Rest Haven-york
Inspection history, citations, penalties and survey trends for this long-term care facility in York, Pennsylvania.
- Location
- 1050 South George Street, York, Pennsylvania 17403
- CMS Provider Number
- 395058
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Rest Haven-york during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow its infection control policies for enteral feeding supplies and dining practices. A resident with a gastrostomy tube had a 60 cc piston syringe and a graduate used for tube flushing left uncovered and unlabeled on a cluttered bedside stand, and a partially used gallon of water was undated, contrary to facility policy requiring labeling, dating, protection from contamination, and daily replacement of such items. An LPN acknowledged these requirements but could not verify when the water was opened, and the same syringe remained in use beyond a day without proper labeling of associated equipment. In the Royal Garden Cafe, a resident was assisted with eating at the same table where staff assembled meal trays containing uncovered silverware, beverages, and meal tickets, and both the Food Service Director and leadership later acknowledged that residents should not be seated at the tray assembly table due to infection control concerns.
A resident with a UTI, flaccid neuropathic bladder, and weakness was observed on multiple occasions moving through and sitting in common and dining areas with an indwelling catheter bag hanging under the chair and urine exposed. This occurred despite a facility policy stating residents have the right to an environment that promotes quality of life, including respect, dignity, and privacy. The DON acknowledged that residents are expected to have a dignified existence.
The facility failed to follow its self-administration medication policy by allowing a resident with Type II DM and CHF to have multiple medications left at the bedside without an interdisciplinary assessment for self-administration. An LPN reported routinely leaving the medications for the resident to take at their leisure with a preferred drink, and the administrator confirmed that no assessment for self-administration had been completed, resulting in noncompliance with nursing services requirements.
Surveyors found that staff did not consistently provide or document required education on risks and benefits or obtain consent before administering psychotropic meds to two residents with dementia and delusional disorders. One resident received Haldol and Trazodone with only vague notes about discussing antipsychotic risks and benefits and a message left for the responsible party, without clear identification of the specific meds or documented consent. Another resident received Risperidone for behavioral symptoms related to vascular dementia with psychotic features, but the record contained no documentation of risk/benefit education or consent, and the NHA confirmed no such consent could be produced.
The facility failed to ensure accurate MDS assessments for two residents. For one resident with chronic kidney disease and dementia, the quarterly MDS incorrectly indicated a UTI in the prior 30 days despite no supporting documentation in the clinical record. For another resident with seborrheic dermatitis and squamous cell cancer of the scalp, multiple quarterly MDS assessments omitted cancer as an active diagnosis, even though the resident had a large scabbed area on the scalp and staff later acknowledged that cancer should have been coded.
The facility failed to ensure complete and specific physician orders and care plan details for oxygen therapy for two residents with COPD and other respiratory conditions. Both residents were observed receiving O2 via nasal cannula at set liter flows, but their care plans did not identify the ordered O2 flow rate or delivery method. Physician orders for each resident only directed routine oxygen use with pulse oximetry checks and documentation of hours, liters, and source, without specifying the prescribed O2 amount or device. The DON acknowledged awareness of these incomplete orders, resulting in noncompliance with nursing services requirements.
A resident with ESRD receiving hemodialysis did not have complete pre- and post-dialysis assessments documented on multiple occasions, and the assessments that were completed omitted required weight monitoring despite care plan directives. Facility policy required pre- and post-dialysis observations and communication with the dialysis center, but an LPN reported that documentation of communication with the dialysis provider was not maintained and that assessments focused only on blood pressure. The DON confirmed that full pre- and post-dialysis assessments and accessible communication with the dialysis center were expected, demonstrating a failure to follow policy and maintain accurate clinical records for dialysis care.
Surveyors identified that a nourishment refrigerator contained dried spilled liquids on a shelf and that an ice machine had visible pink and black substances on internal surfaces that could be wiped away with a dry paper towel. A registered dietitian acknowledged the refrigerator needed cleaning, and an LPN and maintenance staff observed and discussed the soiled ice machine. The ice machine manual required cleaning and sanitizing at least every six months, and leadership reported the machines were on a six‑month cleaning schedule with documented prior inspections, while the administrator stated the refrigerator and ice machine should be clean.
The facility failed to protect residents' privacy by using video/audio monitoring devices without consent or inclusion in care plans. Three residents were monitored without proper documentation or consent, violating their rights to privacy and confidentiality.
The facility failed to maintain the dishwashing machine at the required minimum temperature of 150 degrees, as per their policy, from May 2024 to January 2025. Despite multiple instances of low temperatures, no corrective actions were documented, and key staff were unaware of the issue, indicating a lapse in communication and adherence to food safety protocols.
