility failed to provide a dignified dining experience for Resident R3.
Failure to Report Second Resident Neglect Allegation
Penalty
Summary
The facility failed to report allegations of neglect for one of two sampled residents, Resident R46. The facility policy on Resident Protection from Abuse, Neglect, Mistreatment or Exploitation, dated 5/1/26, required notification to the PA Department of Health through the electronic reporting system within 24 hours and completion of an online PB22 if directed. A facility report dated 6/2/26 showed that Resident R40 alleged neglect by Nurse Aide Employee E4, and during the investigation, statements from Nurse Aide Employee E7 and Registered Nurse Supervisor Employee E1 identified that a second resident, Resident R46, had also been neglected by the same nurse aide. During an interview on 6/25/26, RNS Employee E1 stated that Resident R46 was found with his bed soiled in feces left by Employee E4. Although a PB22 was submitted for Resident R40, the investigation and PB22 were not reported for Resident R46, and the Director of Nursing confirmed that the report for Resident R46 was not submitted to the Department of Health as required.
Failure to Thoroughly Investigate Alleged Resident Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of resident neglect involving two sampled residents, R40 and R46. The facility policy on Resident Protection from Abuse, Neglect, Mistreatment or Exploitation stated that neglect is the failure to provide services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and that allegations identified through complaints or incident reports are to be thoroughly investigated and reported to Administration and the Department of Health within 24 hours. A facility report dated 6/2/26 documented that R40 said he did not ask NA E4 for help because she refused to help him, and that he held his urine and bowel movements all day until the next shift because of this. Statements from NA E7 and the RNS indicated that when the shift began, R40's bed was wet with urine and R46's bed was soiled with dried stool. The RNS stated that R40 would not ask NA E4 for help with the urinal because she would not help him, and that R46's bed was not touched all day. The facility submitted report did not include an investigation of R46 not receiving care and did not substantiate the allegation of neglect for either resident. The DON confirmed in interview that the facility failed to thoroughly investigate the allegation of resident neglect for R40 and R46.
Failure to Notify Physician and Document Elevated Blood Glucose
Penalty
Summary
The facility failed to assess, document, and notify the physician of repeated elevated capillary blood glucose (CBG) results for one resident with diagnoses including diabetes, high blood pressure, and depression. The resident’s physician orders included Accucheck before meals with coverage and Lispro insulin per sliding scale, with instructions to give 12 units and notify the doctor if blood sugar was over 400. The resident’s MDS dated 4/26/26 confirmed the diabetes diagnosis remained current. Review of the clinical record and eMAR showed multiple CBG readings above the ordered threshold, including 411, 482, 562, 407, 404, 428, 487, 401, 443, 469, 420 with a re-check confirming the result, and 471. The record did not show assessment for hyperglycemia, physician notification, or documentation of interventions for the listed dates. The care plan directed staff to administer medications as ordered, check blood sugar levels as ordered, and monitor for signs and symptoms of hyperglycemia and report to the physician. During interviews, two LPNs stated they would notify the doctor for blood sugars over the ordered parameters, give the ordered insulin, recheck the resident in 30 to 60 minutes, and document in the progress notes and eMAR. The DON confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions related to blood glucose, and failed to follow the physician’s orders for the resident.
