Quality Life Services - Sugar Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Worthington, Pennsylvania.
- Location
- 120 Lakeside Drive, Worthington, Pennsylvania 16262
- CMS Provider Number
- 395410
- Inspections on file
- 25
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Quality Life Services - Sugar Creek during CMS and state inspections, most recent first.
The facility did not properly maintain cleanliness and sanitation in the Main Kitchen, with food spillage and brown debris observed on walls behind key preparation and waste areas. A Registered Dietitian confirmed the lack of adherence to required sanitation standards.
The facility did not provide quarterly banking statements to several residents with personal funds managed by the facility, instead sending the statements to their responsible parties. Residents reported not receiving or being aware of these statements, and facility staff confirmed the statements were not sent directly to the residents as required.
Three residents with diagnoses such as anxiety, dementia, and hypertension received Ativan without required 14-day stop dates or documented physician rationale for extended use, and staff failed to document non-pharmacological interventions prior to administration, contrary to facility policy.
The facility did not inform residents about its grievance policy or procedures. Residents were unaware of who the grievance officer was, how to file a grievance, or where to find grievance forms, and there was no evidence in resident council minutes or facility records that this information had been provided. The social worker, who serves as the grievance officer, confirmed the lack of documentation or communication regarding the grievance process.
Two residents experienced actual harm due to neglect when staff failed to follow care plans requiring two-person assistance for transfers. One resident suffered a skin tear during a transfer performed by only one staff member, while another was left unattended in the bathroom and sustained multiple fractures and a dislocation after attempting to self-transfer. The DON confirmed that required protocols were not followed, resulting in neglect.
A resident with significant mobility limitations and a high fall risk was left unattended in the bathroom, contrary to her care plan and physician orders requiring two-person assistance for transfers. After staff left to respond to another alarm, the resident fell and sustained multiple injuries, including a dislocated elbow and fractures. The facility did not conduct a complete and thorough investigation of the incident as required by its own policies.
A resident with significant mobility and safety needs was left unsupervised in the bathroom after requesting privacy, leading to a fall that resulted in multiple fractures and a dislocated elbow. Staff responded to another alarm, leaving the resident unattended, and the incident was not reported to the state as an allegation of neglect, contrary to facility policy and regulatory requirements.
A resident with significant mobility limitations and a high risk for falls was left alone in the bathroom after requesting privacy, resulting in a fall and multiple injuries, including fractures and a dislocation. The facility did not conduct or document a thorough investigation into the incident as possible neglect, as required by policy, and the DON confirmed this failure during interview.
The facility did not ensure that all necessary resident information was communicated to the receiving health care provider during a transfer for a resident with multiple diagnoses, and failed to provide a physician-completed discharge summary for another resident who left against medical advice. These deficiencies were confirmed through record review and staff interviews.
A resident with severe cognitive impairment and a history of unsteadiness experienced an unwitnessed fall resulting in multiple skin tears. Despite facility policy requiring neurological checks after such incidents, no ongoing neurological assessments were performed or documented, as confirmed by the DON.
A resident with dementia and a history of wandering was found in a non-resident area after leaving their unit unsupervised. The resident, who required ongoing redirection, did not have a care plan addressing wandering, and staff confirmed the resident's access to unauthorized areas due to inadequate supervision.
A resident with multiple medical conditions and a PICC line for IV therapy did not have their PICC site dressing changed within the required seven-day interval, as facility policy and professional standards dictate. An LPN confirmed the lapse in care, which resulted in inadequate treatment and care for the resident.
Two residents with PTSD were not provided with trauma-informed care, as their care plans failed to identify or address specific triggers that could lead to re-traumatization. The Social Service Director confirmed that the facility did not take steps to eliminate or mitigate these triggers.
A resident with multiple medical conditions did not receive prescribed artificial tear solution as ordered when an LPN failed to administer the eye drops during a medication pass, despite facility policy requiring medications to be given as prescribed.
Surveyors found that drugs and biologicals were not stored safely or securely in one medication room and three medication carts. Expired Tuberculin vials, prepoured medications left unattended, unlabeled and undated insulin pens, and opened medications without dates were observed. LPNs and the DON confirmed these deficiencies, which were not in line with facility policy or regulations.
A deficiency occurred when an LPN did not follow infection control protocols during a wound dressing change for a resident. The LPN failed to set up a clean barrier field, did not perform hand hygiene after removing gloves, and used a pen from her pocket during the procedure, leading to cross contamination.
Surveyors found that one of three crash carts contained expired supplies, including a Foley Insertion Kit, IV Start Kit, Dressing Kit, Yanker Suction device, and Tracheostomy Care Tray, as well as a syringe piston that was not sealed closed. The Assistant DON confirmed the findings and that the cart was not maintained as required by facility policy.
