Quality Life Services - Sarver
Inspection history, citations, penalties and survey trends for this long-term care facility in Sarver, Pennsylvania.
- Location
- 126 Iron Bridge Road, Sarver, Pennsylvania 16055
- CMS Provider Number
- 395534
- Inspections on file
- 27
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Quality Life Services - Sarver during CMS and state inspections, most recent first.
The facility failed to ensure residents were free from significant medication errors when ordered medications were not administered as prescribed and when medications were unavailable. Two residents with diabetes did not receive ordered bedtime Insulin Lispro doses, one due to the nurse’s inability to log into the eMAR and deciding it was too close to the next dose, and the other because the resident was sleeping. Another resident with cardiac conditions did not receive an ordered dose of Carvedilol when the medication was not available in the cart and required reordering, while the RN later reported that multiple active medications were missing from the cart, the emergency medication kit was not known to be available, and the eMAR did not display all medications due during the scheduled pass.
A resident sustained a serious right shoulder fracture during a transfer, but the facility did not identify or report the injury as potential abuse or neglect, nor did it conduct a root cause analysis as required by policy. The incident was only reported as a hospital transfer, leaving the potential for similar risks to other residents.
A resident sustained a serious shoulder fracture during a transfer, but the facility did not conduct or document a required investigation into the injury of unknown origin, nor did it complete or submit the necessary PB22 forms for staff involved, as mandated by its abuse and neglect policy.
The facility failed to report injuries of unknown source for three residents, as required by policy and federal regulations. One resident had a large bruise on the shoulder and side, another had bruising on the arm and hand, and a third had bruising under the arm consistent with lift use. Incident reports did not indicate notification to the State office, and the DON confirmed the reporting failure.
A facility failed to resolve a resident's grievance in a timely manner, as required by its policy. The resident reported not receiving medication until lunchtime and that her blood sugar was not checked in the morning. The grievance form lacked documentation of the investigation outcome, corrective actions, and resolution. Interviews confirmed the facility's failure to complete the grievance procedure, with missing signatures from the Nursing Home Administrator and Social Services.
The facility failed to notify a physician of abnormal glucose levels for two residents, as required by physician orders and facility policies. One resident experienced a hypoglycemic event with a blood sugar level of 48 mg/dl, and another had multiple instances of hyperglycemia with levels exceeding 400 mg/dl. Clinical records lacked evidence of physician notification for these critical conditions.
A facility failed to investigate a potential misappropriation of property involving a resident's Morphine Sulfate. Discrepancies in drug records were noted without proper documentation, and accusations of staff refusing end-of-shift narcotic counts were not thoroughly investigated.
The facility failed to communicate necessary resident information to the receiving health care provider for three residents transferred to a hospital. Despite the facility's policy requiring a transfer form and documentation, there was no evidence that care plan goals, advanced directives, and other essential information were shared. The Nursing Home Administrator confirmed this deficiency.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about hospital transfers for five residents, as required by regulations. The Nursing Home Administrator admitted to notifying only the local Ombudsman. The residents had various medical conditions necessitating hospital transfers, but the facility did not document the required notifications.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy and state regulations. This deficiency was identified for five residents with various medical conditions, including high blood pressure, anemia, and chronic kidney disease. The lack of documentation confirming notification was confirmed by a clinical consultant.
A facility failed to update a resident's care plan to include a physician-ordered 1800 ml fluid restriction. The resident, with diagnoses of atrial fibrillation, hypertension, and hypercholesterolemia, had a care plan that did not reflect this critical aspect of their care. The Nursing Home Administrator confirmed the oversight during an interview.
A resident with severe visual impairment and dementia was not provided with necessary assistance during mealtimes, as required by their care plan. Observations showed the resident's food was placed out of reach, and no staff were present to assist, leaving the resident unaware of available food. Interviews confirmed the lack of assistance, violating resident rights and nursing services regulations.
