Quarryville Presbyterian Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Quarryville, Pennsylvania.
- Location
- 625 Robert Fulton Highway, Quarryville, Pennsylvania 17566
- CMS Provider Number
- 395336
- Inspections on file
- 17
- Latest survey
- August 30, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Quarryville Presbyterian Retirement Community during CMS and state inspections, most recent first.
Residents repeatedly raised concerns about cold food and flies in the dining room during Resident Council meetings, but the facility did not provide evidence of prompt or effective action to resolve these issues. Pest control records showed no fly treatments, and interviews confirmed that residents felt their complaints were not addressed.
The facility did not ensure that as-needed psychotropic medications were limited to 14 days or had documented physician rationale for continued use, and failed to document non-pharmacological interventions prior to administering these medications for several residents with cognitive impairment and behavioral symptoms. The DON confirmed the lack of required documentation for both medication extension and non-pharmacological interventions.
A deficiency was identified when an ice machine in the main kitchen was found with visible build-up of pink and black substances, and no documentation was available to show that required monthly cleaning had been performed. The Dietary Manager confirmed the need for cleaning, and facility policy required monthly sanitation and quarterly servicing by a third-party vendor.
Two residents with cognitive impairment and diagnoses such as Alzheimer's dementia, depression, and anxiety were given Ativan, a psychotropic medication, without documented informed consent from their representatives. The facility's practice was to obtain consent only for antipsychotic medications, not for other psychotropics, as confirmed by the DON.
The facility did not verify the nurse aide registry status for a newly hired aide or check the nursing license status for a newly hired RN before employment, as required by policy. These omissions were confirmed through personnel file review and staff interviews.
A resident admitted with sinusitis was later diagnosed with COVID-19 and placed on droplet precautions, but the baseline care plan was not updated to reflect the new diagnosis or required precautions, as confirmed by staff and documentation review.
Two residents receiving warfarin for conditions such as atrial fibrillation and heart failure did not have individualized care plans addressing their anticoagulant therapy, as confirmed by facility leadership and review of clinical records.
The facility did not update care plans for two residents to reflect changes in their medical treatments. One resident's care plan listed intermittent catheterization despite having an indwelling Foley catheter, while another resident's care plan included anticoagulant and insulin administration that were no longer being provided. Nursing leadership confirmed that the care plans were not revised as required.
The facility failed to complete a safety assessment for a resident using an electric lifting recliner chair, despite the resident's poor safety awareness and impulsive actions. Additionally, another resident with severe cognitive impairment was transported in a wheelchair without leg rests, causing her foot to drag on the floor, as the staff member did not ensure the use of appropriate assistance devices.
A resident with mild cognitive impairment, Parkinsonism, and dementia, who was dependent on staff for toileting, did not receive assistance according to her individualized scheduled toileting program. Interviews indicated staff did not always respond to her requests outside of scheduled times, and there was no documentation that the toileting program was completed as outlined in her care plan.
A facility failed to complete a physician's discharge summary for a resident prior to or at the time of discharge. The resident was discharged without the necessary documentation, and this oversight was confirmed by the Nursing Home Administrator during an interview.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage 4 Pressure Ulcer, as required by their policy. The absence of EBP signage and communication in the resident's room was observed, and interviews with the DON, Nursing Home Administrator, and Wound Nurse confirmed the lapse. This deficiency was noted under several Pennsylvania Code regulations.
Failure to Promptly Address Resident Council Grievances on Food Temperature and Flies
Penalty
Summary
The facility failed to promptly address grievances raised by the Resident Council regarding food temperatures and the presence of flies in the dining room. Resident Council meeting minutes from three consecutive months documented repeated concerns about these issues. During each meeting, residents were told to report food temperature concerns immediately and were reminded of ongoing pest control efforts, but no evidence was provided to show that the facility took prompt or effective action in response to the Council's repeated complaints. Interviews with residents confirmed that their concerns about cold food and flies were brought up multiple times without resolution. Pest control records showed no treatments for flies during the relevant months, and there was no documentation of new interventions after the initial purchase of a fly catcher. Facility leadership acknowledged the ongoing complaints but did not implement additional measures to address the issues, and tray audits were only conducted prior to the reported concerns.
