Richland Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnstown, Pennsylvania.
- Location
- 349 Votech Drive, Johnstown, Pennsylvania 15904
- CMS Provider Number
- 395610
- Inspections on file
- 30
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Richland Nursing And Rehab during CMS and state inspections, most recent first.
A resident with multiple complex diagnoses was found to have two Exelon transdermal patches applied simultaneously, contrary to physician orders requiring removal of the old patch before applying a new one. Documentation and staff interviews indicated the patch was administered as ordered, but the resident was discovered at the hospital with both patches still on, confirming the old patch was not removed as required.
A resident at Richland Nursing and Rehab, with a history of CHF and pneumonia, did not receive oxygen therapy as ordered, leading to a drop in oxygen saturation. During a transfer, two nurse aides removed the resident's oxygen and failed to reapply it, resulting in an oxygen saturation reading of 87%. Interviews confirmed the oversight, and the DON acknowledged the lapse in care.
The facility failed to maintain its kitchen fire suppression system as required by NFPA 101 standards. The semi-annual inspection was overdue, and there was no documentation for monthly visual inspections. These issues affected one of seven smoke compartments and were confirmed by the Facility Administrator and Maintenance Supervisor.
The facility failed to maintain corridor doors, with a hole above the medication room door knob and a non-latching door to room C132, affecting two smoke compartments. These deficiencies were confirmed by the Facility Administrator and Maintenance Supervisor.
The facility did not follow its pre-approved menu and recipes for a lunch meal, resulting in residents not receiving a dinner roll, margarine, or cream with pineapple tidbits. The chicken vegetable stew was missing several ingredients. Staff cited a supply truck delay as the reason for these omissions, and there was no evidence of communication with the resident council president about the menu changes.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers and reasons for hospitalization for six residents. These included cases of urinary tract infections, heart attack, altered mental status, and status epilepticus. The DON confirmed the lack of required notifications, violating resident rights and discharge policy regulations.
The facility failed to clarify physician orders for three residents, leading to deficiencies in care. One resident's feeding tube order was not updated despite oral medication administration. Another resident missed insulin doses due to outdated orders. A third resident received Midodrine without proper order clarification for specific blood pressure ranges.
The facility failed to complete neurological checks per protocol for a resident after a fall and did not administer medications as ordered for another resident. One resident, with cognitive impairment and vascular issues, showed symptoms of distress after a fall, but the required neurological assessments were not completed. Another resident, with heart failure and hypotension, received Midodrine despite having a systolic blood pressure above the prescribed threshold. The ADON confirmed these lapses in protocol adherence.
The facility failed to account for controlled medications for two residents. One resident, cognitively intact, was missing 60 tablets of Oxycodone prescribed for chronic pain. Another resident, moderately cognitively impaired, was missing 60 tablets of Oxycodone prescribed for polyneuropathy. Investigations confirmed the missing medications, but the facility could not locate them.
The facility failed to maintain effective infection control practices, as evidenced by an LPN not using a gown during wound care for a resident on EBP, improper hand hygiene during wound care for another resident, and handling medications with bare hands. Additionally, a resident with a dialysis catheter lacked appropriate EBP signage.
A facility failed to ensure a resident's call bell was within reach, as required by policy. The resident, who was cognitively impaired and dependent on staff, was observed asking for the call bell, which was found in a nightstand drawer, out of reach. A nurse aide and the DON confirmed the call bell should have been accessible.
The facility failed to notify residents and/or their responsible parties about the bed-hold policy upon hospital transfer for three residents. One resident was transferred due to a large emesis and abdominal pain, another due to altered mental status, and a third after a fall. The Director of Nursing confirmed the lack of documentation for these notifications, which was identified as a concern by the new Business Office Manager.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in documenting medical conditions and treatments. Errors included incorrect coding of injections, nephrostomy tubes, insulin, antibiotics, and antipsychotic medications, as confirmed by staff interviews.
