Quincy Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Waynesboro, Pennsylvania.
- Location
- 6596 Orphanage Road, Waynesboro, Pennsylvania 17268
- CMS Provider Number
- 395378
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Quincy Retirement Community during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy and sequelae of cerebral infarction was transferred and admitted to the hospital on two occasions, but the facility did not include these transfers on its monthly Ombudsman transfer/discharge reports. Review of the Ombudsman reporting logs for the relevant months showed the resident was missing, and the NHA confirmed the omission. The NHA stated that a change in computer programs caused residents who had elected bed-hold status not to populate on the transfer/discharge list, resulting in the failure to notify the Ombudsman as required.
A resident with Alzheimer’s disease, Type II DM with polyneuropathy, and an unstageable left heel pressure ulcer was not managed according to facility policy and professional standards. Nursing staff twice documented a new in-house acquired unstageable heel ulcer on skin checks without selecting the prompt to notify the provider and without documenting physician notification, and one weekly skin evaluation was not completed as ordered. An RN cleansed the heel with povidone iodine and altered footwear to offload pressure using a treatment approach that was not ordered by the physician or part of approved wound protocols. The physician was only notified after a later fall when the heel wound was open and moist, at which time a treatment order was obtained. Additionally, there was no documentation that nursing staff notified the dietician about the pressure ulcer for an extended period, despite policy requiring dietician consultation for residents with skin breakdown, and the dietician became involved only much later when recommending a protein supplement for wound healing.
A resident was found with a large red/purple bruise and swelling on the left forearm after evening care by a male NA, and when asked about the injury, the resident identified "him" and stated she did not want him to touch her again. Facility policy required all such injuries to be investigated for potential abuse and any reasonable suspicion of a crime to be reported within specified time frames, but only the resident’s daughter was notified, and there was no documented notification of the provider or authorities. Subsequent staff interviews described the resident as anxious, restless, and exit seeking, with the bruise not observed earlier and obscured by long sleeves the following day, and the resident later reported that a "big fat white guy" had been rough and mean to her. Administration documented the concern as a grievance and decided not to treat or report it as abuse, resulting in a failure to conduct a timely, thorough abuse investigation and required reporting.
A resident with a history of falls, muscle weakness, and COPD, who typically self-propelled his wheelchair using his feet and did not use leg rests, sustained a fall and nasal fracture when staff pushed his wheelchair without applying leg rests, contrary to facility policy requiring footrests during staff-assisted propulsion. Near the dining room doorway, the resident’s foot became caught or tangled while the wheelchair was being moved by staff, causing him to fall forward out of the chair onto the floor and suffer a forehead abrasion and a depressed nasal fracture, as confirmed by x-ray and clinical documentation.
A facility failed to ensure complete and accurate documentation of a resident's medical records. The resident, with a fracture of the left ulna and anxiety disorder, had orders for a splint to be worn three times a day, which were not documented as completed on several dates. Despite the resident confirming she wore the brace, the facility had no additional information on the missing documentation.
The facility failed to ensure accurate resident assessments, affecting three residents. One resident's MDS did not reflect the administration of antipsychotic medication, another's did not indicate an active colostomy, and a third's did not show a diabetic ulcer. The Nursing Home Administrator acknowledged these errors.
A facility failed to create a comprehensive care plan for a resident with a history of UTIs. Despite being admitted with a UTI and prescribed antibiotics, the care plan lacked focus on UTI management. The NHA confirmed the need for such a plan.
A deficiency was identified when a resident's care plan was not updated to reflect the removal of an indwelling catheter, despite hospital notes and observations confirming its removal. The care plan continued to list the catheter as part of the resident's care needs, and the issue was confirmed by the Nursing Home Administrator.
The facility failed to ensure accurate resident assessments for five residents, including incorrect documentation of pressure ulcers, insulin administration, and diagnoses of sepsis and MDRO. These inaccuracies were identified through clinical record reviews and staff interviews, and the facility acknowledged the coding errors and made modifications to the assessments.
The facility failed to update and revise care plans for three residents. One resident's care plan was not updated after a pressure ulcer resolved, another's did not include necessary documentation for a defibrillator/pacemaker, and a third's was not updated to include a new diagnosis of a multidrug-resistant organism in the urine.