Failure to Limit and Document Use of PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications and that non-pharmacological interventions were attempted prior to administering as-needed (PRN) psychotropic medications. Facility policy required minimizing the use of psychotropic medications, avoiding unnecessary drug use, and promoting non-pharmacological interventions. However, for four residents reviewed, there was no documented evidence that these requirements were met. For multiple residents with cognitive impairment and diagnoses such as dementia, depression, and anxiety, physician orders prescribed PRN Ativan for agitation or anxiety. In several cases, the medication was administered beyond the 14-day limit without documented physician rationale for continuation, as required. Additionally, review of Medication Administration Records and clinical documentation revealed that staff did not document attempts at non-pharmacological interventions prior to administering PRN Ativan, despite care plans and psychiatric consults specifying this requirement. Interviews with the Director of Nursing confirmed the lack of documentation for both the required physician rationale for extended PRN psychotropic use and the use of non-pharmacological interventions prior to medication administration. These findings were observed for four residents over multiple months, indicating a pattern of non-compliance with facility policy and regulatory requirements regarding psychotropic medication management.
Failure to Maintain Sanitary Ice Machine in Kitchen
Penalty
Summary
The facility failed to ensure that ice was made and stored in sanitary conditions in one of its two ice machines located in the main kitchen. According to the facility's policy, ice machines were to be cleaned monthly by removing the ice, washing the interior with a sanitizing solution, and allowing it to dry before refilling. Additionally, a third-party vendor was contracted to service the machine quarterly. However, review of the service log showed no documented evidence of monthly cleaning. During an observation, a build-up of a pink substance was noted on the right-hand corner of a white plastic piece inside the ice machine, and a black substance was observed along the entire length of a strip at the top of the machine, while the chest was full of ice. The Dietary Manager confirmed at the time that the ice machine needed cleaning.
Failure to Obtain Informed Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to inform residents or their representatives in advance about the risks, benefits, and treatment alternatives associated with the use of psychotropic medications prior to administration. Specifically, two residents with cognitive impairments and diagnoses including Alzheimer's dementia, depression, and anxiety were administered Ativan (lorazepam), an antianxiety and antipsychotic medication, without documented evidence of informed consent. For one resident, physician orders indicated the use of transdermal Ativan gel as needed for agitation, and the medication was administered multiple times over several months. However, there was no documentation that the resident's representative was informed or provided consent prior to the initiation of this medication. Similarly, another resident with cognitive impairment and diagnoses of Alzheimer's dementia and anxiety received both oral and transdermal Ativan for anxiety and agitation, as ordered by the physician. The medication administration records confirmed multiple doses were given, but again, there was no evidence in the clinical record that informed consent was obtained from the resident's representative before starting the medication. An interview with the DON confirmed that the facility was only obtaining informed consent for antipsychotic medications, not for other psychotropic medications.
Failure to Verify Nurse Aide Registry and RN Licensure Prior to Hire
Penalty
Summary
The facility failed to follow its own abuse prohibition policy by not verifying the standing of a newly hired nurse aide on the Pennsylvania Nurse Aide Registry prior to employment, as required. Additionally, the facility did not check the licensure status of a newly hired registered nurse with the State Board of Nursing before the nurse began work. These deficiencies were identified through a review of personnel files and confirmed in interviews with the Director of Human Resources, who acknowledged that the required verifications were not completed prior to the respective hires.
Failure to Update Baseline Care Plan for Resident with New COVID-19 Diagnosis
Penalty
Summary
The facility failed to ensure that a baseline care plan was implemented to address a resident's immediate needs following admission. Upon admission, the resident was diagnosed with sinusitis and was to receive medication for three days, which was reflected in the initial care plan. However, the following day, the resident tested positive for COVID-19 and was placed in respiratory isolation with droplet precautions, as observed by signage on the resident's door and confirmed by staff interviews. Despite these developments, there was no documented evidence in the clinical record that the baseline care plan was updated to include the resident's new diagnosis of COVID-19 and the need for droplet precautions. The Assistant Director of Nursing confirmed that the care plan was not revised to reflect these changes.