The facility did not employ a full-time qualified Food Service Director for ten months. The current FSD lacks certification and formal education in food service management. A Registered Dietitian is employed but only works two days a week and focuses on clinical duties. The Nursing Home Administrator confirmed the FSD's lack of qualifications, and a review of another employee's file also showed insufficient qualifications for the role.
The facility failed to communicate necessary resident information to receiving health care providers during transfers for four residents. This included not providing care plan goals for residents with conditions such as high blood pressure, chronic pain, depression, dysphagia, diabetes, and heart failure. The Nursing Home Administrator confirmed that care plans were typically not sent with residents during hospital transfers.
The facility failed to provide colostomy care consistent with professional standards for two residents. One resident's care plan lacked details on the colostomy appliance, while another resident's care plan did not include interventions for a new colostomy, nor was there an assessment of the stoma. These deficiencies were confirmed by the DON and other staff.
The facility failed to ensure accurate MDS assessments for two residents regarding tobacco use. Despite evidence and staff confirmation of smoking, the MDS inaccurately indicated no tobacco use for both residents, violating the RAI User's Manual guidelines.
The facility failed to notify a physician of high blood glucose levels for a resident with diabetes and did not obtain physician orders for a wound on another resident. The first resident's CBG levels exceeded the threshold for physician notification, but no documentation of notification was found. The second resident had a wound with no physician orders documented, confirmed by the DON.
A resident with dementia, anxiety, and muscle weakness was not provided sufficient fluid intake, as observed on multiple occasions without water at her bedside. Staff interviews confirmed the deficiency, with a nurse aide acknowledging the failure to pass water as required. The resident reported being consistently thirsty and having to request water, highlighting the facility's failure to meet her hydration needs.
A facility failed to provide appropriate respiratory care for a resident with obstructive sleep apnea, high blood pressure, and heart failure. The resident's care plan required oxygen therapy, but observations showed CPAP and nasal cannula oxygen tubing improperly stored on the ground. A nurse confirmed the improper storage, indicating a failure in providing adequate respiratory care.
The facility did not date opened medications in the Willow Medication Cart, violating its medication storage policy. An observation revealed that eye drops and a Lantus pen for two residents were not dated upon opening. This was confirmed by an LPN and the Nursing Home Administrator.
The facility failed to properly contain and dispose of garbage in its outdoor trash receptacle, as observed during a survey. The facility's policy requires trash to be deposited into a sealed container, but approximately five empty boxes were found outside the dumpster. This was confirmed by the Food Service Director, potentially leading to rodent and insect infestation, violating management and administrative responsibilities.
A facility failed to maintain accurate clinical records for a resident, resulting in discrepancies regarding the location of a skin tear. The resident, admitted with dementia and other conditions, had a documented fall resulting in a wound. Records inaccurately noted the wound on the left elbow, while observations confirmed it was on the right. The DON confirmed the error, highlighting a failure to adhere to documentation standards.
A resident's wheelchair was not maintained in a safe condition, with a broken right arm that could easily disconnect. Despite the facility's awareness of the issue since March, the necessary repair part was not confirmed until June, resulting in an 84-day delay. The resident, with multiple health conditions, reported the issue had persisted for six weeks, and the Nursing Home Administrator confirmed the failure to maintain the equipment safely.
The facility failed to maintain an infection prevention and control program during a GI illness outbreak by not timely investigating and documenting surveillance, excluding ill staff from working, educating staff on appropriate precautions, and implementing preventative measures. This placed all residents at risk and led to an Immediate Jeopardy situation.
The NHA and DON failed to effectively manage the facility to prevent the transmission of Norovirus, affecting 46 residents. Their inaction led to a violation of several state codes and placed residents in Immediate Jeopardy.
The facility failed to notify the physician and family representative of a change in condition for two residents. One resident experienced two episodes of emesis, and another had four episodes of emesis and two episodes of diarrhea. Despite the RN being aware, there was no documentation of notification to the physician and family, as required by facility policy.
Failure to Maintain Kitchen Cleanliness and Sanitation
Penalty
Summary
The facility failed to maintain proper cleanliness and sanitation in the Main Kitchen, as evidenced by observations of food spillage and brown debris buildup on the walls behind the cook's preparation area, the Robocoupe/blender area, and the garbage can next to the steamer. These findings were confirmed during an interview with a Registered Dietitian, who acknowledged that the facility did not uphold the required standards for kitchen cleanliness and sanitation. The facility's own policy requires adherence to all local, state, and federal standards to ensure a safe and sanitary food service department, which was not met in this instance.
Failure to Provide Residents with Quarterly Banking Statements
Penalty
Summary
The facility failed to provide residents with their quarterly banking statements for personal funds managed by the facility. During a group interview, residents reported not receiving these statements and were unaware that they were entitled to them. A review of documentation showed that for three residents, the quarterly statements were sent to their responsible parties rather than directly to the residents themselves. The Business Office Manager confirmed that the statements were sent to the responsible parties as indicated on the statements, and the Nursing Home Administrator acknowledged that the facility did not send the required statements to the residents who had funds in their accounts.