The facility failed to ensure proper infection control practices, as staff were observed not removing PPE before exiting resident rooms and not disinfecting contaminated surfaces. Employees were seen handling biohazard materials improperly, and there was a lack of awareness about cleaning protocols for shared items. These actions were contrary to facility policies and acknowledged as concerns by the Nursing Home Administrator.
A resident's right to a clean and homelike environment was compromised when their tray table remained dirty and stained over several days. Despite facility policy and staff responsibilities, the tray table was not cleaned, leading to a deficiency.
A facility failed to conduct a Significant Change MDS for a resident admitted to hospice services, as required by CMS guidelines. Instead, an Annual MDS was completed, despite the resident's diagnoses of vascular dementia and hypertension. The Nursing Home Administrator acknowledged the oversight during a staff interview.
A resident with hypertension, anxiety disorder, and neuromuscular dysfunction of the bladder was not provided necessary grooming assistance, resulting in visible facial hair despite expressing a preference for shaving assistance on shower days. The facility's policy requires staff to assist with shaving, but the care plan did not ensure adherence to this policy, and the NHA was unable to provide information on the resident's grooming needs.
A resident with chronic kidney disease and anxiety disorder was admitted without documented wounds, but an LPN noted multiple wounds without proper documentation or referrals. A Registered Nurse did not assess the wounds upon admission, and the physician was not informed. The wound nurse initially reported scabs, but a later observation revealed a full thickness arterial wound. The facility lacked an explanation for the delayed assessment.
A resident with a stage three pressure ulcer did not receive proper care to prevent infection. An LPN failed to perform hand hygiene with soap and water after cleaning a bowel movement and before changing the dressing, using an alcohol-based hand rub instead. The dressing was not dated, and the LPN used a marker from an unclean pocket to label the new dressing. Staff confirmed these actions were inconsistent with professional standards.
A resident with COPD and normal pressure hydrocephalus was observed smoking in the facility parking lot, contrary to the facility's smoke-free policy. The resident's records lacked a smoking safety evaluation and care plan, and there was no secure storage for smoking materials. The facility was aware of the resident's smoking but did not provide adequate supervision or a structured plan for her smoking activities.
The facility did not meet the required 3.20 hours of direct resident care per resident on 13 days across three months. Staffing documentation showed care hours ranged from 3.01 to 3.18, confirmed by the Nursing Home Administrator.
The facility failed to maintain the physical integrity of electrical receptacles, affecting one of three smoke compartments. A broken electrical receptacle was observed in the Classroom, and the Director of Operations confirmed the compromised condition.
The facility did not document monthly visual inspections of portable fire extinguishers over the past year, affecting one of two smoke compartments. The 2nd floor extinguisher in the H.R. Office had not been inspected since November 2024, as confirmed by the Director of Operations.
The facility failed to monitor the use of surge suppressors, leading to a deficiency. A surge suppressor was found supplying power to another surge suppressor in the 1st floor Dietary Office, a practice known as daisy-chaining, which is non-compliant with NFPA standards. The Director of Operations confirmed this issue during an interview.
The facility was found to be non-compliant with building construction requirements as it is a two-story, Type III (200), unprotected ordinary structure, which is not permitted to exceed one story in height according to NFPA 101 standards. This was confirmed by the Director of Operations.
The facility failed to provide the required two remote exits on the second floor, as observed during a survey. The Director of Operations confirmed the deficiency, which does not comply with NFPA 101 standards.
A resident with Diabetes Mellitus Type II and vascular dementia did not receive their prescribed Ozempic medication on four occasions due to it being unavailable. The facility failed to inform administration about the unavailability, leading to a deficiency in care.
Infection Control Failures in Enteral Supply Handling and Dining Tray Assembly
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling, labeling, and storage of enteral feeding supplies for a resident with a gastrostomy tube. Facility policy required all feeding tube syringes to be stored in a clean area, labeled with the resident’s name and date, cleansed with hot water after use, and disposed of after 24 hours, with reusable supplies also labeled and stored appropriately. For a resident diagnosed with dysphagia and gastrostomy, whose medications and routine water flushes were administered via the gastrostomy tube, surveyors observed a 60 cc piston syringe used for tube flushing lying uncovered and unlabeled on the bedside stand, along with an uncovered, unlabeled graduate and an undated gallon jug of water that was two-thirds full. The bedside table was cluttered with personal items. An LPN acknowledged that the syringe, graduate, and water should be labeled and that the water should be dated when opened, but was unsure when the water had been opened and left it in use. The following day, the same syringe dated the prior day was still present in the graduate, and neither the graduate nor the water container were labeled with the resident’s name or date. The Nursing Home Administrator later confirmed that these items should have been labeled, dated, protected from contamination, and replaced daily. Surveyors also found a deficiency in maintaining a safe, sanitary, and comfortable environment in the dining area. During a meal observation in the Royal Garden Cafe, a resident was seated at a table and being assisted by staff to eat lunch at the same table where staff were assembling meal trays for service. The trays at that table contained a napkin, uncovered silverware, beverages, and a meal ticket. The Food Service Director acknowledged that residents should not be seated at the table where meal trays are assembled. In a subsequent interview, the Nursing Home Administrator and Director of Nursing stated that, to avoid infection control concerns, residents should not be seated at the table where meal trays are being assembled.