Failure to Document Offering Flu and Pneumococcal Immunizations
Penalty
Summary
The facility failed to document that each resident was offered influenza and/or pneumococcal immunizations for two of five residents reviewed, Residents R2 and R33. Facility policy stated that influenza and pneumococcal vaccines are offered to all residents, but the clinical record review and MDS documentation did not show that these vaccines were offered or declined for either resident. For R2, the record showed admission with diagnoses including stroke, hemiplegia, and seizures, and the MDS dated 6/19/26 indicated the resident did not receive and was not offered the pneumococcal vaccine. The immunization documentation reviewed on 6/25/26 at 11:00 a.m. did not include information that the pneumococcal vaccines were offered or declined. For R33, the record showed admission with diagnoses including stroke, diabetes, and COPD, and the MDS indicated the resident did not receive the influenza and pneumococcal vaccines. The immunization documentation reviewed on 6/25/26 at 11:00 a.m. did not include information that the influenza and pneumococcal vaccines were offered or declined. During interview on 6/25/26 at 11:45 a.m., the DON confirmed the findings and that the facility failed to document each resident was offered an influenza and/or pneumococcal immunization for Residents R2 and R33.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse and neglect when a nurse aide responded rudely and sternly to the resident’s request for toileting assistance. The resident had diagnoses including vascular dementia, needed assistance with personal care, and had a BIMS score of 04, indicating severe cognitive impairment. The resident was also documented as occasionally incontinent of urine and always incontinent of bowel. Facility records showed the resident’s Kardex listed hand-hold staff assistance for transfers, and the care plan directed staff to check on the resident at least every two hours and assist with toileting as needed, while also observing for patterns of incontinence and evaluating for a toileting schedule if indicated. According to the family member who overheard the interaction, the resident was on the phone and became panicked about having an accident, then asked for help to the restroom. The nurse aide answered the request very rudely, told the resident to get in the bathroom and that he would be in to help, and then stated sternly that he had told the resident earlier not to get feces on the toilet seat and that the resident knew how to use the bathroom. The family member reported the incident to the facility. The nurse aide was unavailable for interview, and the NHA stated the aide was suspended and quit before termination could occur, confirming the facility failed to protect the resident from abuse and neglect.
Failure to Update Care Plans and Kardex for Transfer and Bed Mobility Assistance
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or update person-centered care plans and related Kardex directions for transfer and bed mobility assistance levels for three residents, which resulted in actual harm for one resident. Facility policy required that care plans be working tools, reviewed and revised at specific intervals and as needed to reflect changing needs and goals. For one resident with quadriplegia, a history of stroke, and a seizure disorder, the MDS documented total dependence for functional abilities, and a physician order required assist of two with a mechanical lift for transfers. Physical therapy also recommended total dependence for bed mobility. However, prior to a fall event, there was no physician order addressing bed mobility, the ADL care plan did not include bed mobility requirements, and the Kardex used by nurse aides lacked directions for bed mobility. The DON confirmed that the care plan and Kardex were not updated with the PT recommendation and MDS documentation for bed mobility. This same resident was later found on the floor next to the wall, lying prone with facial lacerations after becoming combative during care provided by a nurse aide. The resident sustained a nondisplaced fracture of the right patella and a nondisplaced, nondepressed nasal bone fracture. The facility’s submitted information indicated that the resident fell out of bed during care, and the nurse aide involved stated she was not aware that the resident required assist of two. The DON confirmed that the information provided to nurse aides did not include the resident’s bed mobility requirements, demonstrating a gap between assessed needs, physician/therapy recommendations, and the directions available to direct care staff. For a second resident with dementia, muscle weakness, and unsteadiness on feet, a physician order required transfer with assist of two staff members. However, the ADL care plan continued to state that the resident used a front-wheeled walker to transfer with staff assistance of one, and there was no documented update to reflect the physician’s order, even though the Kardex did indicate assist of two with a front-wheeled walker. An incident occurred when a GNA attempted to transfer this resident alone; the resident did not stand, and the aide lowered the resident to the ground. Facility documentation noted that the investigation was initiated because the transfer was done with assist of one when the Kardex required assist of two. For a third resident with Parkinson’s disease, a hip fracture, and a history of stroke, a physician order required transfers with assist of two staff and a front-wheeled walker, weight bearing as tolerated. The care plan initiated after readmission did not include the required transfer assistance until about a month later, and the Kardex during that period continued to direct staff to transfer/ambulate the resident with supervision and a rollator, reflecting the pre-fracture assistance level rather than the updated post-fracture requirements.