Failure to Prevent Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications for three out of five reviewed residents. For each of these residents, physician orders for Ativan, a psychotropic medication used to treat anxiety, did not include a required 14-day stop date, nor was there documented physician rationale for extending the medication beyond 14 days. The Medication Administration Records showed that these residents received Ativan multiple times over several months. Additionally, the facility's own policy required that non-pharmacological interventions be attempted and documented prior to administering psychotropic medications, but there was no evidence in the progress notes that such interventions were used or assessed for effectiveness before giving Ativan. The affected residents had various diagnoses, including anemia, hypertension, anxiety, dementia, and a cervical fracture. Despite these conditions, the clinical records and progress notes lacked documentation of non-pharmacological approaches prior to medication administration, as required by facility policy. The Director of Nursing confirmed that the facility did not ensure the medication regimens were free from unnecessary psychotropic medications for these residents.
Failure to Inform Residents of Grievance Policy and Procedures
Penalty
Summary
The facility failed to inform residents about its grievance policy and procedures, as required. Review of the facility's policy indicated that multiple communication avenues should be available for residents, family, and staff to report concerns. However, during a resident group interview, all residents reported not knowing who the grievance officer was, how to file a grievance, where grievance forms were located, or what the process entailed. Residents also stated they did not know how the facility responded to concerns. Examination of resident council minutes over a six-month period showed no discussion of resident rights, grievance procedures, or identification of the grievance officer. The social worker, who is the grievance officer and attends resident council, confirmed that there was no documentation or evidence that residents had been informed about the grievance process or related policies and procedures.
Failure to Prevent Resident Neglect Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure that two residents were free from neglect, resulting in actual harm. For one resident with diagnoses including anemia, heart failure, and hypertension, the care plan required transfers with the assistance of two staff members due to high fall risk and dependency. However, the resident was transferred with only one staff member, contrary to the care plan. During this transfer, the resident sustained a skin tear on the lower left leg, which was likely caused by contact with the bed frame. The incident was discovered when the resident was being assisted back to bed after sitting at the nurse's station, and the skin tear was noted and treated at that time. Another resident, diagnosed with arthritis, Parkinson's disease, and depression, also required two-person assistance for transfers and was considered a high fall risk. The care plan specified the use of a call light and prompt staff response for assistance, as well as the provision of a bedpan or bedside commode as needed. Despite these requirements, the resident was left unattended in the bathroom after being transferred to the toilet. The resident attempted to self-transfer, resulting in a fall that caused a dislocation of the right elbow, a fracture of the right distal radius, and a fracture of the right coronoid process of the ulna. The injuries were confirmed by mobile x-ray and hospital evaluation. In both cases, the facility did not follow established care plans and physician orders regarding the level of assistance required for transfers. The failure to provide the necessary staff support directly led to physical harm for both residents. The Director of Nursing confirmed that the required protocols were not followed, resulting in neglect as defined by the facility's own policies and state regulations.
Failure to Implement Abuse and Neglect Prevention Policies Resulting in Resident Injury
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation, specifically by not ensuring a complete and thorough investigation of a potential neglect incident involving a resident. The facility's policy requires procedures for screening, training, prevention, identification, investigation, protection, reporting/response, and corrective action to protect residents from abuse, neglect, and exploitation. However, documentation and staff interviews revealed that these procedures were not fully followed in the case reviewed. A resident with diagnoses including arthritis, Parkinson's disease, and depression was assessed as requiring assistance from two staff members for transfers and was identified as a high fall risk. The care plan specified that the resident needed prompt assistance and that the call light should be within reach. Despite these requirements, the resident was left unattended in the bathroom after requesting privacy, with the call bell placed in her hand. Staff left to respond to another resident's alarm, and the resident subsequently fell, sustaining a dislocated right elbow, fractures of the distal radius, and the coronoid process of the ulna. The incident was not investigated in accordance with the facility's policy, which mandates a thorough internal investigation using incident reports, interviews, and documentation of injuries. The DON confirmed that the resident was left unattended, resulting in the fall and injuries, and acknowledged that the facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of the incident.
Failure to Report Allegation of Neglect Following Resident Fall and Injury
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident, as required by its own policy and state regulations. The policy mandates immediate notification of the Administrator or Director of Nursing (DON) and subsequent reporting to the Pennsylvania Department of Health when incidents of abuse, neglect, exploitation, or mistreatment are alleged or suspected. Despite this, the facility did not submit a report of neglect to the state survey agency for the incident involving the resident. The resident in question had diagnoses including arthritis, Parkinson's disease, and depression, and was assessed as requiring assistance from two staff for transfers, with safety interventions such as bed and chair alarms and a low bed. The care plan also indicated the need for prompt response to requests for assistance and provision of a bedpan or bedside commode as needed. On the date of the incident, the resident was found self-transferring in the bathroom after requesting privacy, and subsequently fell, resulting in significant injuries including a right elbow dislocation, wrist fracture, and elbow fracture. Staff responded to another resident's alarm, leaving the resident unsupervised in the bathroom. The resident was later found on the floor, in pain, and required medical intervention including x-rays, orthopedic evaluation, and hospital treatment. Despite the severity of the incident and the facility's policy requirements, the event was not reported to the state as an allegation of neglect. The DON confirmed during interview that the facility failed to report the incident as required.