The facility failed to provide care according to professional standards for a resident with chronic skin conditions. Despite physician orders for specific wound care, the clinical record lacked documentation of the resident's skin condition, and staff did not perform thorough evaluations during dressing changes.
The facility failed to implement a Water Management Program for Legionella prevention and did not maintain accurate infection control data. The NHA could not provide evidence of routine Legionella testing, and the IC logs had discrepancies, including incorrect resident admission dates and unconfirmed infections.
The facility failed to ensure that the physician's discharge summaries for two residents included all required documentation. One resident's summary inaccurately documented the cause of death and omitted details of their stay and treatment, while another resident's summary lacked a recapitulation of their stay and treatment. The NHA believed the summaries met regulations despite their brevity.
The facility failed to follow the care plan for a resident with a urostomy and catheter by not recording the characteristics of the urine drained from the urostomy bag, as required. The Nursing Home Administrator confirmed the omission and noted the absence of a physician order for such recording.
A resident with dementia, anxiety, and major depressive disorder had a PRN order for haloperidol without a 14-day stop date or proper documentation. The medication was administered once 20 days after the order, and there was no consent or risk-benefit education provided to the resident's responsible party. The facility admitted these processes were missed, possibly due to the resident's hospice status.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
Surveyors found that the facility failed to notify the Office of the State Long-Term Care Ombudsman about a resident’s hospitalization as required. The resident had diagnoses including metabolic encephalopathy and sequelae of cerebral infarction and was transferred from the facility to the hospital and subsequently admitted on two separate occasions, December 26, 2025, and January 1, 2026. Review of the facility’s Ombudsman transfer/discharge reporting documentation for December 2025 and January 2026 showed that this resident was not included on the monthly transfer/discharge lists submitted to the Ombudsman. During an interview, the Nursing Home Administrator confirmed that the resident was not on the Ombudsman reporting lists for those months and explained that a change in computer programs had resulted in residents who had elected bed-hold status not being generated on the transfer/discharge list. The Administrator also confirmed that it was the facility’s expectation that transfers and discharges be accurately reported to the Ombudsman’s office. This failure to report the resident’s hospital transfers and admissions constituted noncompliance with 28 Pa Code 201.14(a) and 201.18(b)(3).
Failure to Notify Physician and Dietician and to Follow Wound Protocols for Heel Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services, consistent with professional standards and facility policy, for a resident with a left heel pressure ulcer. Facility policy required an RN to assess, document, and notify the physician of a new pressure injury by the end of the following shift and to consult the dietician for all residents at risk for or with skin breakdown. The policy also specified that intact black heels without signs of infection should be treated with pressure redistribution, heel floating, and protective barrier, with no dressing necessary. The resident had diagnoses including an unstageable pressure ulcer of the left heel, Alzheimer’s disease, and Type II diabetes with polyneuropathy. On a skin check dated August 19, 2025, nursing staff identified a new in-house acquired unstageable pressure ulcer on the resident’s left posterior heel, measuring 1 cm by 1 cm with a dry scabbed area and normal surrounding skin. The clinical suggestion to notify the provider for a new onset or worsening condition was not selected on the skin check form, and the corresponding progress note did not document physician notification. The RN cleansed the area with povidone iodine, applied no dressing, removed shoes that appeared too small, placed slipper socks, and documented that pressure would be offloaded, but this treatment was not ordered by the physician nor part of physician-approved wound protocols. A weekly skin evaluation ordered for the resident was not completed on August 22, 2025, with documentation that the LPN was unable to complete it due to time. On August 29, 2025, another skin check documented a new unstageable pressure ulcer on the same left heel, again 1 cm by 1 cm with 100% eschar, and again the suggestion to notify the provider was not selected and the progress note did not show physician notification. On September 4, 2025, after a fall, the resident complained of discomfort to the left heel, and assessment revealed an open wound measuring 1.5 cm by 1.5 cm with a pink moist center; the area was cleansed, collagen applied, and covered with a silicone dressing, and the physician was notified of the fall and resulting open wound, leading to a treatment order that same day. A dietician note dated October 13, 2025, referenced an unstageable pressure injury to the left heel based on an October 9 skin check and recommended a protein supplement, but there was no documentation that nursing staff had notified the dietician of the pressure ulcer between August 19 and October 13, 2025. In an interview, the Nursing Home Administrator confirmed that nursing staff should have notified the physician and dietician when the pressure ulcer was first identified and that the RN had applied a treatment not ordered by the physician or included in approved wound protocols.
