Quality Life Services - New Castle
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Pennsylvania.
- Location
- 520 Friendship Street, New Castle, Pennsylvania 16101
- CMS Provider Number
- 395003
- Inspections on file
- 28
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Quality Life Services - New Castle during CMS and state inspections, most recent first.
The facility did not provide written notice or obtain agreement from residents or their responsible parties before making room changes for multiple residents with conditions such as diabetes, hypertension, heart failure, and dementia. Documentation lacked evidence of required notifications, and this was confirmed by the Nursing Home Administrator.
Four newly admitted residents with complex medical conditions did not have baseline care plans initiated or written summaries of care plans and order summaries provided to them or their representatives within 48 hours of admission, as required. Clinical records lacked evidence of these actions, and staff confirmed the deficiency.
The facility did not maintain safe storage of ice due to the kitchen ice machine's drain hose resting directly on an unclean floor drain without the required air gap, as confirmed by the Maintenance Director and manufacturer guidelines.
Two residents with indwelling foley catheters did not have privacy covers on their catheter bags, resulting in the bags being visible from the corridor. Both residents had significant medical conditions and required catheters, and the DON confirmed that privacy covers should have been in place according to facility policy.
A resident with moderate cognitive impairment and multiple health conditions experienced a significant change in condition, including respiratory distress and new medical interventions. Despite facility policy requiring notification, there was no documentation that the resident's representative was informed of these changes, and the resident expressed a desire for family notification. Staff interviews confirmed the lack of documentation and notification.
A resident with an indwelling Foley catheter did not have physician orders in place for the catheter or related care, and was observed with a urinary drainage bag on the floor and without a privacy cover, contrary to facility policy. The DON confirmed these deficiencies during interviews.
Three residents with respiratory conditions were found using oxygen concentrators with filters covered in dust and gray debris, and in two cases, oxygen tubing and nasal cannulas were observed lying on the floor. Facility policy required regular cleaning of filters, but this was not done, and the DON confirmed the equipment was not maintained as required.
A resident with end stage renal disease and a standing order for dialysis three times weekly did not have their dialysis communication binder available in the facility. The binder, which should contain essential information exchanged between the facility and the dialysis center, could not be located or reviewed. Both the DON and the Administrator confirmed the binder was not accessible, resulting in incomplete and inaccurate dialysis-related records.
Staff did not label opened multi-dose insulin vials with the date of opening in two medication carts, contrary to facility policy and manufacturer instructions. This made it impossible to determine how long the insulin vials had been in use, as confirmed by an RN during surveyor observations.
A resident with an indwelling catheter and wounds did not have enhanced barrier precautions (EBP) implemented as required, including missing signage and physician orders, despite facility policy and CDC guidelines mandating these infection control measures for high-contact care activities.
The facility did not meet the required nurse aide staffing ratios on several occasions across different shifts. On specific days, the number of NAs working was below the required number for the resident census, particularly affecting the overnight shift. The Nursing Home Administrator confirmed these staffing shortages during an interview.
The facility did not meet the required LPN staffing ratios, failing to provide the mandated number of LPNs per residents during both day and overnight shifts on several occasions. The Nursing Home Administrator confirmed these deficiencies.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on two occasions, providing only 2.96 and 3.16 hours on those days. This was confirmed by the Nursing Home Administrator after a review of staffing documents.
The facility failed to maintain kitchen equipment and sanitary operations, with observations revealing unclean ovens and stovetops, and lapses in the cleaning schedule. Additionally, a Dietary Aide was observed preparing coffee without a beard restraint, contrary to the facility's sanitary practices policy. The Dietary Manager confirmed these deficiencies.
A resident with depression, high blood pressure, and anxiety requested Benadryl for itchiness on two occasions, but the facility failed to notify the medical provider as required by policy. The clinical record showed a typed note to the physician with a handwritten response, but lacked documentation of physician notification on the dates of the requests. The DON confirmed the absence of evidence regarding the notification.
A multi-dose vial of Aplisol-PPD in a medication room was found opened and in use without an opened date label, contrary to manufacturer's instructions and facility policy. The DON confirmed the oversight.