Failure to Investigate Possible Neglect After Resident Injury
Penalty
Summary
The facility failed to fully investigate an incident involving a resident who sustained injuries after attempting to self-transfer to the toilet. The resident, who had diagnoses including arthritis, Parkinson's disease, and depression, was care planned as high risk for falls and required assistance of two staff for transfers, with safety interventions such as bed and chair alarms and a low bed. On the day of the incident, the resident was found by a nursing assistant standing at the toilet, self-transferring. The resident requested privacy, and staff placed the call bell in her hand before leaving the room to respond to another resident's alarm. Shortly after, the resident was found on the floor outside the bathroom, complaining of pain in her right arm, wrist, and shoulder. Subsequent assessments and imaging revealed that the resident had sustained a right elbow dislocation, a fracture of the distal radius, and a fracture of the coronoid process. The resident required hospital evaluation and orthopedic intervention, including conscious sedation and reduction of the dislocation. The care plan for the resident included prompt response to requests for assistance and provision of a bedpan or bedside commode as needed, but the incident report indicated that the resident was left alone in the bathroom after requesting privacy, and staff were diverted to another resident's alarm. The facility's policy requires that all incidents of abuse, neglect, or injuries of unknown source be thoroughly investigated and documented, including notification of the Administrator or DON and reporting to the state health department. However, review of facility-submitted reports showed that the incident was not investigated as a possible case of neglect, nor was an allegation of neglect documented. The DON confirmed during interview that the facility failed to fully investigate the incident to eliminate possible neglect.
Failure to Communicate Resident Information and Provide Physician Discharge Summary
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer for one resident. Specifically, for a resident with diagnoses including anemia, dementia, and diabetes, there was no documented evidence that the facility provided the receiving provider with essential information such as care plan goals, advanced directives, specific instructions for ongoing care, resident representative information, and other details required to meet the resident's needs at the receiving facility. This omission was identified during a review of the clinical record following the resident's transfer to a hospital and subsequent return. Additionally, the facility did not provide a discharge summary completed by a physician for another resident who left the facility against medical advice. During a closed record review, it was confirmed by the medical records staff and the Director of Nursing that the discharge summary was missing from the resident's medical record. These findings were based on facility policy review, clinical record review, and staff interviews.
Failure to Perform Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to provide ongoing neurological assessments following an unwitnessed fall for one resident. According to facility policy, all residents who experience a fall, whether witnessed or unwitnessed, are to receive immediate assessment to determine the extent of injury, including neurological checks if a head injury is suspected. The policy also requires monitoring of vital signs and neurological status as indicated and ordered. In this case, the resident was found on the floor after a thud was heard, with the resident reporting that he did not hit his head but sustained four skin tears on his arm. The clinical record and treatment administration record did not include any post-fall neurological checks for this unwitnessed fall. The resident involved had a history of unsteadiness, abnormal gait, hypertension, and severe cognitive impairment as indicated by a low BIMS score. The care plan identified the resident as being at risk for falls. Despite these risk factors and the unwitnessed nature of the fall, the required neurological assessments were not performed or documented. The DON confirmed during interview that the facility did not provide ongoing neurological assessment after the incident.
Failure to Supervise Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with a history of wandering and dementia. The resident, who had diagnoses including a cervical fracture and unspecified dementia, was documented as wandering throughout the building and requiring continuous redirection to stay out of other residents' rooms. On one occasion, the resident was found in a storage area near the kitchen, which was not designated for residents, after being identified by a dietary aide. The resident stated they were looking for a cup of coffee and was subsequently redirected back to the nursing unit by a nurse aide. A review of the resident's clinical record revealed there was no care plan in place addressing the resident's wandering behavior. Staff interviews confirmed the resident's history of wandering and the incident where the resident accessed an unauthorized area. The Director of Nursing acknowledged that the resident had entered a non-resident area and that the situation was brought to the attention of nursing staff by dietary personnel. The lack of a care plan and insufficient supervision contributed to the resident's ability to access areas outside of their designated unit.