Failure to Maintain Dignity and Privacy for Resident With Indwelling Catheter
Penalty
Summary
The facility failed to ensure a resident’s right to a dignified existence and an environment that promotes maintenance or enhancement of quality of life, as required by its Resident Rights policy and 28 Pa. Code 201.29(a). The policy stated that residents have the right to an environment that promotes quality of life, including respect, dignity, and privacy. Clinical record review for Resident 7 showed diagnoses including urinary tract infection, flaccid neuropathic bladder, and weakness. On one observation, the resident wheeled herself from the dining room to her room with her catheter bag hanging down underneath her chair with urine exposed. On another observation, the resident was seated at a dining room table with her catheter bag facing outward underneath her chair, again with urine exposed. In an interview, the Director of Nursing stated she would expect residents to have the right to a dignified existence. These observations demonstrated that the resident’s urinary catheter bag was repeatedly left visible with urine exposed in common and dining areas, contrary to the facility’s policy requiring respect, dignity, and privacy for residents.
Failure to Assess Resident Before Allowing Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined a resident was safe to self-administer medications before allowing this practice. Facility policy titled "Medication- Self Administration-Assessment, Review, Care Planning, Documentation" (revised April 2022) requires a uniform process for assessing residents for self-administration, care planning, and documentation. Resident 10, who had diagnoses including Type II Diabetes Mellitus and Congestive Heart Failure, was observed on February 2, 2026, with a medication cup containing multiple medications placed on the bedside table. During an immediate interview, the resident stated that the Licensed Practical Nurse (Employee 10) leaves the medications there for him to take at his leisure and with his drink of choice. In a subsequent interview, Employee 10 acknowledged that the resident had not been assessed to self-administer medications. The Nursing Home Administrator also confirmed that the medications should not have been left at the bedside and that the resident had not been assessed by the facility for self-administration of medications, indicating noncompliance with the facility’s own policy and 28 Pa. Code 211.12(d)(1)(2)(5) regarding nursing services.
Lack of Documented Risk/Benefit Education and Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide education on the risks and benefits of psychotropic medications and to obtain consent prior to administration, as required by facility policy. The policy on psychotropic drugs, revised June 6, 2019, states that when an antipsychotic is ordered, the resident and/or responsible party will be educated on the risks versus benefits of taking the medication. For one resident with diagnoses including delusional disorder, vascular dementia, depression, and anxiety, physician orders included Haldol in multiple doses and Trazodone. A psychology consult documented that Haldol had been started after a failed gradual dose reduction of Geodon. A progress note from November 3, 2025, stated that antipsychotic risks versus benefits were reviewed with the responsible party, but it did not identify the specific medication discussed. A November 4, 2025, note indicated the resident was admitted with orders to decrease Geodon and start Haldol and that a letter was sent to the responsible party with a copy of the risks versus benefits of antipsychotic medications. A January 20, 2026, note documented initiation of Trazodone for continued signs of distress and that a message was left for the responsible party, without documentation of completed education or consent. For another resident with delusional disorder and dementia, physician orders included Risperidone 1 mg by mouth three times daily, and the care plan identified behavioral problems due to vascular dementia with psychotic features and the possible need for antipsychotic medication. Review of this resident’s medical record did not reveal any documented education on the risks and benefits of Risperidone or any consent from the resident or their representative. During an interview, the Nursing Home Administrator stated they could not provide any documented consent for this resident’s Risperidone use. The DON also stated that the facility should obtain consent and discuss risks and benefits for antipsychotic medication use with the resident or representative prior to administration. These findings were cited under 28 Pa. Code: 211.10(a) Resident care policies and 211.12(d)(1)(5) Nursing services.
Inaccurate MDS Coding for Diagnoses and Infections
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected residents' clinical status for two residents. For one resident with diagnoses including chronic kidney disease and dementia, review of the quarterly MDS dated November 11, 2025, showed Section I2300 coded to indicate a urinary tract infection (UTI) within the last 30 days. However, review of this resident's clinical record did not reveal any evidence that the resident had a UTI in the 30 days prior to that MDS assessment date. For another resident with diagnoses including seborrheic dermatitis and squamous cell cancer of the scalp, observation revealed a large, scabbed area covering the entire top of the head. Review of this resident's quarterly MDS assessments dated May 15, 2025, August 12, 2025, and November 11, 2025, showed that cancer was not documented in Section I as a diagnosis. Interviews with the RN Assessment Coordinator, the DON, and the Nursing Home Administrator confirmed that these MDS assessments should have documented cancer as an active diagnosis.