The facility failed to update care plans for four residents, leading to discrepancies between documented care needs and actual conditions. A resident with a Central Venous Catheter for dialysis had a care plan indicating a fistula, while another resident's resolved infection was not reflected in their care plan. Additionally, two residents with resolved or reopened pressure injuries did not have updated care plans. These oversights were confirmed by the facility's nursing leadership.
A resident with a Stage 4 pressure ulcer did not receive wound care as ordered by the physician. The LPN failed to apply medical grade honey and Calcium Alginate to the resident's left great toe, as prescribed. Instead, the LPN only used Acetic Acid and a dressing, which was confirmed by interviews with the LPN and the ADON/Infection Control Preventionist.
A facility failed to flush a resident's intravenous catheter as per policy, which required flushing to maintain patency and prevent medication mixing. Despite physician orders to flush the PICC line with saline every shift, staff administered Ertapenem Sodium daily without documented evidence of flushing. This was confirmed by the DON and ADON.
The facility failed to properly label and store medications, including undated inhalers and a discontinued insulin pen in the B-wing med cart. The medication refrigerator's temperature was inconsistently monitored, and loose medications were found in the C-wing med cart. These deficiencies were confirmed by staff interviews.
The facility's QAPI committee failed to address recurring deficiencies effectively, as evidenced by repeated issues in quality of care, treatment of pressure ulcers, medication storage, and infection control. Despite plans to conduct audits and review results, these measures were ineffective in maintaining compliance.
The facility failed to meet the required NA-to-resident staffing ratios, with insufficient NAs on several days across different shifts. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in staffing levels.
The facility failed to meet the required LPN-to-resident staffing ratios on specific days in November and December 2024. On certain days, the number of LPNs available during the day and overnight shifts was below the required levels based on the facility census. The Nursing Home Administrator confirmed these deficiencies, and no additional higher-level staff were available to compensate for the shortfall.
A facility failed to notify a resident's representative about a hospital transfer and medication changes. The resident, with moderate cognitive impairment and epilepsy, was transferred to the hospital for status epilepticus without notifying their representative. Additionally, changes in medication orders for Keppra and Pantoprazole were not communicated. The DON confirmed the lack of notification, violating the facility's policy on residents' rights.
Two residents reported that they were not allowed to use the bathroom during meal times due to an infection control policy, leading to incontinence and distress. One resident, with a cancer diagnosis, experienced frequent bowel incontinence, while another, prone to urinary tract infections, had to wait up to an hour to use the bathroom. Staff confirmed the policy, and facility leadership acknowledged it but claimed needs would be addressed individually.
Failure to Remove Old Medication Patch Prior to New Application
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not following a physician's order for medication administration for one resident. According to the facility's policy, medications are to be administered as per the written orders of the attending physician. The resident in question was moderately cognitively impaired, required extensive assistance for daily care, and had multiple diagnoses including acute respiratory failure, heart attack, stroke, myasthenia gravis, and dementia. The physician's order specified that a Rivastigmine (Exelon) transdermal patch should be applied once daily and the old patch removed per schedule. Documentation showed that the patch was administered on consecutive days as ordered, with staff indicating the old patch was removed when the new one was applied. However, a late entry nursing note indicated that the resident was found with two Exelon patches on upon arrival at the hospital. Interviews with the LPN who administered the medication and the DON confirmed that, despite the staff member's assertion that she always removes the old patch before applying a new one, the resident was discovered with two patches. The DON acknowledged that, based on the hospital's report and the facility's investigation, the old patch was not removed as required by the physician's order.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
Richland Nursing and Rehab was found to be non-compliant with the requirement for respiratory care as outlined in 42 CFR Part 483.25(i). The deficiency was identified during an abbreviated complaint survey, where it was observed that the facility failed to ensure that oxygen was provided as ordered by the physician for a resident. The resident, who was severely cognitively impaired and had a history of congestive heart failure and pneumonia, was supposed to receive oxygen at zero to four liters per minute to maintain an oxygen saturation of 90 percent or more. However, during an observation, it was noted that the resident's oxygen was removed by two nurse aides during a transfer and was not reapplied, leading to a drop in the resident's oxygen saturation to 87 percent. Interviews with the nurse aides confirmed that the oxygen was not reapplied after the transfer, which was acknowledged as an oversight. The Director of Nursing also confirmed that the resident should have been provided with oxygen therapy as ordered. This incident highlights a failure in adhering to the facility's policy regarding safe oxygen administration, which required verification of the physician's order and proper application of oxygen therapy.
