Quality Life Services - Mercer
Inspection history, citations, penalties and survey trends for this long-term care facility in Mercer, Pennsylvania.
- Location
- 8221 Lamor Road, Mercer, Pennsylvania 16137
- CMS Provider Number
- 395879
- Inspections on file
- 20
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Quality Life Services - Mercer during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diabetes, did not receive ordered Xultophy insulin on several days because the pharmacy did not supply the medication. The DON confirmed the medication was not administered as required by physician orders, resulting in a failure to follow facility policy.
An LPN failed to perform hand hygiene after removing a soiled dressing and before applying a new dressing during a wound care procedure for a resident with pressure ulcers. This action was not in accordance with the facility's infection control policy, as confirmed by the DON, and created the potential for cross contamination.
The facility did not have a staff member with specialized infection prevention and control training designated as the Infection Preventionist. After the previous IP left, the DON assumed the role without completing the required training, and there was no staff overseeing the infection control program at least part time.
The facility failed to document and assess pressure ulcers for two residents, leading to a deficiency. One resident developed a Stage 2 ulcer with inconsistent documentation, while another was admitted with a Stage 4 ulcer lacking initial and weekly assessments. The Regional Nurse confirmed the absence of required documentation.
Quality Life Services - Mercer failed to provide scheduled showers for three dependent residents, as required by their care plans. Despite facility policy and physician orders, these residents did not receive showers as scheduled, with one resident receiving only a single bed bath in 30 days. Interviews confirmed the lack of adherence to care plans, highlighting a deficiency in providing necessary personal hygiene services.
The facility did not meet the required nurse aide staffing ratios for day, evening, and overnight shifts over a 21-day period. Specific instances of shortages were documented, such as on January 13, 2025, when only 3.88 NAs worked during the day shift for 44 residents, falling short of the required 4.40. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to meet the required LPN-to-resident ratios across various shifts, with significant shortages noted on the overnight shift for 20 out of 21 days reviewed. The day and evening shifts also experienced staffing deficiencies, confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per resident in a 24-hour period on seven days in early January 2025. The lowest recorded was 2.95 hours PPD. This was confirmed by the Nursing Home Administrator.
Failure to Administer Ordered Insulin Due to Pharmacy Non-Delivery
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with multiple diagnoses, including a right femur fracture, metabolic encephalopathy, type 2 diabetes mellitus, and atrial fibrillation. According to the clinical record, there was a physician's order for the resident to receive Xultophy insulin subcutaneously at bedtime for diabetes management. The Medication Administration Record (MAR) indicated that this medication was not administered as ordered on four consecutive days. During an interview, the Director of Nursing confirmed that the insulin was not given because the pharmacy did not provide the medication. This failure to administer the prescribed medication was in direct violation of the facility's policy, which requires that physician orders be followed and carried out by authorized personnel to ensure residents receive all ordered medications and treatments in a timely manner.
Failure to Perform Hand Hygiene During Wound Dressing Change
Penalty
Summary
The facility failed to prevent potential cross contamination during a wound dressing change for a resident with pressure ulcers. According to the facility's wound dressing change policy, hand hygiene is required at multiple steps, including after removing the old dressing and before applying a new one. During an observed dressing change, an LPN cleansed the resident's coccyx wound and applied a new dressing without washing hands after removing the soiled dressing, contrary to the established protocol. The LPN later confirmed not performing hand hygiene during the procedure. The resident involved had a history of cellulitis of the left lower limb, anxiety, osteoarthritis of the knee, and diabetes mellitus. The Director of Nursing confirmed in an interview that hand hygiene should be performed several times during a wound dressing change to ensure proper infection control and prevent cross contamination. The failure to follow hand hygiene protocols during the dressing change constituted a deficiency in infection prevention and control practices.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was designated to be responsible for the infection prevention and control program. Review of the infection control program showed no evidence of any staff member with specialized training in infection prevention and control to fulfill the IP role. The Director of Nursing (DON) reported that the previous IP left the facility on 6/02/25, and since then, the DON had been covering the position without having completed the required specialized IP training. Additionally, the DON confirmed that as of 6/18/25, there were no staff members overseeing the infection control program who worked at least part time at the facility.
Failure to Document and Assess Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper documentation and assessment of pressure ulcers for two residents, leading to a deficiency in compliance with professional standards of practice. Resident R1, who was admitted with conditions including obesity, reduced mobility, and lumbar radiculopathy, developed a Stage 2 pressure ulcer on the coccyx. Although treatments were performed, the facility did not consistently document weekly skin assessments and measurements as required. Documentation was sporadic, with significant gaps between recorded assessments. Similarly, Resident R2, admitted with a Stage 4 pressure ulcer on the sacral region and other conditions such as a urinary tract infection and type 2 diabetes, also lacked proper documentation. The initial skin assessment and subsequent weekly assessments were not documented until nearly two weeks after admission. The Regional Nurse confirmed the absence of necessary documentation for both residents, indicating a failure to adhere to the facility's policy on skin integrity and wound management.