Failure to Communicate and Implement Required Assist Levels Resulting in Falls and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall-prevention measures for two residents, resulting in actual harm for one resident. Facility policy required that after a fall, causes be removed, preventive measures implemented, and the care plan updated with new interventions. For Resident R1, who had quadriplegia, a history of stroke, and a seizure disorder, the MDS documented total dependence for functional abilities, and a physician order required assist of two with a mechanical lift for transfers. The physical therapy discharge summary also indicated total dependence for bed mobility. However, prior to 3/20/26, there was no physician order related to bed mobility, the ADL care plan did not address bed mobility requirements, and the Kardex used by nurse aides lacked directions regarding bed mobility. On the night of the fall, documentation showed that staff were called to Resident R1’s room and found him on the floor, prone with his face into the floor, with multiple lacerations and abrasions. The resident was nude, as a CNA was providing a bed bath at the time. The CNA’s written statement indicated she went to wash the resident, cleaned him, and then rolled him toward herself to finish with linens and his brief. After a few seconds, the resident began yelling and became combative, started coming off the bed, and the CNA attempted to catch and lower him but was unable to prevent him from reaching the floor. The CNA stated she had no knowledge that the resident required assist of two, had seen others perform care alone, and believed the bed was too small. Following this event, the resident was found to have a nondisplaced fracture of the right patella and a nondisplaced, nondepressed nasal bone fracture. Medication records showed an increase in PRN Tramadol use after the fall compared to the period before. For Resident R2, who had dementia, muscle weakness, and unsteadiness on feet, a physician order dated 1/9/26 required transfer with assist of two staff members. The ADL care plan, however, indicated the resident used a front-wheeled walker to transfer with staff assistance of one, and there was no documented update to the care plan reflecting the physician’s order for assist of two. The Kardex did indicate transfer with assist of two staff with a front-wheeled walker. On the morning of 3/18/26, a progress note documented that the resident was being transferred to a wheelchair and did not stand, so the nurse aide lowered her to the ground, with no injury noted. Facility documentation of the incident stated that the GNA attempted the transfer without assistance despite the Kardex indicating assist of two, and written documentation indicated the GNA was unaware of the resident’s transfer status. The DON confirmed that the facility failed to provide adequate supervision to prevent falls for two of four residents, resulting in actual harm for one resident.
Failure to Update Care Plans and Kardex Leading to Injuries During Transfers
Penalty
Summary
The facility failed to correct previously cited deficiencies through its Quality Assurance and Performance Improvement (QAPI) program, resulting in ongoing problems with ensuring that resident care plans and Kardex information reflected current assistance needs. Despite having a written QAPI plan intended to provide ongoing, systematic evaluation and improvement, surveyors found that resident care documents were not updated to incorporate therapy recommendations, physician orders, and Minimum Data Set (MDS) results. This failure meant that direct care staff did not have accurate, up-to-date information on the level of assistance required for residents during bed mobility and transfers. For one resident, the Kardex and care plan were not updated with documented therapy recommendations and MDS results indicating the need for a two-person assist. As a result, a nurse aide provided care alone, and the resident sustained knee and nasal fractures. For another resident, the Kardex and care plan were not updated with a physician’s order requiring two staff members for transfers. A nurse aide, unaware of the two-person assist requirement, attempted to transfer the resident alone and had to lower the resident to the floor. During an interview, the Director of Nursing confirmed that the facility failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed identified concerns.
Failure to Prevent Injury During Bed Mobility Due to Lack of Clear Policies and Communication
Penalty
Summary
The facility failed to prevent injury to a resident during the provision of care, specifically while assisting with bed mobility. The resident in question had significant cognitive impairment, as indicated by a BIMS score of 03, and required substantial to maximum assistance for bed mobility, as documented in the Minimum Data Set (MDS) and daily care records. Physician orders specified the use of bilateral assist rails for bed mobility and a mechanical lift with two staff for transfers. The care plan also directed staff to use caution during transfers and repositioning to prevent injury. However, the facility was unable to provide policies regarding Activities of Daily Living (ADLs), resident transfers, or bed mobility, and the Kardex did not indicate the resident's bed mobility status. On the date of the incident, a nurse aide was assisting the resident with rolling in bed using standard technique when the resident began to push against the handrail, causing a shift in body weight and resistance. The aide applied additional pressure to complete the turn, at which point an audible snap was heard from the resident's leg area, and the resident began to scream in pain. Subsequent x-rays confirmed an acute spiral oblique subtrochanteric fracture of the proximal left femur. Documentation showed that the resident routinely required assistance of two staff for bed mobility on most days in the months leading up to the incident. Interviews with staff revealed inconsistencies in how bed mobility assistance needs were determined and communicated. Some staff relied on point of care charting, while others would ask nurses or therapy staff. The occupational therapist stated that substantial/maximal assistance did not always mean two staff were needed, and that staff were left to decide the level of assistance required. The facility's failure to provide clear policies and consistent documentation regarding bed mobility and assistance needs contributed to the incident in which the resident sustained a significant injury during care.