Failure to Provide Written Notice Prior to Resident Room Changes
Penalty
Summary
The facility failed to provide written notice to residents and/or their responsible parties prior to making room changes for five out of seven residents reviewed. According to the facility's policy, the Social Worker is responsible for contacting family members or responsible parties to discuss room changes. However, clinical records for the affected residents did not contain evidence that residents were asked for their agreement to the room change or that written notification, including the reason for the change, was provided before the move occurred. The residents involved had various medical conditions, including diabetes, hypertension, anxiety, heart failure, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and vascular dementia. Documentation for each resident showed that room changes were made, but there was no record of written notification or consent prior to these changes. The Nursing Home Administrator confirmed during an interview that the required written notifications were not present in the clinical records for these residents.
Failure to Initiate and Communicate Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to residents and/or their representatives for four out of thirteen residents reviewed. Specifically, clinical records for these residents did not contain evidence that a baseline care plan was created within 48 hours of admission, nor that a summary of the care plan and physician orders was provided to the resident or their representative, as required. This deficiency was confirmed through clinical record review and staff interviews, and no facility policy regarding this process was provided. The residents affected had significant medical conditions, including dementia with severe cognitive impairment, protein-calorie malnutrition, pneumonia, malignant neoplasm of the prostate, sleep apnea, end stage renal disease, high blood pressure, kidney failure, diabetes, and amputation. Despite these complex needs, there was no documentation that their immediate care needs were assessed and planned for upon admission, nor that this information was communicated to them or their representatives.
Improper Ice Machine Drainage and Storage
Penalty
Summary
The facility failed to maintain safe storage of ice for residents by not ensuring the proper installation of the kitchen ice machine's drain hose. Review of manufacturer guidelines indicated that an air gap should be maintained between the drain tube and the floor drain. However, observations revealed that the ice machine hose drain was resting directly on the floor drain, with no vertical air gap present. The floor drain and the surrounding area were noted to be rusty and unclean. The Maintenance Director confirmed that the lack of an air gap allowed the hose drain to rest on the unclean floor drain, resulting in unsafe storage conditions for ice.
Failure to Maintain Privacy and Dignity for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure the privacy and dignity of residents with indwelling urinary catheters, as required by facility policy and resident rights regulations. Observations revealed that two residents with foley catheters did not have privacy covers on their catheter bags, making the bags visible from the corridor. One resident was observed sitting in a wheelchair with the catheter bag secured under the seat but lacking a privacy cover, and the resident expressed a desire for a privacy cover. Another resident was observed lying in bed with the catheter drainage bag on the floor, also visible from the corridor and without a privacy cover. Both residents had significant medical histories, including kidney failure, cellulitis, amputation, and diabetes, and had physician orders or documentation for indwelling foley catheters. The Director of Nursing confirmed during an interview that the catheter bags should have had privacy covers in place, as per facility policy. The deficiency was cited under resident rights and nursing services regulations.
Failure to Notify Resident's Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition and new treatments, as required by facility policy and regulatory standards. The resident in question had a history of Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, and obesity, and was identified as having moderate cognitive impairment with a BIMS score of 8/15. On the date in question, the resident experienced acute respiratory symptoms, including low oxygen saturation, irregular heart rate, and purple nail beds, which led to the administration of breathing treatments, diuretics, and steroids. The medical provider documented that the resident was high-risk and had a significant change in condition, resulting in new orders for antibiotics, steroids, and other medications. Despite these significant clinical changes and interventions, there was no documentation in the clinical record that the resident's representative was notified of the change in condition or new treatments. Interviews with the NHA and DON revealed that staff believed the resident did not want family notified, but there was no documentation to support this, and the resident stated a preference for family notification. The facility's policy required documentation of such notifications, including who was informed and their response, but this was not present in the record.
Failure to Ensure Physician Orders and Proper Catheter Care
Penalty
Summary
The facility failed to ensure that adequate physician orders were in place for an indwelling urinary catheter and did not provide appropriate catheter care for one resident. Review of the resident's clinical record showed that the individual was admitted with an indwelling Foley catheter, but there was no evidence of physician orders for the catheter or related care. Facility policy requires verification of physician orders for indwelling catheters and specifies proper handling and placement of catheter bags. Observations revealed that the resident's urinary drainage bag was placed on the floor, visible from the corridor, and lacked a privacy cover, which is contrary to facility policy. The Director of Nursing confirmed both the absence of physician orders for the catheter and that the catheter bag should not have been on the floor and should have had a privacy cover. These findings demonstrate a failure to follow established protocols for catheter care and documentation.