Failure to Timely Report and Thoroughly Investigate Alleged Abuse and Unexplained Bruising
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was thoroughly investigated and reported in a timely manner for one resident. Facility policy on Abuse, Neglect, Exploitation required that all bruises, skin tears, and other found injuries be investigated for potential abuse and that reasonable suspicion of a crime against a resident be reported within 2 hours if serious bodily injury was involved and within 24 hours if not. On December 24, 2025, at 9:00 PM, a NA reported that the resident had a 10 cm x 6 cm red/purple bruise with some swelling on the left forearm near the elbow. When asked how it happened, the resident stated "him" and said she did not want him to ever touch her again. The only person notified per the incident report was the resident’s daughter at 10:20 PM that night; there was no documentation that the provider or appropriate authorities were notified as required by policy and regulation. An Interview/Statement Form completed by the NA on December 24, 2025, at 10:00 PM documented that he noticed the mark while getting the resident ready for bed and that she became restless and tossing and turning during care. A later interview on December 26, 2025, documented the NA’s account that the resident had been wheeling herself around the unit, exit seeking, and pulling herself by the wall prior to care, and that he noticed the bruise only after changing her and returning her to the chair. Additional interviews on December 26, 2025, with another NA and an LPN indicated that the bruise was not observed earlier on December 24, and that on December 25 the resident wore long sleeves and went on LOA with family. On December 26, 2025, the resident told staff that a "big fat white guy" had been rough and mean to her the previous day. The NHA documented the concern as a grievance on December 26, 2025, and later stated that administration decided not to report the incident as abuse and could not determine whether the provider had been notified, demonstrating that the allegation was neither promptly reported nor thoroughly investigated in accordance with policy and regulatory requirements.
Failure to Use Wheelchair Leg Rests During Staff-Assisted Propulsion Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent accidents, specifically related to wheelchair safety and use of leg rests. Facility policies required that the resident environment remain as free of accident hazards as possible and that residents using wheelchairs be provided with properly positioned foot pedals/footrests prior to staff-assisted wheelchair propulsion, unless clinically contraindicated and documented in the care plan. These policies emphasized that wheelchair mobility could be self-propelled by the resident or assisted by staff, based on the resident’s needs, and that footrests must be in place when staff are propelling the wheelchair. The resident involved had diagnoses including a history of falling, muscle weakness, acute and chronic respiratory failure, and COPD. He typically self-propelled his wheelchair throughout the facility using his feet and did not have leg rests on his wheelchair for that purpose. On the day of the incident, progress notes documented that he was found lying on the floor in the hallway outside the dining room on his left side, with an abrasion to his forehead and a swollen, deviated nose. He was alert, answered questions appropriately, denied pain, and had normal neurological checks and extremity movement. Subsequent x‑ray reports showed an acute, depressed fracture of the distal third aspect of the bridge of his nose. Witness statements from staff described that the resident’s feet became tangled or caught while he was in his wheelchair near the dining room doorway, leading to his fall. One nurse aide stated that the resident was rolling out of the dining room when his feet got tangled and he fell. Another nurse aide reported that the resident was sitting in front of the dining room doorway and that when a staff member pushed his wheelchair to move him so other residents could get through, his foot got caught in the wheel and he fell forward out of the chair; this statement also noted that the resident did not wear leg rests because he self‑propelled during the day. A licensed practical nurse reported observing a nurse aide pushing the resident in his wheelchair when the resident’s foot became caught, causing him to fall forward out of the wheelchair onto the floor, while another aide nearby appeared to be attempting to alert the aide who was pushing the chair. The nursing home administrator later confirmed that the resident typically self‑propelled without leg rests and that the aide should have applied leg rests if she was going to move or transport the resident in his wheelchair.