A facility failed to provide appropriate care for a resident receiving IV therapy and did not monitor wounds for two residents. One resident's IV tubing lacked a date, and the midline dressing was lifting, while another resident's skin tear was not documented for two weeks. A third resident's wound measurements were not recorded for over two weeks. These issues were confirmed by staff and the Nursing Home Administrator.
The facility failed to conduct weekly pressure ulcer assessments for two residents, as required by their policy. One resident with dementia and depression developed a stage 2 pressure injury, but a weekly assessment was missed. Another resident with seizure disorder and neurogenic bladder had a care plan for weekly wound assessments, but measurements were not completed on two occasions. These lapses were confirmed by staff interviews.
The facility failed to provide appropriate catheter care for two residents with indwelling urinary catheters. One resident's catheter bag was not covered, and an irrigation set was improperly stored. Another resident's catheter bag lacked a privacy cover and was incorrectly positioned. These deficiencies were confirmed by LPNs and acknowledged by the Nursing Home Administrator.
The facility failed to provide appropriate respiratory care for three residents. A resident's oxygen concentrator and CPAP machine were improperly stored, while two other residents had undated and improperly stored respiratory equipment. LPNs confirmed these deficiencies, and the Nursing Home Administrator acknowledged the failure.
The facility failed to maintain accurate physician's orders and conduct proper assessments for residents using bed rails. One resident had side rails without physician orders or care plan identification, while another had orders for side rails but did not use them. A third resident's assessment lacked a side rail evaluation despite having enabler bars. These deficiencies were confirmed through observations and staff interviews.
The facility failed to follow pharmacy procedures for controlled drug reconciliation on a medication cart. A resident's Morphine Sulfate record showed adjustments due to spillage/dehydration without the required date, time, and witness signatures. The Nursing Home Administrator confirmed this failure.
A facility failed to document and administer a pneumococcal vaccine to a resident with heart failure, depression, and high blood pressure. Despite a physician's order and signed consent, the vaccine was not given due to a scheduling error. This deficiency was identified during a review of the resident's immunization records and an interview with a clinical consultant.
The facility failed to meet state-mandated staffing requirements from mid-July to early August 2024. It did not provide the required number of nurse aides per resident during daylight, evening, and night shifts, and also fell short of the minimum 3.2 hours of direct care per patient daily for several days. These deficiencies were confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, exhibited increased elopement risk and behavioral changes. Despite incidents of wandering, aggression, and exit-seeking, the facility failed to update the care plan to reflect the resident's current status and needs. The care plan did not include new interventions to address these behaviors, as confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to inadequate supervision. Despite wearing a Wanderguard bracelet, the resident managed to exit the facility unsupervised, triggering alarms multiple times. Staff, including a maintenance employee, failed to adequately monitor the resident's movements, leading to the elopement incident.
Failure to Administer Ordered Insulin and Cardiac Medications as Prescribed
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when ordered medications were not administered as prescribed and when medications were unavailable. For one resident with anxiety, depression, and diabetes, a physician’s order directed administration of Insulin Lispro via sliding scale before meals and at bedtime. A progress note documented that the resident did not receive the ordered bedtime Insulin Lispro because the nurse was unable to log into the computer and determined it was too close to the next dose to administer. For a second resident with similar diagnoses and an order for Insulin Lispro via sliding scale before meals and at bedtime, a progress note documented that the resident did not receive the ordered bedtime insulin dose because the resident was sleeping. A third resident with heart failure, hypertension, and atrial fibrillation had a physician’s order for Carvedilol 6.25 mg by mouth twice daily for ventricular tachycardia. The January MAR showed a nurse entry to “see nurse’s note” for an evening dose, and a subsequent progress note documented that the medication was not available in the medication cart and needed to be reordered. In a written statement, the RN reported that multiple active medications were not available in the cart during the scheduled evening medication pass and that they were not informed that an emergency medication kit was available in the facility. The RN also reported that the eMAR did not display all medications due during the scheduled pass, and that additional missed medications were only identified after a later review. An LPN interview confirmed that medications are to be given within one hour before or after the scheduled time and that residents should be awakened to receive medications.