Improper Labeling and Storage of Insulin Medications
Penalty
Summary
Facility staff failed to properly label and store insulin medications in accordance with facility policy and accepted professional standards. During an observation of the Blue medication cart, several insulin vials and pens were found to be either undated upon opening, lacking expiration dates, or not disposed of after expiration. Specifically, one Aspart insulin vial was found with both open and expiration dates, two Aspart vials were missing expiration dates, one Lantus vial was opened but not dated, and three Lantus flex pens were opened, undated, and not stored in individual bags, increasing the risk of cross-contamination. Additionally, the medication cart was left unattended in a resident lounge with medications accessible to residents, guests, and visitors. Staff interviews confirmed these findings, with both an LPN and the Assistant Director of Nursing acknowledging that the medications were not stored or labeled according to policy. Facility policies require that insulin vials be marked with the resident's name, the date opened, and an expiration date, and that all medications be stored in a locked, organized, and sanitary manner. The observed deficiencies included failure to date insulin vials upon opening, failure to dispose of expired vials, and improper storage of medications, all of which were confirmed by facility staff during the survey.
Failure to Prevent and Manage Pressure Ulcers Associated with Medical Device
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of pressure ulcers in a resident with a right ankle fracture who was immobilized with a T scope brace. The resident, who had multiple diagnoses including respiratory failure, traumatic brain injury, and decreased mobility requiring assistance of two staff for bed mobility, was ordered to wear the brace at all times except for hygiene. Despite this, there was no documentation of skin checks to the right leg for 16 days after the brace was applied, and weekly skin assessments were inconsistently documented, with several missed opportunities noted in the Treatment Administrative Record. As a result of these lapses, the resident developed a Stage I pressure ulcer on the right inner and outer knee, and a Stage III pressure ulcer on the right lateral ankle, both associated with the use of the medical device. The care plan was not updated to reflect the resident's increased risk for pressure ulcers or the need for individualized interventions and skin assessments. Staff interviews confirmed that required interventions to prevent pressure ulcers were not implemented, leading to actual harm for the resident.
Failure to Provide Supervision and Hot Liquid Safety Results in Resident Burn
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for one resident, resulting in harm. The resident, who had multiple diagnoses including respiratory failure, traumatic brain injury, communication deficit, repeated falls, and required physical assistance with eating, was served hot soup measured at 170 degrees Fahrenheit. The resident's care plan and physician orders specified that hot liquids should be served with lids and that the resident required supervision and assistance during meals. However, these interventions were not followed, and the resident was left unsupervised with uncovered hot soup, which he subsequently spilled onto his right upper, inner thigh, causing a second-degree burn. Staff interviews and documentation confirmed that the dietary and care plans indicated the need for lids on hot liquids and staff assistance, but these were not implemented at the time of the incident. The DON acknowledged that the resident should have had a lid on the soup and required assistance during meals, which was not provided. As a result, the resident suffered a burn injury that required treatment, demonstrating a failure to follow established safety protocols and care plan interventions.
Failure to Monitor and Document Sexual Behaviors
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of behaviors for a resident who had a history of stroke, lung disease, and falls. The resident was involved in an incident where he inappropriately touched another resident without consent. Documentation showed that the resident admitted to the behavior and was questioned about increased sexual drives, to which he was unsure, and he refused a transfer to a Behavioral Health Unit. The facility physician was notified and prescribed medication to address hypersexual behaviors. Despite the prescription of Medroxyprogesterone to decrease sexual drive, the resident's Medication Administration Record and Treatment Administration Record did not include any monitoring of sexual behaviors. There was no documentation of behavior monitoring by nursing, social services, or nursing assistants, and the resident's whereabouts were not tracked to prevent further incidents. The resident's room was located near rooms occupied by female residents, increasing the risk of recurrence. The Director of Nursing confirmed the lack of proper monitoring and documentation for this resident.