Plan Of Correction
1. Licensed Practical Nurse applied oxygen to Resident 3 and checked Resident's 3 oxygen saturation (measurement of the percentage of oxygen-rich hemoglobin in arterial blood) using a pulse oximeter (a device which measures the percentage of oxygen-rich hemoglobin in arterial blood) which showed Resident 3's oxygen saturation was at 94% on 2 liters of oxygen which is in line with her physician's order of her blood oxygen saturation being maintained at 90% or above. 2. At the time that it was noted that Resident 3's oxygen had not been properly reapplied post mechanical lift transfer, Admissions Coordinator, a licensed nurse, performed a set of nursing rounds to ensure other Residents ordered oxygen had it properly applied. No other Residents found to be missing their oxygen placement. 3. Education will be provided to Certified Nurses Aides to ensure that oxygen is properly reapplied to Residents after necessary removal for care tasks. 4. Licensed Practical Nurses will audit, per shift, Residents who are ordered to have oxygen to ensure that it is in place. Director of Nursing, or designee, will review three Residents per shift three times a week for two weeks, then monthly as needed, to ensure audits are being properly completed. Results will be reviewed with the Quality Assurance Performance Improvement committee.
Deficiency in Kitchen Fire Suppression System Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically affecting one of seven smoke compartments. During a documentation review on December 23, 2024, it was found that the most recent semi-annual inspection and maintenance of the kitchen fire suppression system was completed on March 6, 2024, and was overdue for another inspection by the end of September 2024. Additionally, the facility lacked documentation for the required monthly visual inspections of the kitchen fire suppression system. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Supervisor.
Plan Of Correction
1. No Residents were found to have been affected by the deficient practice. On 12-23-24, the Director of Maintenance performed the required monthly visual inspection. 2. All Residents have the potential to be affected by the deficient practice. 3. The Director of Maintenance was educated on regulation K0324 by the Administrator. The Administrator added the monthly kitchen fire suppression visual inspection to the list of tasks in TELS, a software which schedules and tracks maintenance tasks. The Administrator contacted two new vendors to schedule the biannual kitchen fire suppression system. 4. The Administrator will receive weekly emails from TELS updating the status of the monthly visual inspection for monitoring purposes.
Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining corridor doors, as observed during a survey on December 23, 2024. Specifically, there was a hole above the door knob to the medication room, which compromises the door's ability to resist the passage of smoke. Additionally, the door to room C132, which is equipped with a door closer, failed to self-latch when tested. These issues were identified in two of the seven smoke compartments within the facility. The deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Supervisor on the same day. The failure to maintain the integrity of corridor doors as required by NFPA 101 and CMS regulations indicates a lapse in ensuring that doors resist the passage of smoke and maintain proper latching mechanisms. This oversight affects the safety and compliance of the facility's smoke compartments.
Plan Of Correction
1. No Residents were found to have been harmed by the deficient practice. On 12-30-24, the Director of Maintenance completed repairs on the hole in the Medication Room door, and the hinge keeping room C132 from latching properly. 2. All Residents have the potential to be harmed by the deficient practice. 3. The Director of Maintenance was educated on regulation K 0363 by the Administrator. The Administrator, or designee, will perform weekly rounds with the Director of Maintenance, or designee, to check for compliance. 4. The Administrator will receive weekly emails from TELS, a software which schedules and tracks maintenance tasks, updating the status of the monthly visual inspection for monitoring purposes.