Failure to Identify and Investigate Serious Injury as Potential Abuse or Neglect
Penalty
Summary
The facility failed to identify and investigate a serious physical injury as a potential case of abuse or neglect for one resident. The resident sustained a displaced avulsion fracture of the right shoulder during a transfer from bed to wheelchair, which was accompanied by a loud crack, pain, and swelling. An x-ray confirmed the fracture, and the resident was transferred to the hospital for further evaluation. The facility's policy requires that serious physical injuries be reported to the state agency, investigated, and appropriate documentation completed for each alleged perpetrator. However, the facility only notified the state agency of the resident's hospital transfer and did not report the incident as alleged abuse or neglect, as required for injuries of unknown origin. There was no documented evidence that a root cause analysis was conducted to determine if abuse or neglect contributed to the injury. This failure to properly identify, report, and investigate the incident left the potential for other residents to be at risk for abuse or neglect.
Failure to Investigate Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse and neglect policy in response to a serious physical injury of unknown origin sustained by a resident. According to the facility's policy, any serious physical injury resulting in pain and impaired physical functioning requires a thorough investigation, including completion of reports and PB22 forms within five working days. However, after a resident experienced a displaced right humeral fracture during a transfer from bed to wheelchair, there was no documented evidence that the facility conducted or completed the required investigation or submitted the necessary PB22 forms for each alleged perpetrator involved. Review of the resident's medical records indicated that the injury occurred during a pivot transfer, when the resident heard and felt a loud crack in her shoulder, resulting in pain and swelling of the right hand. The injury was confirmed by a hospital emergency room evaluation. Staff interviews further confirmed that the facility did not follow its own abuse or neglect policy, as there was no documentation of a thorough investigation, no verification of return demonstration of the transfer procedure by the alleged perpetrator, and no submission of PB22 forms as required by policy.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report injuries of unknown source for three residents, as required by both facility policy and federal regulations. The facility's policy, dated 11/21/24, mandates that all reports of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must be investigated and documented, with notification to the PA Department of Health/Long Term Care Division within 24 hours. However, the facility did not adhere to this policy for the residents in question. Resident R1, admitted on 9/9/22, was found with a large bruise on 1/8/25, covering the right shoulder, side, breast, and under the breast. The incident report did not indicate that the State office was notified of this injury of unknown source. Similarly, Resident R2, admitted on 2/24/23, was noted to have bruising on the right arm and left hand on 1/11/25, with no witnessed injury. The incident report for Resident R2 also lacked notification to the State office. Resident R3, admitted on 2/28/23, was reported to have bruising under the right arm on 1/16/25, which was consistent with the use of a Sit-to-Stand lift. Again, the incident report did not show that the State office was notified. The Director of Nursing confirmed during an interview that the facility failed to report these injuries of unknown source for all three residents, as required by regulations.
Failure to Resolve Resident Grievances Timely
Penalty
Summary
The facility failed to effectively resolve and provide timely responses to resident grievances, as evidenced by a review of facility policy, resident grievances, and interviews with residents and staff. The facility's policy, dated 8/17/23, emphasizes the importance of addressing grievances promptly to maximize quality of care and satisfaction. However, the review of the Grievance/Complaint Logs for October and November 2024 revealed that a grievance filed by a resident on 10/27/24 was not addressed in a timely manner. The resident reported not receiving medication until lunchtime and that her blood sugar was not checked in the morning. The grievance form lacked documentation of the investigation outcome, corrective actions, and resolution, indicating a failure to adhere to the facility's grievance policy. Interviews conducted on 11/19/24 confirmed the facility's failure to resolve and respond to grievances effectively. The Director of Nursing acknowledged that the grievance procedure was not completed in its entirety for one of the three grievances reviewed. Additionally, the concern form was missing signatures from the Nursing Home Administrator and Social Services, further highlighting the facility's non-compliance with its grievance policy. This deficiency is in violation of several Pennsylvania Code regulations, including those related to the responsibility of the licensee, management, resident care policies, and resident rights.