Resident Bedroom Size Below Regulatory Minimum
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms, as mandated by regulation. During an observation of the facility's floor plan, it was found that 16 out of 25 resident rooms did not meet this requirement, with individual resident space ranging from 64.92 to 78.40 square feet per bed in affected rooms. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the room sizes were less than the required 80 square feet per resident. The findings were based on direct measurement and review of the facility's room dimensions.
Failure to Provide Required Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service education within 12 months of the hire date anniversary for five nurse aides. Review of staff education records and facility-provided documents showed that each of these nurse aides received between four and nine hours of in-service education during the relevant 12-month periods, falling short of the regulatory requirement. The Director of Nursing confirmed during an interview that the required education was not completed for these staff members. This deficiency was cited under 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.20(c) for responsibility of the licensee and staff development, respectively.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident. The resident, who had multiple sclerosis and neuromuscular dysfunction of the bladder, was re-admitted to the facility and had a suprapubic catheter in place. According to a physician's order, the catheter was to be emptied every two hours with documentation. On one occasion, the resident reported through a grievance form that a CNA did not empty the catheter bag as required, resulting in the bag containing 1300cc of urine instead of the usual 500cc. The resident expressed concern about potential illness due to this incident. The facility's policy required all allegations of abuse or neglect to be reported to the appropriate authorities, including the PA Department of Health/Long Term Care Division. However, a review of reports submitted to the state field office showed that this specific allegation was not reported. The Assistant Director of Nursing confirmed during an interview that the facility did not report the resident's allegation of neglect as required by policy and state regulations.
Incomplete and Inaccurate Clinical Record Documentation Following Resident Incidents
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents. For one resident with epilepsy, obesity, and dysphagia, an incident occurred in which another resident inappropriately touched her. While immediate actions were taken to separate the residents and assess for injuries, documentation in the clinical record was incomplete, lacking detailed information as required by facility policy. The care plan was updated days later, but the initial documentation did not fully capture the assessment, interventions, and communications as outlined in facility procedures. For another resident with encephalopathy, depression, and alcohol dependence, an incident was reported where the resident was found outside the facility after allegedly climbing out of a window. Although the resident had a history of wandering risk, assessments were inconsistent, with some indicating risk and others not. The care plan included interventions for monitoring and documenting wandering behavior, but documentation was not accurate or complete regarding the incident. The DON confirmed that the facility failed to ensure accurate and complete documentation for both residents following these incidents.
Failure to Administer Insulin as Ordered Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect by not administering insulin as ordered to four of eight residents with diabetes. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. Clinical record reviews showed that residents with diagnoses including hypertension, cerebrovascular disease, and Type 2 diabetes had physician orders for scheduled insulin administration. On the specified date, a registered nurse obtained blood sugar readings for several residents but did not administer the required insulin coverage before meals as ordered. In one case, a blood sugar reading was not obtained, resulting in no insulin being given. Documentation and staff interviews confirmed that the missed insulin doses were identified by the RN Supervisor, and the responsible RN acknowledged not covering the residents' blood sugars after obtaining accuchecks, stating that priorities were not in line and residents were put at risk. The Director of Nursing and Assistant Director of Nursing confirmed the failure to administer insulin as ordered, which constituted neglect under facility policy and state regulations.
Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration of insulin for four out of eight residents reviewed. Facility policy required medications to be administered according to physician orders, manufacturer specifications, and professional standards. However, documentation showed that insulin was not administered as ordered for multiple residents with type 2 diabetes and other comorbidities such as hypertension and cerebrovascular disease. In several cases, blood sugar checks were either not performed as ordered or, when performed, were not followed by the required insulin coverage prior to meals. For example, one resident did not receive sliding scale insulin coverage before breakfast despite a blood sugar check, and another did not have a blood sugar reading obtained, resulting in no insulin being given. A review of staff documentation and interviews confirmed that the responsible RN did not administer insulin coverage after obtaining blood sugar readings for four residents. The Nursing Home Administrator, DON, and Assistant DON acknowledged that insulin administration was not consistently managed under the facility's medication administration policy, leading to these significant medication errors. The findings were supported by clinical record reviews, staff statements, and direct confirmation from facility leadership.