Failure to Change PICC Line Dressing per Protocol
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident with a peripherally inserted central catheter (PICC) in accordance with professional standards of practice. Facility policy required that PICC line dressings be changed every seven days or sooner if soiled, using aseptic technique. However, during an observation, the resident's PICC site dressing was found to be dated two weeks prior, indicating that the dressing had not been changed within the required timeframe. The resident involved had multiple diagnoses, including heart failure, diabetes, and osteomyelitis of the right ankle and foot, and was receiving intravenous Zosyn via the PICC line. The care plan specified that the IV site should be checked for signs of infection and that the dressing should remain intact and be changed according to protocol. During an interview, an LPN confirmed that the dressing had not been changed as required, resulting in a failure to follow professional standards for PICC line care.
Failure to Identify and Address PTSD Triggers in Resident Care Plans
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with post-traumatic stress disorder (PTSD). Both residents' care plans acknowledged their PTSD diagnoses but did not identify specific triggers or outline strategies to avoid or mitigate those triggers. This omission was confirmed by the Social Service Director, who acknowledged that the facility did not identify PTSD triggers for these residents, thereby failing to take steps to eliminate or reduce the risk of re-traumatization. The residents involved had additional medical conditions, including anemia, high blood pressure, coronary artery disease, and dementia, as documented in their clinical records and Minimum Data Set (MDS) assessments.
Failure to Administer Ordered Eye Drops
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anemia, heart failure, and hypertension did not receive medication as ordered by the physician. The physician's order specified that artificial tear solution was to be administered as one drop in both eyes twice daily. During a medication pass observation, an LPN prepared the resident's medications and placed the artificial tears in her pocket but failed to administer the eye drops to the resident as required. The LPN continued with medication administration for other residents without returning to provide the missed eye drops. Upon inquiry, the LPN acknowledged that the eye drops had not been given as ordered. Facility policies reviewed indicated that medications are to be administered safely and as prescribed, and that physician orders must be followed and carried out by authorized personnel. The failure to administer the prescribed eye drops constituted a significant medication error for this resident.
Failure to Store and Label Medications Properly in Medication Rooms and Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in a safe, secure, and orderly manner in one of two medication rooms and in three of five medication carts. Specifically, expired vials of Tuberculin were found in the Hemlock medication room, and multiple medication carts contained prepoured pills and liquid medications that were not immediately administered, as well as medications that were not properly labeled or dated. For example, the Hickory hall medication cart contained several medication cups with prepoured pills and a cup of prepoured liquid medication for residents who were not present, and the Hemlock hall medication cart had a Lantus insulin pen without an open or expiration date. Additionally, the [NAME] hall medication cart contained bisacodyl suppositories stored together with oral medications, an unlabeled and undated Tioujeo insulin pen not stored in a bag, and several opened bottles of medications and sprays without dates. These findings were confirmed by interviews with LPNs and the Director of Nursing, who acknowledged the failure to store all drugs and biologicals in accordance with facility policy and regulatory requirements.
Failure to Prevent Cross Contamination During Wound Dressing Change
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection prevention and control procedures during a dressing change for a resident with a right lateral unstageable wound. The facility's policies require the use of medical aseptic technique, including setting up a clean barrier field, performing hand hygiene after glove removal, and stopping the procedure if aseptic technique is broken. During the observed dressing change, the LPN placed dressing supplies on a towel on the resident's bed rather than on a disinfected over-bed table with a protective barrier, as required by policy. Additionally, after removing the resident's boot and sock, the LPN changed gloves but did not perform hand hygiene. After applying ointment, the LPN removed her gloves, used a pen from her pocket to date the dressing, returned the pen to her pocket, and then applied new gloves without performing hand hygiene. The LPN confirmed during an interview that she did not set up a clean barrier field and did not complete hand hygiene after glove removal, resulting in a failure to prevent cross contamination during the dressing change.
Expired and Unsealed Supplies Found on Crash Cart
Penalty
Summary
Surveyors determined that the facility failed to ensure that equipment was in safe operating condition for one of three crash carts located in the Exam Room. During an observation, multiple expired supplies were found on the crash cart, including a Foley Insertion Kit, IV Start Kit, Dressing Kit, Yanker Suction device, and a Tracheostomy Care Tray. Additionally, a syringe piston was found not sealed closed. Review of the facility's Emergency Cart policy indicated that the cart should be appropriately stocked and ready for use in emergencies, with its inventory maintained. The Assistant Director of Nursing confirmed these findings and acknowledged that the required standards for equipment readiness were not met.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to employ a full-time qualified Food Service Director (FSD) for ten months, from August 2023 through June 2024. During an initial tour, the current FSD, Employee E3, admitted to not being a Certified Dietary Manager (CDM) and lacking formal education or certificates in food service management. The facility employs a Registered Dietitian (RD) who is present only two days per week and is responsible solely for clinical duties. The Nursing Home Administrator confirmed that Employee E3 did not meet the necessary qualifications. A review of Employee E2's file, who had been employed since August 2023, also showed a lack of qualifications for the FSD role. The RD further confirmed the absence of a qualified FSD for the entire ten-month period, violating 28 Pa. Code: 211.6(c)(d) Dietary services.