Failure to Notify Physician of Abnormal Glucose Levels
Penalty
Summary
The facility failed to notify a physician of abnormal glucose levels for two residents, as required by the physician's orders and facility policies. Resident R33, who has diagnoses including diabetes, renal insufficiency, and heart failure, experienced a hypoglycemic event with a blood sugar level of 48 mg/dl. Despite the administration of orange juice and a carbohydrate snack, the clinical record did not document any notification to the physician about this critical condition, which was a requirement per the facility's hypoglycemia protocol. Similarly, Resident R20, who has diabetes and other chronic conditions, exhibited multiple instances of hyperglycemia with blood glucose levels exceeding 400 mg/dl on several occasions in September 2024. The facility's records, including clinical nurse notes and physician documentation, lacked evidence of physician notification for these abnormal glucose readings, as mandated by the resident's physician orders. Interviews with Clinical Consultant Employee E2 confirmed these lapses in communication for both residents.
Failure to Investigate Misappropriation of Property
Penalty
Summary
The facility failed to thoroughly investigate a potential allegation of abuse/neglect related to the misappropriation of property for a resident. The facility's policy on resident protection from abuse, neglect, mistreatment, or exploitation requires that all reports of such incidents be investigated and documented thoroughly. However, the facility did not adhere to this policy when discrepancies were noted in the controlled drug records for a resident's Morphine Sulfate. The records showed adjustments in the drug amount with reasons cited as spillage/dehydration, but lacked proper documentation such as date, time, and witness signatures. Additionally, there were accusations that nursing staff refused to perform end-of-shift narcotic counts, which were not thoroughly investigated. Witness statements from LPNs indicated that some nurses did not want to perform the narcotic count at the end of their shifts, and the facility failed to provide additional documentation to show that these accusations were investigated. The Nursing Home Administrator was unsure if further statements were obtained, and the facility did not provide evidence of a thorough investigation into these allegations.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for three residents who were transferred to a hospital and expected to return. The facility's policy on medical emergencies, dated 12/1/23, required that a transfer form be completed and appropriate documentation be sent with the resident. However, for Residents R28, R34, and R40, there was no documented evidence that specific information, such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information, was communicated to the receiving facility. Resident R28, diagnosed with high blood pressure, hyperlipidemia, and hip pain, was transferred on 12/12/23. Resident R34, with anemia, respiratory failure, and depression, was transferred on 2/9/24. Resident R40, diagnosed with high blood pressure, asthma, and muscle weakness, was transferred on 6/27/24. In each case, the clinical records lacked documentation of the necessary communication to the receiving health care provider. The Nursing Home Administrator confirmed this failure during an interview on 9/26/24.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five residents. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The residents involved were transferred to the hospital on various dates, but the facility did not document evidence of notifying the Ombudsman as required. The Nursing Home Administrator confirmed during an interview that the facility only notified the local Ombudsman, not the state Ombudsman, which is a violation of the regulations. The residents affected had various medical conditions, including high blood pressure, hyperlipidemia, anemia, respiratory failure, depression, asthma, muscle weakness, encephalopathy, chronic kidney disease, acute respiratory failure, diabetes, and chronic respiratory failure. These conditions necessitated hospital transfers, but the facility's failure to notify the Ombudsman was consistent across all cases reviewed. The deficiency was noted under 28 Pa. Code 201.29 (a)(c)(3)(2) regarding resident rights.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their own policy and state regulations. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 12/1/23, mandates that nursing staff provide a copy of the bed-hold notice to residents upon transfer. However, for five residents who were transferred to the hospital, there was no documented evidence that this notification was provided. These residents included individuals with various medical conditions such as high blood pressure, hyperlipidemia, anemia, respiratory failure, and chronic kidney disease. The clinical records of these residents, identified as R20, R28, R34, R40, and R67, showed that they were transferred to the hospital on different dates, but none had documentation of receiving the bed-hold policy notice. For instance, Resident R28 was transferred on 12/12/23, and Resident R34 on 2/9/24, among others. The deficiency was confirmed during an interview with Clinical Consultant Employee E2, who acknowledged the facility's failure to comply with the notification requirement for all five hospital transfers.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for Resident R123 to accurately reflect the current status of the resident. Resident R123 was admitted with diagnoses including atrial fibrillation, hypertension, and hypercholesterolemia. The Minimum Data Set (MDS) assessment confirmed these diagnoses as current. Physician orders dated 9/17/24 indicated a 1800 ml fluid restriction for the resident. However, the Resident Care Plan Summary Report, also dated 9/17/24, did not include this fluid restriction. During an interview, the Nursing Home Administrator confirmed the failure to revise the care plan as required, which is a violation of 28 Pa. Code: 211.11(d) regarding resident care plans.