Failure to Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to appropriately respond to a resident's change in condition, specifically regarding bowel management and cardiovascular monitoring. The facility's policy for bowel management was not followed for a resident who experienced a significant delay in bowel movements. Despite the resident not having a bowel movement for several days, the administration of Senna and Bisacodyl, as per the facility's protocol, was not documented. This oversight led to the resident experiencing lower abdominal pain and a firm, tender abdomen with decreased bowel sounds, prompting the resident to call 911 for hospital transport. Additionally, the resident's blood pressure was recorded at dangerously high levels, significantly above their normal range, yet the nursing staff did not take immediate action. The resident was eventually admitted to the Intensive Care Unit with serious conditions, including osteomyelitis, hydronephrosis, and hydroureter, and required intravenous antibiotics. The Nursing Home Administrator confirmed that the nursing staff should not have attempted to delay the resident's request for hospital evaluation, acknowledging the failure to respond appropriately to the resident's emergent symptoms.
Failure to Notify Physicians of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting four residents. The facility's policies required staff to notify physicians of clinical changes, including abnormal lab values, and to document these notifications. However, the facility did not adhere to these policies, resulting in a lack of physician notification for residents with abnormal CBG levels. Resident R6, diagnosed with diabetes, dementia, and depression, had multiple instances of elevated CBG levels, including readings of 416, 450, and 439, without physician notification or assessment for hyperglycemia. Similarly, Resident R31, with diabetes, anxiety, and high blood pressure, experienced hypoglycemic episodes with CBG levels of 51, 51, and 52, yet was not assessed for hypoglycemia, and the physician was not notified. Resident R39, with diabetes, depression, and shortness of breath, also had low CBG readings of 58, 53, and 57, without appropriate assessment or physician notification. Resident R45, diagnosed with diabetes and high blood pressure, consistently had a CBG level of 341 over several dates, but the facility failed to assess for hyperglycemia or notify the physician. Interviews with LPNs revealed inconsistencies in their understanding of when to notify physicians, with varying thresholds for abnormal CBG levels. The Director of Nursing confirmed the facility's failure to notify physicians of changes in residents' conditions related to blood glucose levels.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls for a resident identified as R25, who had a history of dementia and unsteadiness on feet. The resident experienced two falls within a short period. The first fall occurred in the dining room, where the resident was found on the floor with a small skin tear on the left elbow. It was noted that the resident's shoes were not non-skid and slid easily on the floor, but this was not initially documented as a predisposing factor in the incident report. The care plan at that time did not include an intervention for non-skid footwear. The second fall happened when the resident attempted to walk independently and slid, reopening the previous skin tear on the right elbow. Again, the resident was wearing shoes that slid easily on the floor. This time, the incident report acknowledged improper footwear as a predisposing factor. Despite the resident's dementia and poor safety awareness, the care plan was not updated to include non-skid footwear until after the second fall. The Nursing Home Administrator and Director of Nursing confirmed the failure to implement necessary interventions to prevent falls.