Failure to Develop Individualized Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop individualized care plans addressing anticoagulant therapy for two residents. For one resident, the quarterly MDS assessment indicated cognitive impairment and the need for assistance with care, as well as an active order for warfarin to treat atrial fibrillation. Despite these needs, there was no documented evidence of a care plan related to anticoagulant therapy for this resident, as confirmed by the Director of Nursing. Similarly, another resident, who was cognitively intact and required staff assistance for daily care, had diagnoses including heart failure and was also receiving warfarin per physician's orders. The Assistant Director of Nursing confirmed that this resident's care plan did not address care and treatment needs related to anticoagulant medication use. These findings were based on a review of facility policy, clinical records, and staff interviews.
Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to accurately reflect the current care needs of two residents. For one resident with a history of stroke who was cognitively intact and required assistance with daily care, the care plan indicated the need for intermittent straight catheterization, despite a physician's order for an indwelling Foley catheter for urinary retention. The resident confirmed the presence of an indwelling catheter, and the Assistant Director of Nursing acknowledged that the care plan had not been revised to reflect this change. For another resident with a history of hip fracture and diabetes, the care plan included interventions for anticoagulant therapy with Lovenox and insulin administration. However, a review of the Medication Administration Record for two consecutive months showed no evidence that the resident received either medication. The Director of Nursing confirmed that the resident was no longer receiving Lovenox or insulin and that the care plan should have been updated to reflect this change.
Failure to Complete Safety Assessments and Ensure Use of Assistance Devices
Penalty
Summary
The facility failed to complete a safety assessment for a resident who used an electric lifting recliner chair. This resident, who was cognitively intact but required staff assistance for daily care and had chronic kidney disease, was found on his knees facing his recliner with his upper body resting on it after attempting to get up to ring his call bell. Documentation indicated that the resident had poor safety awareness and impulsive behaviors, yet no safety assessment specific to the use of the electric lifting recliner chair was completed for him. Additionally, the facility did not ensure that appropriate assistance devices were in place for another resident who was severely cognitively impaired, required assistance with daily care, and used a wheelchair for mobility. This resident was observed being transported by a hospitality aide without leg rests on her wheelchair, resulting in one foot dragging on the floor. The aide stated that she did not use leg rests because the resident could self-propel and was unsure if foot petals were available. The DON confirmed that leg rests should have been used during transport if the resident could not lift her feet off the floor.
Failure to Follow Scheduled Toileting Program for Dependent Resident
Penalty
Summary
The facility failed to ensure that a scheduled toileting program was followed for a resident with mild cognitive impairment, Parkinsonism, and dementia, who was dependent on staff for toileting and hygiene. The resident's care plan specified a detailed toileting schedule, including assistance at least every two hours during awake times, at bed checks, upon rising, before and after meals, at bedtime, and whenever requested. However, interviews with the resident and her husband revealed that staff did not always provide toileting assistance when the resident requested it, instead adhering strictly to the scheduled times. Review of the resident's clinical documentation and toileting program records over several months showed no documented evidence that the scheduled toileting program was completed as outlined in the care plan. The Director of Nursing confirmed the lack of documentation supporting completion of the toileting program as scheduled. This deficiency was identified through review of facility policies, clinical records, and staff and resident interviews.
Failure to Complete Physician's Discharge Summary
Penalty
Summary
The facility failed to ensure that a physician's discharge summary was completed prior to or at the time of discharge for a resident. The clinical record review revealed that the resident was discharged on July 2, 2024, but there was no evidence of a completed discharge summary by the physician at that time. This deficiency was confirmed during an interview with the Nursing Home Administrator on July 10, 2024, who acknowledged that the discharge summary was not completed as required.
Failure to Implement Enhanced Barrier Precautions for Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who required them, leading to a deficiency in infection prevention and control. The facility's policy on EBP, dated March 2024, mandates the use of gowns and gloves during high-contact care activities for residents at higher risk of colonization or infection with multi-drug resistant organisms (MDROs). This includes residents with chronic wounds or indwelling medical devices. However, during an observation, it was found that there was no EBP signage or communication in the room of a resident with a Stage 4 Pressure Ulcer to the coccyx, indicating a lapse in following the EBP process. Interviews with the Director of Nursing, Nursing Home Administrator, and Wound Nurse confirmed that the EBP process was not adhered to for the resident in question. This oversight was identified during a survey, and it was determined that the facility did not ensure the necessary precautions were in place to prevent the transmission of MDROs. The deficiency was cited under several Pennsylvania Code regulations, highlighting the importance of management, clinical records, and nursing services in maintaining infection control standards.
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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