Failure to Obtain Complete Oxygen Therapy Orders and Integrate Them Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory services by not obtaining complete physician orders for supplemental oxygen and not incorporating specific oxygen parameters into residents’ care plans. The facility’s oxygen therapy policy, last revised April 25, 2018, did not include an expectation for physician orders for supplemental oxygen. For one resident with COPD and acute kidney failure, surveyors observed the resident seated in a wheelchair at bedside receiving oxygen via nasal cannula at 2 L/min. The resident’s care plan, initiated for COPD, did not specify the amount of supplemental oxygen or the delivery method. The physician’s order for this resident directed “routine oxygen use” with oxygen saturation checks every shift and documentation of hours, liters, and source, but did not include a prescribed oxygen flow rate or the delivery device to be used. A second resident, with diagnoses including COPD and bronchiectasis, was observed seated in a wheelchair at bedside receiving oxygen via nasal cannula at 3 L/min. This resident’s COPD care plan similarly lacked documentation of the ordered oxygen flow rate and the oxygen delivery method. The physician’s order for this resident also stated “routine oxygen use” with oxygen saturation checks every shift and documentation of hours, liters, and source, but did not specify the amount of oxygen to be delivered or the delivery method. During interview, the DON acknowledged awareness of these orders, which did not contain complete parameters for oxygen therapy as required under nursing services regulations (28 Pa. Code 211.12(d)(1), (3), and (5)).
Failure to Maintain Complete Dialysis Assessments and Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records and communication related to dialysis care for a resident receiving hemodialysis. Facility policy on dialysis care required communication with the dialysis center, completion of pre-dialysis observations to be sent or faxed to the dialysis center, and completion of post-dialysis observations with notification of the physician and dialysis center as needed. The resident’s clinical record showed diagnoses of end stage renal disease and dependence on renal dialysis, with physician orders for pre- and post-dialysis observations on specified days and times. The care plan documented that the resident had hemodialysis due to renal failure, with interventions including dialysis treatments on specific days, monitoring and documenting vital signs and weight, and dialysis treatments per physician order. However, there were no documented physician orders for dialysis itself. Review of the electronic medical record revealed that complete pre- and post-dialysis assessments were not documented on multiple specified dates, and the assessments that were completed did not include weight monitoring as required by the care plan. An LPN stated that the facility did not maintain documentation of communication with the dialysis center and that pre- and post-dialysis assessments were limited to monitoring blood pressure, not weight. The DON stated that pre- and post-dialysis assessments should be completed and that communication between the dialysis center and the facility should be available. These findings showed noncompliance with facility policy and state regulations regarding clinical records and nursing services for dialysis care.
Unclean Nourishment Refrigerator and Ice Machine Surfaces
Penalty
Summary
The deficiency involves failure to store and serve food and beverages in accordance with professional food safety standards for one pantry refrigerator and one ice machine. During an observation with the registered dietitian, the Flowers unit nourishment refrigerator was found to have dried yellow and red liquids on the bottom shelf, and the dietitian acknowledged that the refrigerator needed to be cleaned. Review of the ice machine equipment manual indicated that the machine should be cleaned and sanitized at least every six months, and that an extremely dirty ice machine must be taken apart for cleaning and sanitizing. In a separate observation with an LPN, the Lily Lane ice machine was found to have pink and black substances on the baffle/deflector, as well as a black substance on the inside top panel, drip tray, and bottom rim of the cover in front of the evaporator grid; these substances could be wiped away with a dry paper towel. Maintenance staff reported that someone had touched the ice and that he was in the process of emptying and cleaning the machine, but he was unsure of the name of the chemical he used to clean it. The Director of Operations stated that the ice machines were on a six‑month cleaning schedule, and documentation showed the Lily Lane ice machine had been inspected on two prior dates. The Nursing Home Administrator stated that the refrigerator and ice machine should be clean.