Failure to Provide Mandatory Abuse Prevention Training
Penalty
Summary
The facility failed to provide mandatory annual training on the prevention of abuse, neglect, and misappropriation for four out of ten staff members, specifically Employees E2, E3, E5, and E7. The facility's assessment, which was reviewed on multiple occasions, indicated that staff training should include topics such as abuse, neglect, misappropriation, the Elder Justice Act, residents' rights, person-centered care, dementia training, and infection control and prevention. However, a review of the facility's documents and training records revealed that these employees did not have documented training on effective communication, which is a critical component of preventing abuse and neglect. The specific employees identified in the deficiency include Nurse Aide (NA) Employee E2, who was hired on 4/21/99, NA Employee E3, hired on 5/9/11, Registered Nurse (RN) Employee E5, hired on 5/8/17, and RN Employee E7, hired on 4/22/13. Each of these employees failed to receive the required in-service education on the prevention of abuse, neglect, and misappropriation within the specified timeframe for their respective hire dates. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the facility's failure to provide the necessary training for these staff members.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident, identified as Resident R39, to maintain the highest practicable mental and psychosocial well-being. Resident R39 was admitted with diagnoses of persistent mood disorder and depression, with a BIMS score indicating moderate cognitive impairment. The resident's care plan included monitoring for signs of depression and adverse effects of antidepressant medication. However, after a gradual dose reduction of Depakote, the resident exhibited increased behavioral symptoms, including striking out at a nurse aide and expressing a desire to die. Despite these concerning behaviors, the facility did not conduct an in-person or telehealth evaluation of the resident's increased behavioral symptoms and possible suicidality. The psychiatrist further decreased the resident's medications without evaluating the resident for these behaviors. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, confirmed the failure to provide appropriate treatment and services to address the resident's mental health needs, as required by the facility's policies and state regulations.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide mandatory training on effective communication for four out of ten staff members, as required by their own policies. The facility assessment indicated that staff training and education should include topics such as abuse, neglect, misappropriation, the Elder Justice Act, residents' rights, person-centered care, dementia training, and infection control and prevention, with effective communication being a mandatory annual training topic. However, upon review of the facility's documents and training records, it was found that Nurse Aide Employee E2, Nurse Aide Employee E4, Licensed Practical Nurse Employee E6, and Registered Nurse Employee E7 did not have documented training on effective communication within the specified time frames. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Provide Residents' Rights Training
Penalty
Summary
The facility failed to provide mandatory annual training on residents' rights for two staff members, specifically a Nurse Aide and a Registered Nurse. The facility's assessment, which outlines required training topics such as abuse, neglect, and residents' rights, was reviewed and confirmed that these two employees did not have documented training on residents' rights within the specified timeframe. The Nurse Aide, hired in 1999, and the Registered Nurse, hired in 2013, both lacked this training between April 2023 and April 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) for six out of ten staff members, as required by their policy. The review of facility documents and training records revealed that Nurse Aides (NAs) and Registered Nurses (RNs) with hire dates ranging from 1999 to 2022 did not receive documented QAPI in-service education within the specified annual period. This lack of training was confirmed during an interview with the Nursing Home Administrator. The facility's assessment indicated that staff training and education should include mandatory annual topics such as abuse, neglect, misappropriation, the Elder Justice Act, residents' rights, person-centered care, dementia training, and infection control and prevention. However, the absence of QAPI training for the identified staff members highlights a deficiency in adhering to these training requirements. The report cites specific Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development, underscoring the facility's failure to meet these standards.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide mandatory training on Compliance and Ethics for six out of ten staff members, as required by their own policies. The facility's assessment, which was reviewed on multiple occasions, mandates annual training on various topics, including Compliance and Ethics. However, upon reviewing the education documents and training records, it was found that Nurse Aides E2, E3, and E4, Registered Nurses E5 and E7, and Licensed Practical Nurse E6 did not have documented training on Compliance and Ethics within the specified time frames corresponding to their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of compliance with the training requirements for these staff members. This deficiency is in violation of several Pennsylvania Code regulations, specifically those related to the responsibility of the licensee, management, and staff development. The absence of documented training indicates a failure in the facility's staff development and management processes, as outlined in the cited regulations.
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What surveyors actually found near you
We read the 132 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Markleysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quality Life Services - Henry Clay | 1.7 mi | ★★★★★ | 2 | 0 |
| Goodwill Mennonite Home, Inc. | 16.1 mi | ★★★★★ | 1 | 0 |
| Laurel Ridge Center | 17.8 mi | ★★★★★ | 1 | 0 |
| Uniontown Nursing And Rehab | 18.3 mi | ★★★★★ | 1 | 0 |
| Mt Macrina Manor | 19.2 mi | ★★★★★ | 1 | 0 |
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