Failure to Assist Resident with ADLs During Mealtimes
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for a resident, identified as Resident R39, who was observed to require partial to moderate assistance for eating due to severe visual impairment and other medical conditions such as high blood pressure and dementia. The facility's policy mandates a program of ADL assistance to maintain residents' functional abilities, yet during observations on two consecutive days, Resident R39 was left unattended during mealtimes. The resident's lunch tray was placed in a manner that left several food items out of reach, and no staff were present to assist her, despite her care plan indicating the need for staff assistance during meals. Interviews with the resident and staff confirmed the lack of assistance. Resident R39, who is legally blind, was unaware of the food items on her tray and expressed hunger when informed of the remaining food. A nurse aide, upon being notified, confirmed that the resident had not been assisted as required and that the food was cold. The clinical consultant also confirmed the facility's failure to provide the necessary ADL assistance, which is a violation of the resident's rights and nursing services regulations.
Deficiencies in IV Therapy and Wound Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services for a resident receiving intravenous therapy. Resident R34, who had diagnoses of anemia, respiratory failure, and depression, was observed with an IV catheter in her right upper extremity. The facility's policy required that midline catheter dressings be changed at specified intervals to prevent infections. However, during an observation, it was noted that Resident R34's IV tubing did not have a date, and the midline dressing was lifting away from the skin and lacked a date. This was confirmed by an LPN and the Nursing Home Administrator. Additionally, the facility did not adequately monitor and document the wounds of two residents. Resident R37, who had high blood pressure, muscle wasting, and unsteadiness, had a skin tear on the left shin. Weekly skin assessments were not documented for the weeks of 9/8/24 and 9/15/24, despite the facility's policy requiring weekly documentation. Similarly, Resident R52, with high blood pressure, non-Alzheimer's dementia, and peripheral vascular disease, had a wound on the right calf. The last documented measurements were on 9/10/24, and no further measurements were recorded until 9/25/24, as confirmed by an LPN. These deficiencies indicate a failure to adhere to the facility's policies on intravenous therapy and wound management, resulting in inadequate care for the residents involved. The lack of proper documentation and monitoring of wounds and IV therapy could potentially lead to adverse outcomes for the residents, as confirmed by the Nursing Home Administrator.