Failure to Follow Pre-Approved Menu and Recipes
Penalty
Summary
The facility failed to adhere to its pre-approved planned menu and recipes for a lunch meal on December 19, 2024. The posted menu indicated that residents were to receive chicken vegetable stew, spaghetti noodles, dinner roll, pineapple tidbits with cream, two-percent milk, coffee/tea, and margarine. However, during the lunch tray delivery, it was observed that the residents did not receive the dinner roll or margarine, and the pineapple tidbits were served without cream. Additionally, the chicken vegetable stew served did not contain several ingredients listed in the facility's recipe card, including chopped ham, lima beans, crushed tomatoes, diced celery, and minced garlic. Interviews with the Dietary Manager and another staff member revealed that the missing cream was due to a delay in the supply truck's arrival, and the staff attempted to make the stew as hearty as possible with the available ingredients. There was no documented evidence that the changes in the menu were discussed with the resident council president, indicating a lack of communication and planning to address the shortfall in ingredients. This failure to follow the planned menu and recipes constitutes a deficiency in meeting the nutritional needs of the residents as required by the facility's dietary services regulations.
Plan Of Correction
1. There were no ill effects noted to residents in the facility due to menu change. 2. Dietary Manager educated on regulation of the notification to residents of menu changes. 3. Dietician or designee will audit to ensure lunch meal is accurate to communicated menu weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital and the reasons for hospitalization for six residents. Resident 9 experienced a large emesis and acute abdominal pain, leading to hospitalization for a urinary tract infection and small bowel obstruction. Resident 28 was transferred to the hospital and admitted with a heart attack. Resident 36 was hospitalized with a urinary tract infection, and Resident 37 was admitted with altered mental status. Resident 43 was sent to the hospital following a fall and complaints of left hip pain, and Resident 62 was admitted with status epilepticus. In all these cases, there was no documented evidence that written notices were provided to the residents' representatives. The Director of Nursing confirmed that the facility did not provide the required written notices to the residents and/or their representatives when the residents were transferred to the hospital. This failure to notify is a violation of the residents' rights as outlined in the facility's discharge policy and resident rights regulations. The lack of documentation and communication regarding the transfers and reasons for hospitalization represents a significant deficiency in the facility's compliance with regulatory requirements.
Plan Of Correction
1. Resident 9, 28, 36, 37, 43 and 62 were notified of transfer to out to hospital by phone; however, they were not notified in writing. 2. Facility reviewed regulation for notice of requirements before transfer/discharge of a resident. Facility put in place utilizing a form to meet the regulation to accompany the bed hold notice. Business Office Manager and Registered Nurse Supervisor's were educated on sending written notice of resident transfer/discharge to responsible party. 3. Social Service director or designee will complete audit to ensure written transfer/discharge notice is sent for hospital transfer weekly times two weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Clarify Physician Orders for Three Residents
Penalty
Summary
The facility failed to clarify a questionable physician's order for three residents, leading to deficiencies in care. For one resident, there was an order to flush a feeding tube with water before and after administering medications, despite the resident no longer receiving medications through the tube. Interviews with the resident and staff confirmed that the feeding tube was not in use for medication administration, yet there was no documented evidence that the physician was contacted to clarify the order. Another resident, who was cognitively intact and had diabetes, had a physician's order to receive insulin at specific times. However, the resident did not receive the insulin on multiple occasions as the staff held the medication based on outdated orders. The Assistant Director of Nursing confirmed that the insulin should not have been held without clarifying the new orders with the physician. A third resident, also cognitively intact, had orders to receive Midodrine for low blood pressure under specific conditions. The medication was administered when the resident's systolic blood pressure was between 90 and 120 mmHg, a range not covered by the existing order. The Assistant Director of Nursing confirmed that the order should have been clarified with the physician to address this gap.