Privacy Breach Due to Unauthorized Video/Audio Monitoring
Penalty
Summary
The facility failed to protect the privacy of residents by using video/audio monitoring devices without proper consent or inclusion in the residents' care plans. Three residents, identified as Residents 16, 27, and 65, were subject to video/audio monitoring without their consent or the consent of their representatives. The facility's policy on resident rights was not adhered to, as it did not include a procedure for obtaining consent for video/audio monitoring or ensuring the privacy of residents. Resident 27, who had chronic kidney disease and a history of stroke, was observed to have a camera-like device on their bedside dresser. The device was used to monitor the resident at night due to a history of falls. However, the use of this monitoring device was not included in the resident's comprehensive care plan. Similarly, Resident 16, with peripheral vascular disease and type II diabetes, was monitored without a physician's order or inclusion in their care plan. The monitoring device transmitted both video and audio, which was not disclosed to the Nursing Home Administrator. Resident 65, diagnosed with epilepsy and dementia, also had a monitoring device in use without proper documentation in their care plan. The facility's Nursing Home Administrator admitted that there was no policy or procedure for the protection of residents' privacy with the use of video/audio monitors and that no consent was obtained from the residents or their representatives. The facility's failure to protect residents' privacy rights was a clear violation of the residents' rights to privacy and confidentiality.
Plan Of Correction
All video monitoring devices have been removed from resident rooms. All residents that had video monitoring removed will have their fall care plans reviewed and updated by IDT as needed. All staff will be educated on resident rights to privacy and confidentiality of their personal and medical records including accommodations, medical treatment, written and verbal communications, personal care, visits, and meetings of family and resident groups. Video monitoring will no longer be used in the facility; all staff have been notified, and all cameras have been removed. A QA tool has been developed to review 10% of residents weekly to ensure privacy and confidentiality of their personal and medical records including accommodations, medical treatment, written and verbal communications, personal care, visits, and meetings of family and resident groups. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Failure to Maintain Safe Dishwashing Temperatures
Penalty
Summary
The facility failed to utilize kitchen equipment in accordance with professional standards for food service safety, specifically regarding the operation of the dishwashing machine. The facility's policy, last revised in December 2007, requires that the dishwashing machine's wash and rinse temperatures be monitored during each major use, with a minimum wash temperature of 150 degrees. If the temperature falls below this threshold, staff are instructed to suspend machine washing and notify the appropriate personnel. However, observations and reviews of the dish machine temperature logs from May 2024 through January 2025 revealed multiple instances where the wash temperature was below the minimum safe temperature, with no corrective actions noted. Interviews with facility staff, including the Food Service Director and the Nursing Home Administrator, indicated a lack of awareness and follow-through regarding the low temperatures recorded. The Food Service Director was not informed of the low temperatures in January 2025, and the Nursing Home Administrator could not confirm if the facility's process was followed when the dish machine was operating below the acceptable temperature. This deficiency highlights a failure in communication and adherence to established protocols for ensuring food safety in the facility's main kitchen.
Plan Of Correction
The dishwasher in the kitchen is operating in accordance with facility guidelines, department policy, manufacturer's specifications, and regulatory guidelines. The policy has been updated for dietary staff to notify the dietary manager or dietician of dishwasher water temperatures below 150 degrees. It is the responsibility of the manager/dietician to notify maintenance as needed for repair. Dietary staff have been educated on the updated policy and notification procedures when dishwasher water temperatures are below 150 degrees. A QA tool has been developed to review 10% of dishwasher temperatures weekly to ensure dishwasher water temperatures are above 150 degrees. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Infection Control Lapses in PPE Handling and Disinfection
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by staff, as observed in two resident care areas. Employees 7 and 8 were seen wearing protective gowns while providing care to a resident on enhanced barrier precautions. However, they exited the resident's room still wearing the gowns and disposed of them in a hallway garbage can, contrary to the facility's policy that requires PPE to be removed before leaving the room. The Nursing Home Administrator acknowledged the expectation that gowns and gloves should be removed inside the room and placed in a garbage bag before disposal in the hallway. In another incident, Employee 6 completed a dressing change for a resident with a pressure ulcer but failed to disinfect the bedside table after placing a biohazard garbage bag on it. The Nursing Home Administrator confirmed that the expectation was for the bedside table to be cleansed after contamination. Additionally, during a dressing change for another resident, Employee 15 and Employee 19 exited the room wearing gowns and gloves, with Employee 15 handling a red biohazard bag with her bare hand after removing her gloves in the hallway. This action was identified as an infection control concern by the Nursing Home Administrator. The report also highlighted that Employee 15 was unaware of when the key used to access a utility closet was last cleaned, raising further infection control concerns. The Nursing Home Administrator confirmed that staff should remove PPE inside the room and dispose of it properly to prevent contamination. These observations indicate lapses in adherence to infection control policies, potentially increasing the risk of infection spread within the facility.