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 during facility-initiated transfers for four residents. This deficiency was identified through clinical record reviews and staff interviews. The facility did not document or convey specific information, such as care plan goals, to the receiving health care providers for residents who were transferred to the hospital and expected to return. This lack of communication was noted for residents with various medical conditions, including high blood pressure, chronic pain syndrome, depression, dysphagia, diabetes, heart failure, and unsteadiness on feet. The report highlights that the facility did not adhere to the requirements outlined in Title 42 CFR S483.15(c)(2), which mandates documentation and communication of specific resident information during transfers. The Nursing Home Administrator confirmed that the facility typically did not send care plans with residents when they were transferred to the hospital. This oversight affected the safe and effective transition of care for the residents involved, as the receiving health care providers did not receive the necessary information to meet the residents' specific needs.
Failure to Provide Adequate Colostomy Care for Residents
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for two residents. Resident R58, who was admitted with a colostomy, had a care plan that did not include essential details such as the type of appliance, size of the appliance or wafer, and type of collection bag required for colostomy maintenance. Despite a physician's order for colostomy care every shift and as needed, these critical elements were missing from the care plan, as confirmed by the Director of Nursing. Similarly, Resident R262, who was admitted with a new colostomy, did not have care interventions related to the colostomy included in their care plan. Furthermore, there was no assessment of the resident's stoma to ensure adequate perfusion from the time of admission through a specified period. The Licensed Nurse Assessment Coordinator confirmed the absence of a baseline care plan for the resident's colostomy, and the Nursing Home Administrator acknowledged the failure to provide care consistent with professional standards.
Inaccurate MDS Assessments for Tobacco Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the tobacco use status of two residents, identified as Resident R9 and Resident R58. According to the Resident Assessment Instrument (RAI) User's Manual, the MDS assessments should include accurate information about a resident's health conditions, including tobacco use. However, the MDS for both residents incorrectly indicated that they did not use tobacco, despite evidence to the contrary. Resident R9's MDS dated 5/17/24 showed no tobacco use, yet a facility list and a smoking assessment confirmed that Resident R9 smoked cigarettes. Similarly, Resident R58's MDS also inaccurately reflected no tobacco use, while multiple smoking assessments and staff interviews confirmed that Resident R58 smoked cigarettes. Interviews with facility staff, including the Registered Nurse Assessment Coordinator (RNAC) and the Director of Nursing, confirmed the inaccuracies in the MDS assessments for both residents. The RNAC acknowledged that Resident R58 was observed smoking upon arrival at the facility, and the Director of Nursing confirmed the failure to accurately document Resident R9's tobacco use. These discrepancies indicate a failure to adhere to the facility's policy and the RAI User's Manual guidelines, which require accurate and timely completion of MDS assessments to reflect residents' current health conditions.
Failure to Notify Physician and Obtain Orders for Resident Care
Penalty
Summary
The facility failed to notify the physician of increased Capillary Blood Glucose (CBG) levels for a resident with diabetes mellitus, high blood pressure, and an overactive bladder. The resident had a physician order to check CBG levels in the morning and notify the physician if the result was less than 60 mg/dL or greater than 400 mg/dL. On two occasions, the resident's CBG levels were recorded as 415 mg/dL and 458 mg/dL, but there was no documentation that the physician was notified of these abnormal high blood glucose levels as ordered. The Director of Nursing confirmed this failure during an interview. Additionally, the facility did not obtain physician orders for a wound on another resident who was admitted with dementia, a rib fracture, and high blood pressure. The resident had a large abrasion with dried blood below the right elbow, but the clinical record did not include an order for the wound from the time of admission through several days later. An observation revealed an undated bandage on the resident's right elbow, and the Director of Nursing confirmed the lack of physician orders for the wound.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to ensure that Resident R54 was offered sufficient fluid intake to maintain proper hydration and health. The resident, who has diagnoses of dementia, anxiety, and muscle weakness, was observed on multiple occasions without water at her bedside. On June 10, 2024, Resident R54 reported having asked for water an hour prior, yet no water was present, and she was observed with a dry mouth. The resident expressed that she is always thirsty and that staff do not leave water at her bedside, requiring her to ask for it. Interviews with staff confirmed the deficiency. Nurse Aide, Employee E5, acknowledged that water is supposed to be passed every shift and in between, confirming the failure to offer sufficient fluid intake. On June 13, 2024, further observations and interviews with Activity Aide, Employee E6, and the Director of Nursing confirmed that Resident R54 did not have water at her bedside, reinforcing the facility's failure to meet the hydration needs of the resident.