Plan Of Correction
1. Resident 19, 63, 76's orders were clarified with the medical director. 2. Review of residents with tube feed flush order, midodrine hold parameter and insulin hold parameter's were reviewed. Registered Nurse's were educated on clarification of flush orders when tube feeding is discontinued and clarification of hold parameters when therapeutic interchange is made and to review midodrine hold parameters for accuracy. 3. Assistant Director of Nursing or designee will audit three residents with tube feed flush order, midodrine order or insulin with hold parameters weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Follow Protocols for Neurological Checks and Medication Administration
Penalty
Summary
The facility failed to adhere to its protocol for completing neurological checks following a fall for one resident. This resident, who was moderately cognitively impaired and had diagnoses including peripheral vascular disease and atrial fibrillation, was found on the floor without injury. However, later that day, the resident exhibited symptoms such as right-sided weakness, mouth drooping, and confusion. Although a neurological assessment form was initiated, the assessments were not completed according to the facility's protocol, which required checks every 15 minutes for one hour, every hour for four hours, and every four hours for 19 hours. Additionally, the facility did not administer medications as ordered by the physician for another resident. This resident, who was cognitively intact and had diagnoses of heart failure and hypotension, was prescribed Midodrine to be administered with meals on specific days, provided their systolic blood pressure was below 120 mmHg. Despite this, the medication was administered on several occasions when the resident's systolic blood pressure exceeded 120 mmHg. The Assistant Director of Nursing confirmed that the neurological assessments and medication administration were not conducted as per the facility's protocols.
Plan Of Correction
1. Resident 37 did not have documented neurological assessments (neurochecks) fully completed prior to transfer to hospital. Medication error completed on resident 76, hold parameter clarified, resident notified and Medical Director notified. There were no ill effects to resident 76. 2. Licensed Staff educated on completion of neurochecks and following hold parameters for midodrine. 3. Director of Nursing or designee will review neurochecks for completion weekly times four weeks and monthly times two months. Director of Nursing or designee will audit residents with midodrine hold parameters weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for two residents. For one resident, a quarterly Minimum Data Set (MDS) assessment revealed that the resident was cognitively intact, required assistance with care needs, and received opioid medication for chronic pain syndrome. Physician's orders indicated the resident was to receive 10 mg of Oxycodone every six hours as needed. However, an investigation found that 60 tablets of Oxycodone were unaccounted for after being delivered, with only one of the two cards of medication located. For another resident, the MDS assessment showed moderate cognitive impairment, continuous pain, and the use of opioid medication for polyneuropathy. Physician's orders specified 5 mg of Oxycodone every eight hours. An investigation revealed that 60 tablets of Oxycodone were missing, with only one card of medication found from a delivery of 88 tablets. The Director of Nursing confirmed the facility's inability to locate the missing medications for both residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident 19, who had a Stage 4 pressure ulcer and was on Enhanced Barrier Precautions (EBP), a Licensed Practical Nurse (LPN) did not apply a gown during wound care, contrary to the facility's policy and the resident's care plan. The LPN incorrectly assumed that EBP was no longer necessary due to the discontinuation of the resident's feeding tube, which was not aligned with the guidelines for residents with wounds. Resident 62, who required extensive assistance and had skin integrity issues, was also subject to improper infection control practices. During wound care, the LPN failed to remove gloves and perform hand hygiene after completing the wound care and before touching the resident's oxygen equipment and bedding. This action was against the facility's policy, which mandates hand hygiene between tasks to prevent cross-contamination. Additionally, during medication administration for Residents 45 and 47, another LPN handled medications with bare hands and did not perform hand hygiene between residents. This practice violated the facility's policy requiring gloves when handling medications and hand hygiene between residents. Furthermore, Resident 76, who had a dialysis catheter, did not have appropriate signage for EBP until a day after it was ordered, indicating a lapse in implementing necessary infection control measures.