Incomplete Documentation of Resident's Medical Records
Penalty
Summary
The facility failed to ensure that Resident 5's medical records were complete and accurately documented. Resident 5 had diagnoses including a fracture of the left ulna and an anxiety disorder. A review of the resident's January Treatment Administration Record (TAR) revealed that the order for the resident to wear a splint three times a day and ensure the left arm splint was on at all times was not documented as completed on several dates across different shifts in January and February 2025. During an interview with Resident 5, it was revealed that she wore the brace at all times since her cast was removed approximately two weeks prior. Despite this, the facility had no additional information to provide regarding the missing documentation, as confirmed in an email correspondence with the Nursing Home Administrator. The NHA stated that it was the facility's expectation for documentation to be completed accurately.
Plan Of Correction
1. Resident 5 evaluated for any negative outcome related to missing documentation of splints. No negative outcomes have been identified. Licensed staff will be educated on TAR documentation requirements for all Residents with orders for splints or braces. 2. Residents with splints or braces will be audited to review documentation and orders for the last 14 days. 3. DON or designee will complete audits for documentation for Residents with a splint or brace present in the TAR. Audits will continue weekly for 4 weeks, monthly for 2 months. 4. Audits and findings will be submitted in the Quarterly QAPI committee meetings.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for three residents, leading to deficiencies in reflecting their current medical status. For one resident, the Medication Administration Record indicated an ongoing order for Olanzapine, an antipsychotic medication, since September 2024. However, the Minimum Data Set (MDS) assessment completed in December 2024 did not reflect the administration of antipsychotic medications, despite the resident receiving them. The Nursing Home Administrator later acknowledged the incorrect coding of the MDS assessment. Another resident had an active colostomy, as noted in a physician encounter report, and required colostomy care every shift. Despite this, the September 2024 MDS assessment did not indicate the presence of an ostomy. Similarly, a third resident was receiving wound care for a diabetic ulcer on the left heel, as documented in a wound consult report. However, the December 2024 MDS assessment failed to reflect the presence of a diabetic ulcer. The Nursing Home Administrator confirmed the existence of these MDS errors.
Plan Of Correction
1. Resident 1, 13, 64 had MDS modified during survey to correct data. The RNAC will be educated on the importance of reviewing the resident record and accurately documenting this information on the MDS. 2. Audit will be completed on residents with orders for Antipsychotics, Ostomies, and Pressure ulcers to ensure that resident medication/condition is accurately coded on the MDS. 3. DON or designee Audits for accurate MDS coding for Residents with Antipsychotics, ostomies, and pressure ulcers will continue for 5 Resident MDS weekly for 4 weeks, monthly for 2 months. 4. Audits and findings will be submitted in the Quarterly QAPI committee meetings.
Failure to Develop Comprehensive Care Plan for UTI History
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of urinary tract infections (UTIs). The resident, who was admitted to the facility with a diagnosis of a UTI and has a history of UTIs, was prescribed Macrobid and Nitrofurantoin MCR as preventive measures. Despite these medical interventions, the resident's care plan did not include a focus on managing or preventing UTIs. During an interview, the Nursing Home Administrator confirmed that a comprehensive care plan addressing the resident's history of UTIs should have been developed. This oversight was identified through a review of the resident's clinical records, which highlighted the absence of a care plan tailored to the resident's specific medical needs related to UTIs.
Plan Of Correction
1. Resident 43 care plan was updated during survey to reflect history of urinary tract infections. Licensed staff will be educated on ensuring development of the resident care plan to include Urinary Tract Infection prevention for Residents with History of urinary tract infections. 2. Resident care plans for residents with history of Urinary Tract infections days will be audited to ensure the care plan includes measures to monitor and prevent future urinary tract infections. 3. DON or designee Audits for accurate care plan documentation for new Residents with history of urinary tract infections will continue weekly for 4 weeks, monthly for 2 months. 4. All audits and findings will be submitted in the Quarterly QAPI committee meetings.