Failure to Maintain Clean Respiratory Equipment and Prevent Infection
Penalty
Summary
The facility failed to maintain cleanliness and prevent the spread of infection in the provision of respiratory care equipment for three residents. Observations revealed that the oxygen concentrator filters for all three residents were covered with a large amount of gray, fluffy substance, indicating that the filters had not been cleaned as required by facility policy. The policy specified that filters should be removed, rinsed, and dried weekly or more often if needed to keep them clean and free of dust. Additionally, for two residents, the oxygen tubing and nasal cannula were found lying on the floor, which was confirmed by both resident statements and staff interviews. The residents involved had significant medical conditions, including obstructive sleep apnea, end stage renal disease, high blood pressure, chronic obstructive pulmonary disease, respiratory failure, and obesity. Physician orders for these residents included continuous or as-needed oxygen therapy via nasal cannula. Despite these orders, the equipment used to deliver oxygen was not maintained in a sanitary manner, as evidenced by the dirty filters and tubing/cannulas in contact with the floor. The DON confirmed that the observed conditions did not meet facility standards for respiratory care equipment cleanliness.
Failure to Maintain Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident requiring dialysis services. According to the facility's agreement with the dialysis center, the facility is responsible for providing all relevant medical and administrative information about the resident, while the dialysis center is to supply the facility with updates and guidance regarding the resident's renal condition. However, review of the clinical record for a resident with end stage renal disease and a physician's order for dialysis three times weekly revealed that the dialysis communication binder, which should contain essential information exchanged between the facility and the dialysis center, was not readily available in the facility. Interviews with the resident, the DON, and the Nursing Home Administrator confirmed that the dialysis communication binder could not be located or reviewed at the time of the survey. The resident mentioned that the binder is usually kept in their wheelchair but was unsure of its current location. Both the DON and the Administrator acknowledged that the binder was not accessible, indicating a lapse in maintaining required medical records and communication as stipulated by facility policy and regulatory requirements.
Failure to Date Opened Multi-Dose Insulin Vials
Penalty
Summary
Facility staff failed to label multi-dose insulin vials with the date they were opened in two of three medication carts, as required by facility policy and manufacturer instructions. During observations, three opened and undated multi-dose insulin vials were found in one medication cart, and two opened and undated vials were found in another. The facility's policy directed staff to place a date opened sticker and record the date of opening and expiration on each vial, and the manufacturer's instructions specified that insulin vials expire 28 days after opening. A registered nurse confirmed that the vials were not dated upon opening, making it impossible to determine how long the vials had been in use.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter and Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for one resident who required such measures due to the presence of an indwelling urinary catheter and ongoing wound care. According to the facility's policy and CDC guidelines, EBP—including the use of isolation gowns and gloves during high-contact care activities—are necessary to prevent the spread of multidrug-resistant organisms (MDROs). Observations revealed that the resident's room did not have the required signage to alert staff and visitors of EBP requirements, despite the resident having both a catheter and wounds that necessitated these precautions. Interviews with the Director of Nursing confirmed that the resident's room lacked EBP signage and that the clinical record did not contain physician orders for EBP. The resident's medical history included an amputation of the left foot, diabetes, high blood pressure, and a coccyx wound, all of which increased the need for strict infection control measures. The failure to implement EBP as outlined in policy and regulatory requirements constituted a deficiency in the facility's infection prevention and control program.
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 the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum NA ratios on several occasions across different shifts. On the day shift of December 7, 2024, the facility had a census of 134 residents but only 13.27 NAs worked when 13.40 were required. On the evening shift of December 6, 2024, with a census of 136 residents, 11.97 NAs worked instead of the required 12.36. The overnight shift experienced the most significant shortages, with five days between December 2 and December 14, 2024, not meeting the required ratios. For instance, on December 2, 2024, with a census of 135 residents, only 6.70 NAs worked when 9.00 were required. The Nursing Home Administrator confirmed during an interview on January 3, 2025, that the facility did not meet the minimum NA ratios for the specified days and shifts. This acknowledgment indicates a systemic issue in maintaining adequate staffing levels to meet regulatory requirements. The report does not provide details on any specific residents affected or the direct impact on resident care, focusing instead on the staffing discrepancies and the facility's acknowledgment of these deficiencies.
Plan Of Correction
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. 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. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Nursing home administrator, Director of Nursing, 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. Nursing Home Administrator or designee will audit daily staffing ratios and along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.