Plan Of Correction
1. Residents 19, 45, 47, 62 and 76 had no ill effects. Resident 76's enhanced barrier precautions were added. 2. Review of residents with central venous catheters were reviewed to ensure enhanced barrier precautions were reviewed and ensured to have enhanced barrier precautions were in place. Licensed Staff educated on following enhanced barrier precautions, hand washing following a treatment and not touching medications with bare hands. 3. Assistant Director of Nursing or designee will audit residents with central venous catheters have enhanced barrier precautions in place weekly times four weeks and monthly times two months. Registered Nurse Assessment Coordinator or designee will audit that enhanced barrier precautions during wound care and hand washing following wound care is being completed weekly times four weeks and monthly times two months. Admissions Director or designee will audit to ensure medications are not being touched with bare hands weekly times four weeks and monthly times two weeks. 4. The Quality Assurance Performance Improvement committee will review previous survey/complaint deficiencies to ensure compliance.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring the call bell was within reach. The facility's policy, dated November 21, 2024, mandates that call bells should be accessible to residents. A quarterly Minimum Data Set (MDS) assessment for the resident, dated November 6, 2024, indicated cognitive impairment and dependency on staff for all care needs, with a care plan specifying that the call bell should be within reach due to decreased mobility. On December 16, 2024, at 10:15 a.m., the resident was observed lying in bed, asking for the call bell, which was found in the nightstand drawer, out of reach. A nurse aide confirmed that the resident could use the call bell and it should have been accessible. The Director of Nursing also confirmed that the call bell should have been within reach.
Plan Of Correction
1. Resident number 2's call bell was placed within reach. 2. Staff rounded in facility to ensure resident call bells were within reach. If found, resident call bells were placed within reach. Education provided to nursing staff to ensure call bells are within resident's reach. 3. Director of Nursing or designee will complete audit to ensure resident's call bells are within reach weekly times two weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents and/or their responsible parties about the bed-hold policy upon transfer to the hospital for three residents. Resident 9 was transferred to the hospital with a large emesis, acute abdominal pain, and a history of bowel obstruction, and was admitted with a urinary tract infection and small bowel obstruction. Resident 37 was found on the floor with no injuries but was transferred to the hospital and admitted with altered mental status. Resident 43 experienced a fall and complained of left hip pain, leading to a hospital transfer and admission. In all these cases, there was no documented evidence that the residents or their responsible parties were informed about the facility's bed-hold policy at the time of transfer. The Director of Nursing confirmed the lack of documentation regarding bed-hold notifications for these residents. The issue was identified by the new Business Office Manager on September 9, 2024, indicating a lapse in the facility's protocol to inform residents or their representatives about the bed-hold policy during hospital transfers. This deficiency was cited as past noncompliance, highlighting a failure in communication and documentation processes within the facility.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of their medical conditions and treatments. For one resident, the MDS assessment incorrectly indicated that the resident received injections during the assessment period, despite no documented evidence of such injections. Additionally, the assessment failed to note the presence of a nephrostomy tube, which was consistently treated as per physician's orders. Another resident's MDS assessment did not reflect the administration of insulin injections, which were documented in the Medication Administration Records (MARs), and incorrectly indicated the receipt of antibiotics, which were not administered. Further inaccuracies were found in the MDS assessments of two other residents. One resident's assessment failed to document the application of an antibiotic ointment to a diabetic ulcer, despite treatment records confirming its use. Another resident's assessment inaccurately coded the receipt of antipsychotic medication, despite consistent administration as per physician's orders. These errors were confirmed through interviews with facility staff, including the Assistant Director of Nursing and the Registered Nurse Assessment Coordinator, highlighting a failure in accurately coding and documenting resident assessments.