Plan Of Correction
Residents 24, 12, 37 have been evaluated for signs of infection - no symptoms noted. Surfaces in resident rooms have been properly disinfected. All residents will be monitored for symptoms of infection via review of nursing documentation and daily staff observations with care. All bedside tables have been disinfected. Enhanced barrier precautions and contact precautions policies updated to include staff will doff personal protective equipment prior to leaving resident room, place in a trash bag and dispose of in trash receptacle in hallway. Red bag receptacles will be placed in all resident rooms for residents requiring a dressing change or other care when trash may be soiled with blood or body fluids. Treatment application policy updated to include disinfecting all surfaces after completion of treatments. All staff will be educated on enhanced barrier precautions and contact precautions policies. Nursing staff will be educated on treatment application policy. Unit reviews by nursing supervisors will be completed to ensure compliance. A QA tool has been developed to review 10% of treatment applications weekly to ensure compliance with enhanced barrier precautions, contact precautions and treatment application policies to ensure compliance. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for a resident, identified as Resident 106. Observations made over three consecutive days revealed that the resident's tray table was consistently dirty, with a mat on top stained with a red substance. Despite the facility's policy stating that residents have the right to a clean environment, the tray table remained uncleaned. During an interview, the Nursing Home Administrator indicated that housekeeping staff conduct weekly room cleanings, while nursing staff are responsible for daily cleaning of tray tables. However, this responsibility was not fulfilled, leading to the deficiency.
Plan Of Correction
Resident 106's bedside table and mat have been cleaned. Tray tables in all resident rooms have been checked for cleanliness and cleaned as needed. All staff have been educated on resident rights to a safe, clean, comfortable and homelike environment; including cleanliness of bedside tables by nursing staff with care each day. Dirty mats will be discarded and replaced as needed. A QA tool has been developed to review 10% of resident environments weekly to ensure resident rights to a safe, clean, comfortable and homelike environment. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Failure to Conduct Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to conduct a Significant Change Minimum Data Set (MDS) assessment for a resident who was admitted to hospice services. According to the Centers for Medicare and Medicaid Services' Resident Assessment Instrument Version 3.0 Manual, a Significant Change MDS is required when a terminally ill resident enrolls in a hospice program. However, the facility conducted an Annual MDS assessment instead, with an assessment reference date of April 4, 2024, despite the resident being admitted to hospice on March 29, 2024. The resident in question had diagnoses including vascular dementia and hypertension. During a staff interview, the Nursing Home Administrator acknowledged that the facility should have conducted a Significant Change MDS due to the resident's enrollment in hospice services. This oversight was identified during a survey, and a modified MDS was later provided, indicating a change to a significant change in status assessment.
Plan Of Correction
Resident R 70's MDS has been corrected to reflect significant change. All residents receiving hospice services have had their last MDS reviewed to ensure any determination of significant change is reflected on MDS. Corrections will be made as needed. RNAC has been educated on the need for significant change MDS completion within 14 days after determination of resident significant change in status and in relation to hospice services. A QA tool has been developed to review 10% of hospice residents weekly to ensure significant change MDS completion within 14 days after determination of resident significant change in status. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain grooming. Specifically, Resident 7, who has diagnoses including hypertension, anxiety disorder, and neuromuscular dysfunction of the bladder, was observed on multiple occasions with a quarter inch of facial hair over her upper lip and chin. Despite having a shower on January 27, 2025, and expressing a preference for assistance with shaving on shower days, Resident 7 did not receive the necessary grooming assistance. The facility's policy on shaving residents, last revised in 2017, requires staff to prepare for and shave residents as needed, documenting the process in the electronic health record. However, the care plan for Resident 7, which was last edited in December 2024, did not ensure that staff followed the specific ADL information. The Nursing Home Administrator was unable to provide information regarding Resident 7's facial hair and later stated that staff should offer shaving with showers and as desired. This deficiency was identified under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(2)(5).
Plan Of Correction
Resident 7 has had facial hair removed. All residents have been observed and facial hair removed as needed per policy. Education provided to nursing staff, residents who are unable to carry out activities of daily living have the right to necessary services to maintain good nutrition, grooming, and personal and oral hygiene; including removal of facial hair. A QA tool has been developed to review 10% of residents weekly to ensure residents who are unable to carry out activities of daily living maintain good nutrition, grooming, and personal and oral hygiene; including removal of facial hair. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Failure to Assess and Document Wounds Upon Admission
Penalty
Summary
The facility failed to provide care and services that met professional standards for a resident with stage three chronic kidney disease and anxiety disorder. Upon admission from the hospital, the resident's discharge records did not indicate any wounds. However, a Licensed Practical Nurse (LPN) documented multiple wounds on the resident's feet and chest, but marked 'None of the above were present' in the admission document for ulcers, wounds, and skin problems. The LPN also marked 'No Referrals Necessary' for wound care, and did not provide further information on the wound characteristics or type. A Registered Nurse did not assess the wounds upon admission, and there was no documentation to the physician about the wounds. The physician's assessment the following day did not note any lesions, indicating a lack of communication. The facility's wound nurse did not assess the resident's foot until two days after admission, and initially reported scabs rather than wounds. However, a subsequent observation revealed a wound with eschar on the resident's toe, which was later diagnosed as a full thickness arterial wound by a consultant. The facility had no explanation for the lack of a timely assessment by a Registered Nurse.