Failure to Conduct Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to properly assess pressure ulcers for two residents, R2 and R60, as per their policy on Skin Integrity and Wound Management. Resident R2, who has diagnoses of dementia and depression, developed a stage 2 pressure injury in-house on the sacrum/coccyx/anal area. The facility's policy required weekly wound assessments, but a Weekly Skin and Wound Note was not completed for the week of 9/16 - 9/20/24. This lapse was confirmed by Clinical Consultant Employee E2 during an interview. Similarly, Resident R60, with diagnoses of seizure disorder, epilepsy, and neurogenic bladder, had a physician's order for weekly skin checks and a care plan that required weekly wound assessments. However, the last recorded measurements were on 9/6/24, and assessments were not completed on 9/13/24 and 9/20/24, as confirmed by LPN Employee E9. The Clinical Consultant Employee E2 confirmed the facility's failure to properly assess pressure ulcers for these residents.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with indwelling urinary catheters. Resident R25, who was admitted with diagnoses including obstructive uropathy and heart failure, had a care plan indicating a risk for urinary tract infection due to the presence of an indwelling catheter. During an observation, it was noted that Resident R25's catheter drainage bag was not covered with a dignity pouch as required by facility policy. Additionally, an irrigation set was found undated and improperly stored, with acetic acid not secured or dated, which was confirmed by an LPN. Similarly, Resident R34, who had an indwelling Foley catheter, was observed with a catheter bag lacking a privacy cover and positioned facing the entrance of the room, contrary to care plan interventions. This was confirmed by an LPN. The Nursing Home Administrator acknowledged the facility's failure to ensure appropriate treatment and services for both residents, as required by state regulations.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as observed during a survey. Resident R33, who has diagnoses of renal insufficiency, heart failure, and high blood pressure, was found with an oxygen concentrator and nasal cannula tubing lying uncovered on the floor, without a date as required by facility policy. Additionally, the CPAP machine's headgear tubing was resting in a cobweb on the floor. Licensed Practical Nurse (LPN) Employee E4 confirmed these observations, indicating non-compliance with the facility's policy to replace and store respiratory equipment properly. Resident R34, diagnosed with anemia, respiratory failure, and depression, was observed with nasal cannula tubing and a humidification bottle that lacked a date. The nebulizer machine's face mask was hanging on the oxygen concentrator and was not stored in a plastic bag when not in use. Similarly, Resident R40, with high blood pressure, asthma, and muscle weakness, had a nebulizer machine with the mouthpiece and medication cup lying on a table, undated and not stored in a plastic bag. LPN Employee E1 confirmed these deficiencies, and the Nursing Home Administrator acknowledged the facility's failure to provide appropriate respiratory care for these residents.
Inaccurate Physician Orders and Assessments for Bed Rail Use
Penalty
Summary
The facility failed to maintain accurate physician's orders and conduct proper assessments for residents using bed rails. For Resident R25, the physician's orders did not include the use of side rails, and the care plan did not identify their use, despite the resident being observed with rails on both sides of the bed. The assessment for Resident R25 also failed to indicate a side rail evaluation. Similarly, Resident R26's physician orders included side rails for repositioning, but the care plan did not specify the adaptive equipment in use, and the resident was observed without side rails, which she confirmed she did not want. The clinical consultant confirmed that the physician orders should have been discontinued. For Resident R33, the physician's orders and care plan included the use of enabler bars to promote mobility and independence, but the assessment failed to indicate a side rail evaluation. The resident was observed with bilateral rails on the upper half of the bed. The clinical consultant confirmed the facility's failure to have accurate physician's orders for two residents and to conduct ongoing accurate assessments for another resident. These deficiencies were identified through observations, clinical record reviews, and staff interviews.
Failure to Implement Controlled Drug Reconciliation Procedures
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on one of its medication carts, specifically the Pennsylvania Medication Cart. According to the facility's policy on the management of controlled drugs, any destruction of drugs must be witnessed by another licensed staff member, and both the person who destroys the drug and the witness must sign the documentation. Additionally, a complete count of all controlled drugs is required at the change of shifts, with two licensed nurses performing the count and signing the inventory. However, the facility did not adhere to these procedures. The clinical record review revealed that a resident, who was admitted with diagnoses including high blood pressure, muscle wasting, and unsteadiness on feet, had a physician's order for Morphine Sulfate, a controlled pain medication. The Controlled Drug Record for this resident showed adjustments in the medication amount due to spillage/dehydration, but these entries lacked the required date, time, and witness signatures. The Nursing Home Administrator confirmed the failure to implement the necessary pharmacy procedures during an interview.