LPN Staffing Shortages in Facility
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) as mandated by regulations effective July 1, 2023. Specifically, the facility did not maintain a minimum of one LPN per 25 residents during the day shift on December 10, 2024, when only 5.00 LPNs were available for a census of 132 residents, falling short of the required 5.28 LPNs. Additionally, the facility did not meet the minimum requirement of one LPN per 40 residents on the overnight shift for five days within the reviewed period. On December 3, 6, 7, 10, and 14, 2024, the number of LPNs working was consistently below the required number based on the resident census for each of those nights. The Nursing Home Administrator confirmed these staffing shortages during an interview on January 3, 2025.
Plan Of Correction
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. 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. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. 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. Nursing Home Administrator or designee will audit daily staffing ratios along with all steps taken to fill vacancies 5 days a week and ongoing. 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 nursing care per resident per day on two specific days. On December 6, 2024, the facility provided only 2.96 hours per patient day (PPD), and on December 11, 2024, it provided 3.16 PPD. This deficiency was identified through a review of the facility's nursing staffing documents covering the period from December 1, 2024, to December 14, 2024. The Nursing Home Administrator confirmed during a telephone interview that the facility did not meet the required minimum nursing care hours on these dates.
Plan Of Correction
The facility was unable to make corrective action for the minimum number of general nursing care hours for the identified days that have already passed. All residents received care in accordance with their care plans and physician orders. Director of nursing or designee will re-educate the labor manager and the RN supervisors on the 7/1/2024 for PPD requirements. Facility continues to offer incentives, competitive wages, and several other benefits in an effort to hire for all open positions. Nursing Home Administrator, Director of Nursing, and Labor manager will conduct daily staffing meetings Monday - Friday to review nursing staffing 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 to ensure shifts are filled and facility meets PPD requirements. Nursing Home Administrator or designee will audit daily staffing PPD along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly Quality Assurance Performance Improvement meeting.
Failure to Maintain Kitchen Sanitation and Employee Hygiene
Penalty
Summary
The facility failed to maintain kitchen equipment and sanitary operations in the main kitchen, as evidenced by observations and staff interviews. The facility's policy required daily cleaning of ovens and stovetops, with a more thorough monthly cleaning schedule. However, observations revealed that the stovetops and ovens were not cleaned as per the schedule, with dried food, debris, and aluminum foil found inside the ovens. The facility's records showed significant lapses in the cleaning schedule, with the oven not cleaned for eight of the last ten months and the stove not cleaned for seven of the last nine months. The Dietary Manager confirmed these findings during an interview. Additionally, the facility's policy on employee sanitary practices required all employees to wear hair restraints to prevent hair from contacting exposed food. However, during an observation of the tray line, a Dietary Aide was seen preparing coffee for residents without a beard restraint, despite having a beard of sufficient length that required one. The Dietary Manager confirmed that the employee should have been wearing a beard restraint, indicating a failure to adhere to the facility's sanitary practices policy.
Failure to Notify Physician of Resident's Treatment Needs
Penalty
Summary
The facility failed to notify a medical provider of a need to alter treatment due to resident symptoms and/or complaints for one of seven residents reviewed. The facility's policy requires staff to communicate changes in a resident's condition to the physician and document the notification and response. However, the clinical record of a resident with diagnoses including depression, high blood pressure, and anxiety, showed that the resident requested Benadryl for itchiness on two occasions, but there was no evidence that the medical provider was notified of these complaints. The resident's clinical record contained a typed note to the physician indicating a request for Benadryl, with a handwritten response lacking a date and time. Despite this, there was no progress note correlating with the typed note and response, and no evidence of physician notification on the dates the resident requested Benadryl. The Director of Nursing confirmed the lack of documentation regarding the notification of the medical provider about the resident's complaints and requests.
Failure to Label Multi-Dose Vial of Aplisol
Penalty
Summary
The facility failed to label a multi-dose vial of Aplisol-tuberculin purified protein derivative (PPD) injection with the date it was opened in one of the medication storage rooms, specifically in Two East Hall. According to the manufacturer's instructions, vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency. The facility's policy on medication storage, last reviewed on June 27, 2023, mandates that medications and biologicals be stored safely and properly, following the manufacturer's recommendations. During an observation on June 14, 2024, at approximately 10:30 a.m., it was noted that the vial was opened and in use but lacked an opened date label. The Director of Nursing confirmed the vial was undated and in daily use, acknowledging it should have been labeled with the date it was opened.
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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