Plan Of Correction
Resident 240 has been assessed by a RN and CRNP. Physician has been notified of alterations in skin integrity and all documentation has been updated to include characteristics and type of alteration in skin. All residents' current skin wound records have been reviewed for appropriate documentation of character and/or type of alterations in skin. Residents with wound infections, diabetic ulcers, venous ulcers, arterial ulcers, pressure ulcers, open lesions, surgical wounds, and stage 2 and greater burns will be assessed by an RN, referral to wound CRNP will be completed, and physician will be notified if not done previously. Admission policy and skin wound policies will be updated to include residents with wound infections, diabetic ulcers, venous ulcers, arterial ulcers, pressure ulcers, open lesions, surgical wounds, and stage 2 and greater burns will be assessed by a RN, referral to wound CRNP will be completed, and physician will be notified. All licensed nursing staff will be educated on updated policies and requirements for wound documentation to include character and type of wound. A QA tool has been developed to review 10% of admissions weekly to ensure residents with wound infections, diabetic ulcers, venous ulcers, arterial ulcers, pressure ulcers, open lesions, surgical wounds, and stage 2 and greater burns are assessed by a RN, referral to wound CRNP is completed, and physician is notified. 10% of wound documentation forms will be reviewed weekly to ensure new alterations in skin integrity include documentation of character and type of wound. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Failure in Pressure Ulcer Care and Infection Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent infection for a resident with a stage three pressure ulcer on the sacrum. During a wound dressing observation, a Licensed Practical Nurse (LPN) was seen preparing the resident for a dressing change. After repositioning the resident, the LPN noticed a bowel movement and cleaned it up. However, the LPN did not perform hand hygiene with soap and water after cleaning the bowel movement and before starting the dressing change, opting instead to use an alcohol-based hand rub. Additionally, the dressing on the resident's wound was not dated. The LPN was also observed retrieving a marker from her pocket with bare hands to label the new dressing, which was not considered a clean area. This was confirmed during a staff interview, where it was acknowledged that the LPN should have performed hand hygiene with soap and water and that the pocket was not a clean surface. Furthermore, it was confirmed that wound dressings should be labeled with the date, time, and initials when applied.
Plan Of Correction
Resident 37 has been evaluated for infection. No signs or symptoms of wound infection noted at this time. All residents with wounds will be evaluated for symptoms of infection. Residents with symptoms of infection will be assessed by an RN and the physician or CRNP will be notified. Treatment application policy will be updated to include washing hands versus using alcohol-based hand sanitizer when hands are visibly soiled. Clarification of wound dressing date has been updated in treatment application policy to include dating dressing during equipment set up prior to removal of old dressing. All licensed staff will be educated on updated policy to ensure prevention of infection. A QA tool has been developed to review 10% of treatment applications weekly to ensure policy compliance and prevention of infection. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Failure to Maintain a Smoke-Free Environment for Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for Resident 26, who was observed smoking a cigarette in the facility parking lot despite the facility's policy of being a smoke and tobacco-free campus. Resident 26, who has chronic obstructive pulmonary disease and normal pressure hydrocephalus, was seen smoking next to an employee, indicating a lack of supervision and adherence to the facility's smoking policy. The resident's clinical records did not include a smoking evaluation for safety, nor was there a care plan addressing safety while smoking. Interviews revealed that Resident 26 kept cigarettes and a lighter in her room without a secure place to store them, posing a potential risk to other residents. The facility was aware of the resident's smoking habits and required her to leave the grounds to smoke, but employees were not permitted to assist her during work hours. This lack of a structured plan and supervision for Resident 26's smoking activities contributed to the deficiency in maintaining a hazard-free environment.
Plan Of Correction
Resident 26 will be evaluated for safety with smoking. She will be offered a lock box for her room to keep her cigarettes and lighter in. A care plan will be developed ensuring residents' safety while smoking. All residents requesting to smoke off facility property will have a safety evaluation completed. Storage will be provided for cigarettes and cigarette lighting devices. A care plan will be developed to ensure resident safety while smoking. Facility smoking policy has been updated to include resident assessment for safety with smoking, providing proper storage of cigarettes and cigarette lighting devices, and care plan development to ensure safety. All facility staff will be updated on the revised policy. Staff will be educated that they are not permitted to assist residents with smoking while clocked in to work. A QA tool has been developed to review all residents that smoke weekly to ensure policy compliance. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Non-Compliance with Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.20 hours of direct resident care per resident per 24-hour period on 13 specific days across three different months. The deficiency was identified through a review of facility staffing documentation and confirmed during an interview with the Nursing Home Administrator. On the specified dates, the facility provided between 3.01 and 3.18 hours of care, falling short of the mandated minimum. This shortfall was documented for several days in July and October 2024, as well as January 2025, indicating a pattern of non-compliance with the required staffing levels.