Inadequate Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident R75, who was admitted with diagnoses including obstructive sleep apnea, high blood pressure, and heart failure. The resident's care plan indicated the need for oxygen therapy due to ineffective gas exchange. Physician's orders required the weekly change and dating of oxygen tubing for both general oxygen therapy and CPAP use. However, observations revealed that the CPAP oxygen tubing was not in use and was found on the ground during a survey. Further observations noted that the nasal cannula oxygen tubing was also not in use and was on the ground. A registered nurse confirmed that the oxygen tubing was not stored properly when not in use. This lack of proper storage and maintenance of respiratory equipment led to the determination that the facility did not provide adequate respiratory care for the resident, violating specific state codes related to the responsibility of the licensee and nursing services.
Failure to Date Opened Medications in Medication Cart
Penalty
Summary
The facility failed to adhere to its medication storage policy by not dating opened medications in one of its medication carts, specifically the Willow Medication Cart. During an observation, it was noted that several medications were not dated upon opening, including TobraDex and Muro 128 eye drops for one resident, and a Lantus pen and Dorzolamide HCl-Timolol Maleate eye drops for another resident. This oversight was confirmed by an LPN and the Nursing Home Administrator during interviews. The facility's policy requires that opened medications be dated to ensure proper usage within the manufacturer's specified timeframe.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly contain and dispose of garbage in its outdoor trash receptacle, as observed during a survey. The facility's policy on Waste Disposal, dated 4/8/24, requires that trash be deposited into a sealed container outside the premises. However, during an observation on 6/10/24 at 11:00 a.m., approximately five empty boxes were found piled up outside of the dumpster. This improper disposal of garbage was confirmed by the Food Service Director, Employee E93, during an interview conducted at the same time. The failure to properly contain and dispose of garbage could potentially lead to rodent and insect infestation, violating the facility's management and administrative responsibilities as outlined in 28 Pa. Code 201.18(b)(3) and 28 Pa. Code 207.2(a).
Inaccurate Clinical Documentation for Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for a resident, identified as Resident R260. The deficiency was identified during a clinical record review and staff interview. The facility's policy on medical records, dated December 12, 2023, mandates that medical records must contain complete and accurate documentation that clearly identifies the resident and justifies the diagnoses, condition, treatment, care approaches, and responses to the care provided. However, discrepancies were found in the documentation of Resident R260's medical records. The resident was admitted with diagnoses including dementia, a rib fracture, and high blood pressure. A progress note dated June 5, 2024, indicated that the resident was admitted from the hospital after a fall, with a large abrasion and dried blood below the right elbow. Contradictory information was found in the Non-Pressure Wound Tool report dated the same day, which described the affected area as the left elbow with a skin tear. An observation and interview on June 10, 2024, revealed that the resident had a bandage on the right elbow and confirmed the skin tear resulted from a fall at home. Further confirmation from the Director of Nursing on June 12, 2024, verified that the wound was indeed on the right elbow, highlighting the facility's failure to maintain accurate clinical records for Resident R260. This discrepancy in documentation was a violation of the facility's policy and state regulations regarding clinical records and nursing services.
Failure to Maintain Safe Wheelchair Condition
Penalty
Summary
The facility failed to maintain patient care equipment in a safe operating condition for a resident, identified as Resident R11. The resident, who has diagnoses including dementia, morbid obesity, hemiplegia following a cerebral infarction, and muscle weakness, was admitted to the facility on an unspecified date. The facility was aware of the need to repair the resident's wheelchair as early as March 14, 2024, but the order for the necessary wheelchair part was not confirmed until June 6, 2024, resulting in an 84-day delay. During interviews conducted on June 11 and June 12, 2024, it was revealed that the right arm of the resident's wheelchair had been broken for six weeks and could easily disconnect if pulled. The Nursing Home Administrator confirmed awareness of the issue and acknowledged the failure to maintain the equipment safely.
Failure to Implement Infection Control Measures During GI Illness Outbreak
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not timely investigating and documenting surveillance, excluding ill staff from working, educating staff on appropriate precautions related to gastrointestinal (GI) illness, and implementing preventative measures to address an outbreak of GI illness among residents. The report indicates that the facility did not follow CDC guidelines for the prevention and control of norovirus gastroenteritis outbreaks in healthcare settings. Specifically, the facility did not cohort symptomatic residents, place them on contact precautions, or ensure proper use of personal protective equipment (PPE). Additionally, the facility failed to actively promote hand hygiene using soap and water during the outbreak, as recommended by the CDC and the Pennsylvania Department of Health (PADOH) Toolkit for Control of Norovirus Outbreaks in Long-Term Care Facilities. The report highlights several instances where the facility's inaction led to the spread of the GI illness. For example, Resident CR8 developed symptoms on 4/25/24, but the facility did not initiate surveillance until five days later. Resident CR8 was not placed on contact precautions, and the resident's physician was not notified. Similarly, Resident R14 had episodes of emesis, but no contact precautions were implemented, and the resident remained cohorted with an asymptomatic resident. The facility's line list of residents who contracted the GI illness was incomplete, failing to document several residents who developed symptoms. The facility also failed to exclude ill staff from working, allowing them to return to work before completing the required 48 hours of symptom resolution. Multiple staff members, including LPNs, nurse aides, housekeeping aides, and maintenance technicians, returned to work while still potentially contagious. Additionally, the facility did not notify visitors of the outbreak, failed to post appropriate signage, and did not screen visitors for symptoms of GI illness. These lapses in infection control procedures placed all 100 residents at risk and led to an Immediate Jeopardy situation.