Care Plan Not Updated for Resident's Catheter Removal
Penalty
Summary
A deficiency was identified in the care planning process for a resident with type 2 diabetes mellitus and stage 3 chronic kidney disease. The resident's care plan was not updated to reflect the removal of an indwelling catheter, which had been removed as per hospital notes dated October 26, 2024. Despite the removal of the catheter, the care plan continued to list it as part of the resident's care needs. The oversight was discovered during a review of the resident's clinical records and was confirmed through observation and staff interviews. The Medication and Treatment Records for February 2025 did not include any orders for an indwelling catheter, further indicating that the care plan was outdated. The Nursing Home Administrator acknowledged the issue in email correspondence, confirming the deficiency in the care planning process.
Plan Of Correction
1. Education to Licensed staff, to ensure that care plans are updated timely to reflect current and accurate resident care plan. 2. Resident care plans for residents with current indwelling catheters, and residents that have had indwelling catheters discontinued over the last 30 days will be audited for accuracy. 3. DON or designee Audits for accurate care plan documentation for Residents with discontinued and current indwelling catheters will continue weekly for 4 weeks, monthly for 2 months. 4. Audits and findings will be submitted in the Quarterly QAPI committee meetings.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' statuses for five of the 18 residents reviewed. Resident 8's clinical record indicated the presence of an unstageable deep tissue injury upon admission, but the MDS assessment incorrectly noted that the injury was not present upon admission. Resident 19's MDS assessment inaccurately documented the administration of insulin, failing to indicate the use of hypoglycemic medication despite the resident receiving insulin injections during the assessment period. Similarly, Resident 49's MDS assessments did not reflect the use of Lantus Solostar insulin, which was administered during the look-back periods for both the comprehensive and quarterly MDS assessments. Resident 56's MDS assessment failed to indicate diagnoses of sepsis and multidrug-resistant organism (MDRO) despite clinical records and hospital discharge summaries confirming these conditions. Resident 76's MDS assessment inaccurately documented the administration of insulin injections, although there were no physician orders for insulin in the resident's clinical record. These inaccuracies were identified through clinical record reviews and staff interviews, and the facility acknowledged the coding errors and made modifications to the assessments. The facility's failure to ensure accurate resident assessments was a violation of 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Update and Revise Care Plans
Penalty
Summary
The facility failed to ensure the care plans for three residents were reviewed and revised appropriately. Resident 8 had a care plan for a pressure ulcer that was not updated when the ulcer resolved. Despite the pressure ulcer being resolved on February 20, 2024, the care plan was not revised to reflect this change. This issue was confirmed during an interview with the Nursing Home Administrator (NHA) and Director of Nursing on March 6, 2024, and further corroborated by an email from the NHA later that day. Resident 19's care plan did not include documentation of the presence of a defibrillator/pacemaker or the necessary interventions and safety measures, despite a physician's order for a pacemaker device remote check dated September 19, 2023. This omission was confirmed during interviews with the NHA and the Registered Nurse Assessment Coordinator (RNAC) on March 7, 2024. Additionally, Resident 56's care plan was not updated to include a new diagnosis of a multidrug-resistant organism (MDRO) in the urine following hospitalization for a complicated urinary tract infection. This deficiency was confirmed during a staff interview on March 7, 2024, and an email from the NHA later that day.
Failure to Document and Assess Resident's Skin Condition
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for Resident 19. The resident, who had diagnoses including diabetes mellitus, ischemic cardiomyopathy, and polyneuropathy, was observed with dressings on both lower legs. Physician orders required specific wound care treatments, but the clinical record lacked documentation of the resident's skin condition. Nurses' notes from November 2023 to March 2024 indicated dressing changes but did not describe the skin's appearance. Additionally, a physician's progress note from February 2024 did not assess the resident's skin condition. The care plan for the resident's chronic skin condition was incomplete, lacking a goal and detailed interventions. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) did not follow the resident during weekly wound rounds, and the nurses responsible for dressing changes did not document assessments of the skin condition. A late entry progress note from March 2024 described multiple open areas on the resident's legs but lacked measurements. The ADON confirmed that staff did not document the size of the open areas and acknowledged the need for thorough evaluations to determine treatment effectiveness. The facility did not provide additional information to address these concerns.