Plan Of Correction
Residents #1 and #2 had their wounds measured and documentation completed. A skin sweep will be completed of all residents by DON/designee to ensure all skin concerns are documented. Education will be provided to the DON by the Clinical Services Specialist. The DON will provide education to the staff RNs regarding the process of evaluating wounds on a weekly basis. New admissions will be reviewed at the AM clinical meeting for skin concerns. Audits will be completed once a week for 4 weeks to ensure wounds are evaluated on a weekly basis. Results of the audits will be reviewed at the Quality Assurance meeting.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
Quality Life Services - Mercer was found to be non-compliant with the requirement to provide necessary services for activities of daily living, specifically in the area of personal hygiene and showers for dependent residents. The facility's policy, revised in March 2020, mandates that showers be provided according to a pre-determined schedule and as needed, with staff assistance documented in Point Click Care. However, the survey revealed that three residents, who required substantial or maximal assistance for bathing, did not receive showers as per their physician orders and facility policy. Resident R3, who required substantial assistance, reported not having a shower in 2-3 weeks, with records showing only one bed bath in the past 30 days. Resident R4, also dependent on staff for bathing, had not received a shower in the past 30 days despite being scheduled for showers twice a week. Similarly, Resident R5, requiring substantial assistance, only received one shower and five bed baths over the same period. Interviews with the Nursing Home Administrator and Regional Nurse confirmed the lack of evidence for scheduled showers, indicating a failure to adhere to the residents' care plans.
Plan Of Correction
Residents #3, 4, and 5 have had their showers. Other residents have been assessed to ensure showers are being given. Shower schedule will be reviewed to ensure that all residents are included in the schedule. Education will be provided by DON/designee to all nursing staff regarding shower schedule, documentation of showers, and ensuring showers are given according to the schedule. Initial audit will be completed to review resident's preference for shower and/or bed bath. Audits will be completed 3 times a week x 4 weeks on all shifts, by DON/designee, to ensure showers are being completed. Results of the audits will be reviewed at the Quality Assurance meeting.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by regulations effective July 1, 2024. Specifically, the facility did not maintain a minimum of one NA per 10 residents during the day shift for 21 consecutive days, from December 31, 2024, to January 20, 2025. Additionally, the facility did not meet the required ratio of one NA per 11 residents during the evening shift on 10 out of 21 days within the same period. Furthermore, the overnight shift consistently fell short of the required one NA per 15 residents for all 21 days reviewed. The review of nursing staffing documents revealed specific instances of NA shortages across all shifts. For example, on January 13, 2025, with a census of 44 residents, only 3.88 NAs worked during the day shift when 4.40 were required. Similarly, on January 12, 2025, during the overnight shift, only 2.25 NAs worked when 2.93 were required for a census of 44 residents. These staffing deficiencies were confirmed by the Nursing Home Administrator during an interview on January 22, 2025.
Plan Of Correction
1. The facility was unable to make corrective action for the (nurse aide ratio) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. 2. Director of nursing or designee will re-educate the labor manager and the Registered nurse supervisors on the 7/1/2024 requirements for Nurse Aide ratios. 3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. 4. Nursing home administrator, DON, and Labor manager will conduct daily staffing meetings Monday - Friday to review (nurse aide ratios) throughout the day, the following day, and the weekend. In the event of vacancies, the Labor Manager or designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. 5. Director of Nursing or designee will audit daily staffing ratios and along with all steps taken to fill vacancies 5 days a week and ongoing. 6. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.
LPN Staffing Shortages Across Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain the minimum LPN-to-resident ratios on several occasions across different shifts. On the day shift, the facility was short of the required LPNs on one out of 21 days reviewed, with a census of 42 residents requiring 1.68 LPNs, but only 1.00 LPN was present. The evening shift experienced shortages on three days, with the facility failing to meet the required LPN ratio for resident counts ranging from 42 to 44. The overnight shift was particularly affected, with shortages on 20 out of 21 days reviewed, where the facility consistently had only 1.00 LPN working despite needing between 1.05 and 1.13 LPNs based on the resident census. The deficiencies were confirmed through a review of the facility's nursing staffing documents and an interview with the Nursing Home Administrator. The administrator acknowledged the failure to meet the minimum LPN ratio requirements on the specified shifts and dates. This consistent shortfall in staffing indicates a systemic issue in maintaining adequate nursing coverage, which is crucial for ensuring the safety and well-being of the residents.
Plan Of Correction
1. The facility was unable to make corrective action for the (Licensed Practical Nurse ratio) for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. 2. Director of Nursing or designee will re-educate the Labor Manager and the RN Supervisors on the 7/1/2024 Licensed Practical Nurse ratio requirements. 3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. 4. Nursing Home Administrator, Director of Nursing, and Labor Manager will conduct daily staffing meetings Monday - Friday to review (Licensed Practical Nurse ratios) throughout the day, the following day, and the weekend. In the event of vacancies the Labor Manager or designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. 5. Director of Nursing or designee will audit daily staffing ratios along with all steps taken to fill vacancies 5 days a week and ongoing. 6. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on seven specific days between January 1, 2025, and January 13, 2025. A review of the facility's nursing staffing documents revealed that the hours of direct resident care fell below the required minimum on these dates, with the lowest being 2.95 hours per patient per day on January 12, 2025. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 22, 2025, who acknowledged that the facility did not meet the required staffing levels on the specified dates.
Plan Of Correction
1. The facility was unable to make corrective action for direct care staff for identified days that have already passed. All residents received care in accordance with their care plans and physician orders. 2. Director of Nursing or designee will re-educate the Labor Manager and the RN supervisors on the 7/1/2024 for direct care staff PPD requirements. 3. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. 4. Nursing Home Administrator, Director of Nursing, and Labor Manager will conduct daily staffing meetings Monday - Friday to review (PPD) throughout the day, the following day, and the weekend. In the event of vacancies, the Labor Manager or Designee will follow staffing policies including offering open shifts to internal staff, contracted agency staff, and offering current staff to stay extra or start earlier. 5. DON or designee will audit daily staffing PPD along with all steps taken to fill vacancies 5 days a week and ongoing. 6. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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