Removal Plan
- All Residents will be assessed immediately for any signs and symptoms of norovirus, if identified the following will occur: Residents will be cohorted to a single unit when possible. Resident will immediately be placed in contact isolation until symptom free for a minimum of 48 hours. RN Supervisor will notify MD for orders for contact isolation. Orders will be placed into the chart for contact isolation. Residents will remain in their rooms when possible, and educate on norovirus fact sheet. The residents who exhibit symptoms will be placed in isolation with signage on the door to indicate the appropriate PPE that is needed to provide care. The Registered Nurse Assessment Coordinator (RNAC) will ensure that the resident's care plan is updated with the norovirus upon identification.
- For duration of outbreak the facility will do the following: Residents will remain in their rooms when possible. Residents will be cohorted to a single unit when possible. Activities will be provided on each individual unit during outbreak period. Residents will be encouraged to have their meals in their rooms.
- The IDT team will review infection control procedures and policies and update as needed.
- Whole house education will be provided by DON or designees on the following: Hand hygiene and the use of soap and water. Signage on the door to indicate the appropriate PPE that is needed to provided care. How to protect themselves as well as other residents from being exposed to Norovirus using the Norovirus Face sheet and Tool kit. Education will be provided to all current staff members before the start of their next shift including agency. A notice is placed at the time clock informing staff to report to DON or designee to complete education.
- The DON, ADON, infection Preventionist, and NHA or designee will review documentation on the current residents for signs and symptoms of nausea, vomiting, and diarrhea during am clinical throughout the duration of the outbreak. DON, ADON, NHA, IP or designee will audit during outbreak daily, after outbreak will monitor weekly for the first month, and monthly thereafter.
- Families and staff will be notified of an outbreak with the norovirus via alert media. Signs will be posted at the entrance doors indicating that there is an outbreak of the Norovirus. Visitor screening tool will be placed at the front desk during the outbreak. All visitors will be screened for signs and symptoms of the illness and instructed to speak to a member of the nursing team prior to visiting. Staff experiencing signs and symptoms of norovirus will notify manager immediately and will not be permitted to return to work until 48 hours after symptoms resolve.
- The DON and/or the infection Preventionist will follow-up with the local department of health for further guidance and testing requirements for outbreak.
- Housekeeping will increase frequency by the minimum of twice a day of cleaning and disinfecting of residents rooms with active Norovirus symptoms and common areas, and high touch areas. Ongoing infected resident rooms will have additional disinfecting using Rapid Multi Surface Disinfectant Cleaner.
- The review of infection control procedures and policies will be reviewed during our monthly quality assurance meeting to ensure compliance.
Failure to Prevent Norovirus Transmission
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the development and transmission of communicable infections, specifically Norovirus, affecting 46 residents. The job descriptions for both the NHA and DON outlined their responsibilities to ensure compliance with federal, state, and local standards and to maintain the highest degree of resident care. However, during an interview, both the NHA and DON confirmed their failure to manage the facility effectively, leading to the transmission of Norovirus. This failure placed residents in Immediate Jeopardy and violated several state codes, including 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(b)(1)(3)(e)(1), 28 Pa. Code 207.2 (a), and 28 Pa. Code 211.12(d)(1)(2)(3)(5).
Failure to Notify Physician and Family of Change in Condition
Penalty
Summary
The facility failed to notify the physician and a family representative of a change in condition for two residents, Resident R14 and Resident CR8. Resident R14, who had diagnoses of anxiety, depression, and dementia, experienced two episodes of emesis on 4/25/24. Despite the Registered Nurse being aware, there was no evidence in the clinical record that the physician and family representative were notified of this change in condition. Similarly, Resident CR8, who had diagnoses of high blood pressure, dementia, and depression, experienced four episodes of emesis and two episodes of diarrhea on 4/25/24. Although the RN was notified, there was no documentation indicating that the physician and family representative were informed of the change in condition. During interviews, it was confirmed that the facility's policy requires timely notification of the physician and family when a resident exhibits a change in condition. Licensed Practical Nurse, Employee E6, stated that any notification must be documented in the resident's clinical record and indicated that she had informed the RN Supervisor, who is responsible for calling the physician. The Director of Nursing confirmed that the facility failed to notify the physician and family representative for the changes in condition for both residents. This failure is a violation of the facility's policy and state regulations.
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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