Failure to Implement Water Management and Maintain Accurate Infection Control Data
Penalty
Summary
The facility failed to implement a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella. The facility's policy on Legionellosis did not address baseline or annual testing for water-borne contaminants. Additionally, the facility's guidelines, based on a CDC toolkit, identified the need for a water management program due to the facility's risk factors, including being a healthcare facility with residents who have weakened immune systems and a centralized hot water system. During an interview, the Nursing Home Administrator (NHA) was unable to provide evidence of routine environmental sample results for Legionella testing and mentioned difficulties in finding a local service provider for the testing. This indicates a lack of proper implementation of the water management program as required by the guidelines and policies in place. The facility also failed to maintain accurate infection control data. A review of the infection control (IC) monthly log for January 2024 revealed discrepancies, such as residents listed as suspected for infections without updates to confirm or rule out the infections. For instance, one resident was documented with incorrect admission dates and had confirmed infections that were not accurately recorded in the IC log. The Infection Control Preventionist (ICP) admitted that the system marks all residents as suspected and only those reported to the state system are marked as confirmed, leading to inaccuracies in tracking infections. The NHA acknowledged that the IC data should be accurate, highlighting a significant deficiency in the facility's infection control practices.
Deficient Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to ensure that the physician's discharge summary included all required documentation for two residents reviewed for discharge. For Resident 83, the discharge summary inaccurately documented the cause of death as Alzheimer's dementia, despite the resident not having a prior diagnosis of Alzheimer's dementia. The summary also failed to include a recapitulation of the resident's stay, including the course of illness and treatment, such as the hospice admission. Resident 83 had been admitted with Parkinson's disease and respiratory syncytial virus, and their health declined significantly before expiring due to acute cardiopulmonary collapse, pneumonia, and RSV bronchitis. For Resident 85, the discharge summary was similarly deficient, only stating that the resident was admitted to the hospital and had dropped their bed hold, with diagnoses of confusion and ambulatory dysfunction. The summary did not include a recapitulation of the resident's stay, including the course of illness and treatment. Resident 85 had been diagnosed with Parkinson's disease, encephalopathy, and muscle weakness. The Nursing Home Administrator and Assistant Director of Nursing were informed of these concerns, but the NHA felt the summaries met the regulations despite their brevity.
Failure to Follow Care Plan for Urinary Catheter Management
Penalty
Summary
The facility failed to provide care and services for urinary catheters consistent with the resident's comprehensive plan of care for one resident. Resident 63, who had diagnoses including chronic kidney disease and osteomyelitis with sepsis, utilized a urostomy with a catheter for urine elimination. The comprehensive plan of care for Resident 63 included an intervention for nursing staff to check and record the characteristics of the urine drained from the urostomy bag, such as amount, type, color, and odor. However, a review of Resident 63's clinical record revealed that staff were not recording these characteristics as required by the care plan. During a staff interview, the Nursing Home Administrator confirmed that staff were not recording the urine characteristics and added that there was no physician order to do so. This failure to follow the care plan's intervention for monitoring and recording the urine characteristics led to the deficiency cited under 28 Pa code 211.12(d)(1)(5) Nursing services.
Failure to Ensure Resident Was Free of Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free of unnecessary psychotropic medications. Specifically, Resident 61, who had diagnoses including dementia, anxiety, and major depressive disorder, had a PRN order for haloperidol without a 14-day stop date or documentation justifying the extension of the order. The PRN haloperidol was ordered on February 8, 2024, and was administered once on February 27, 2024, 20 days after the order was written. There was no documentation in the physician's progress note regarding the rationale for continuing the PRN haloperidol past the 14-day threshold. During interviews, the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing acknowledged the oversight. The DON indicated that the PRN haloperidol was added to support hospice philosophy for end-of-life comfort, but there was no consent or documentation of risk versus benefit education with Resident 61's responsible party. Additionally, no Abnormal Involuntary Movement Scale (AIMS) screenings were completed. The facility admitted that these processes were missed for Resident 61, possibly due to their hospice status.
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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