Plan Of Correction
There has been no negative effect on residents due to nursing hours <3.20. Staffing hours have been evaluated for future schedules to ensure compliance with State Regulation of a minimum of 3.20 hours of direct care for each resident daily. RN Nursing Supervisors have been educated on staffing requirements. A policy has been developed to ensure minimum staffing requirements are met to the best of the facilities ability via communication with current staff and staffing agencies in the event of terminations, resignations, call-offs and failure of staff to report to work, resulting in staffing levels below minimum requirements. Nursing hours will be evaluated daily by RN nursing supervisors to ensure compliance. A QA tool has been developed to review 10% of nursing hours weekly to ensure minimum staffing levels are met to the best of the facilities ability per policy. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Compromised Electrical Receptacle Integrity
Penalty
Summary
The facility failed to maintain the physical integrity of electrical receptacles, specifically affecting one of three smoke compartments within the component. During an observation on January 13, 2025, at 10:50 AM, a physically broken electrical receptacle was identified within the Classroom. This finding was confirmed through an interview with the Director of Operations at the same time, who acknowledged the compromised condition of the electrical receptacle.
Plan Of Correction
The classroom electrical receptacle has been replaced. The facility will have all the electrical receptacles checked to ensure the physical integrity of electrical receptacles. The Director of Operations or designee will complete 10% monthly audits in each facility component to ensure the physical integrity of electrical receptacles. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Failure to Document Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to provide documentation verifying that portable fire extinguishers were visually inspected on a monthly basis within the previous twelve months. This deficiency affected one of two smoke compartments within the component. Specifically, a review of documentation revealed that the 2nd floor portable fire extinguisher located within the H.R. Office had not been visually inspected since November 26, 2024. An interview with the Director of Operations confirmed the lack of documentation for monthly visual inspections of portable fire extinguishers over the last twelve months.
Plan Of Correction
The fire Safety instructor inspected and documented the 2nd floor portable fire extinguisher. All fire extinguishers in the facility will be inspected for proper documentation to verify that they were visually inspected on a monthly basis within the last twelve months. Director of Operations or designee will complete monthly audits of each portable fire extinguisher in the facility to ensure they are properly inspected and documented. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Improper Use of Surge Suppressors in Dietary Office
Penalty
Summary
The facility failed to properly monitor the use of surge suppressors, resulting in a deficiency. During an observation on January 13, 2025, at 11:20 AM, it was discovered that a surge suppressor was supplying electrical power to another surge suppressor within the 1st floor Dietary Office. This practice, known as daisy-chaining, is not compliant with the National Fire Protection Association (NFPA) standards. The Director of Operations confirmed the presence of the daisy-chained surge suppressors during an interview conducted at the same time.
Plan Of Correction
The surge suppressor plugged into another surge suppressor has been removed from the Dietary Office. The facility's electrical equipment will be checked to ensure it has been monitored, no components are affected, assembled by qualified personnel and meet NFPA conditions. Director of Operations or designee will complete 10% monthly audits in each facility component to ensure the physical integrity of electrical receptacles. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
Non-compliance with Building Construction Requirements
Penalty
Summary
The facility was found to be non-compliant with building construction requirements during an observation on January 13, 2025. The building in question is a two-story, Type III (200), unprotected ordinary structure. According to the NFPA 101 standards for existing buildings, this type of construction is not permitted to exceed one story in height. This deficiency was confirmed through an interview with the Director of Operations, who acknowledged that the construction type is not suitable for healthcare facilities.
Deficiency in Exits on Second Floor
Penalty
Summary
The facility was found to be deficient in providing the required number of exits on the second floor, as observed during a survey on January 13, 2025. The National Fire Protection Association (NFPA) 101 standards mandate that each story and smoke compartment must have at least two exits that are remote from each other. However, it was observed that the second floor lacked two acceptable exits that were remote from each other. This deficiency was confirmed through an interview with the Director of Operations, who acknowledged the absence of the required exits.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and physician orders. The resident, who had diagnoses including Diabetes Mellitus Type II and vascular dementia, had a physician order for Ozempic (semaglutide) to be administered subcutaneously once a day on Fridays. However, the Medication Administration Record (MAR) revealed that the medication was not administered on four occasions in March and April 2024, with the reason documented as 'Drug/Item unavailable.' The facility's administration was not immediately informed of the medication's unavailability. It was only after the administrator was notified that an investigation was initiated. Prior to this, the facility failed to administer the medication on the specified dates and did not inform the administration or management about the medication's unavailability, which led to the deficiency.
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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