Failure to Document and Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to accurately document education and immunization administration related to pneumococcal vaccines for a resident identified as R26. The facility's policy on administering pneumococcal vaccines requires identifying adults in need of vaccination, screening for contraindications, providing the Vaccine Information Statement (VIS), and recording the vaccination details in the medical record. However, for Resident R26, who was admitted with diagnoses of heart failure, depression, and high blood pressure, there was no evidence in the clinical record that the pneumococcal vaccine was administered despite a physician's order dated 5/20/24. The deficiency was identified during a review of Resident R26's immunization consent records, which showed an initial consent on 4/12/24 that was not addressed by 9/26/24. A second consent was signed on 5/20/24, but the vaccination was not administered. An interview with Clinical Consultant Employee E2 revealed that the order was entered into the computer but was not scheduled to be given, leading to the failure in documentation and administration of the vaccine. This deficiency was noted under the Pennsylvania Code sections related to nursing services and resident rights.
Facility Fails to Meet State-Mandated Staffing Requirements
Penalty
Summary
The facility failed to ensure sufficient nursing staff to comply with state laws regarding mandated minimum staffing requirements from July 15, 2024, to August 5, 2024. According to the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, the facility was required to have a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. The facility did not meet these requirements for the entire period reviewed, with specific deficiencies noted on each shift. For the daylight shift, the facility consistently had fewer nurse aides than required, failing to meet the minimum staffing levels for all 21 days reviewed. The evening and night shifts also experienced significant staffing shortages. The facility failed to provide the required number of nurse aides for 18 out of 21 evening shifts and 20 out of 21 night shifts. Additionally, the facility did not meet the minimum requirement of 3.2 hours of direct resident care per patient daily for 11 out of the 21 days reviewed. These deficiencies were confirmed by the Nursing Home Administrator during a telephonic interview on August 6, 2024.
Failure to Update Care Plan for Resident with Elopement Risk
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident R1, to accurately reflect the current status and needs of the resident. The resident was admitted with diagnoses including Non-Alzheimer's Dementia, renal insufficiency, high blood pressure, and anxiety, and was assessed with severe cognitive impairment. The care plan initially included interventions for elopement risk, such as the use of a Wanderguard bracelet and providing distractions to prevent wandering. Despite multiple incidents indicating increased elopement risk and behavioral changes, the care plan was not revised to include new interventions. The resident exhibited behaviors such as ramming a wheelchair into a heater, wandering into unauthorized areas, and making threats. The resident was also found attempting to exit the facility multiple times, triggering the Wanderguard alarm, and was involved in incidents of verbal aggression and confusion. The facility's failure to update the care plan was confirmed by the Nursing Home Administrator. The care plan did not reflect the resident's ongoing behaviors of exit-seeking, confusion, agitation, and wandering, which were documented in progress notes. This lack of updates and revisions to the care plan did not align with the facility's policy on comprehensive care planning and elopement prevention.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who had severe cognitive impairment due to non-Alzheimer's dementia, was identified as being at risk for elopement and was equipped with a Wanderguard bracelet. Despite this, the resident managed to exit the facility unsupervised, triggering the Wanderguard alarm multiple times. The resident's care plan included measures to distract him from wandering, but these were not effectively implemented. The resident exhibited behaviors such as wandering, attempting to exit the facility, and becoming agitated and aggressive. Progress notes indicated multiple instances where the resident attempted to leave the facility, including opening the front doors and activating the Wanderguard alarm. On one occasion, the resident was able to access an elevator with a maintenance employee who was unaware of the resident's restrictions, leading to the resident's unsupervised movement within the facility. Interviews and documentation revealed that staff, including a maintenance employee, were not adequately attentive to the alarms or the resident's movements. The facility's policies on elopement prevention and accident prevention were not effectively followed, contributing to the resident's ability to elope. The nursing home administrator confirmed the failure to provide adequate supervision, which resulted in the elopement incident.
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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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