Plan Of Correction
1. Resident 35, 36, 48 and 60's current Minimum Data Set (MDS) assessments are accurate. Facility was unable to correct past MDS due to them being closed. 2. Review of residents with nephrostomy tubes, antibiotic ointment, insulin injections and antipsychotic medications were reviewed for accuracy. Registered Nurse Assessment Coordinator was educated on ensuring accuracy of the MDS coding with current orders. 3. Registered Nurse Assessment Coordinator or designee will audit three residents with nephrostomy tube, antibiotic ointment, insulin injections or antipsychotic medications weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans to reflect changes in residents' care needs for four residents. Resident 28, who was cognitively impaired and required dialysis, had a care plan indicating the use of a fistula for dialysis. However, observations revealed the use of a Central Venous Catheter instead, and the care plan was not updated to reflect this change. The Director of Nursing confirmed the oversight. Resident 33, who was cognitively intact and had a diagnosis of multi-drug resistant organisms, was initially on contact precautions due to ESBL - E. coli. Physician's orders later indicated that the resident was no longer on contact precautions, but the care plan was not updated to reflect this change. The Assistant Director of Nursing/Infection Preventionist confirmed that the care plan should have been updated. Resident 39, who was cognitively impaired and had no pressure injuries, was on Enhanced Barrier Precautions due to a chronic wound. Observations showed that the resident's pressure ulcers had resolved, but the care plan was not updated to reflect this. Similarly, Resident 68, who had a reopened Stage 3 pressure injury, did not have an updated care plan to include this condition. The Director of Nursing confirmed the care plan was not revised for Resident 68.
Plan Of Correction
1. Resident 28, 33, 39 and 68's care plans were updated. 2. Review of residents with central venous catheter, resolution of contact isolation, resolution of enhanced barrier precautions due to skin breakdown and new pressure ulcers were reviewed to ensure care plans were accurate. Registered Nurse Assessment Coordinator's were educated on ensuring timely updating of resident care plans is being completed. 3. Registered Nurse Assessment Coordinator or designee will audit three residents care plan with a central venous catheter, resolution of contact isolation, resolution of enhanced barrier precautions due to skin breakdown and new pressure ulcers weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for one resident, identified as Resident 19, by not following the physician's orders for wound treatment. Resident 19 had a Stage 4 pressure ulcer on the left heel and a non-stageable pressure ulcer at another site. The care plan indicated an actual skin breakdown on the resident's left great toe, requiring specific treatment as per physician's orders. These orders included cleansing the wound with Acetic Acid 0.25 percent, applying medical grade honey, and then applying Calcium Alginate before securing with gauze and paper tape. On December 16, 2024, during an observation of wound care, it was noted that the LPN did not apply the medical grade honey and Calcium Alginate as ordered. Instead, the LPN only cleansed the wound with Acetic Acid and applied a dressing soaked in the same solution, followed by a dry gauze and paper tape. This deviation from the prescribed treatment was confirmed through interviews with the LPN and the Assistant Director of Nursing/Infection Control Preventionist, indicating a failure to adhere to the physician's orders for wound care.
Plan Of Correction
1. Resident 19's treatment was properly completed per physician order. Licensed Practical Nurse was educated on following physician treatment orders. 2. Licensed Staff educated on following physician treatment orders. 3. Registered Nurse Assessment Coordinator or designee will audit three treatments weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Flush IV Catheter as per Policy
Penalty
Summary
The facility failed to ensure proper flushing of an intravenous line for a resident, as required by their policy. The policy, dated November 21, 2024, mandates that midline and central line intravenous catheters be flushed to maintain patency, prevent mixing of incompatible medications, and ensure the complete administration of medication. The policy specifies using the SASH method (saline, administer medication, saline, heparin) for intermittent treatments. For Resident 10, physician's orders dated November 14, 2024, required staff to flush the peripherally inserted central catheter (PICC) with 10 ml of 0.9 percent Normal Saline every shift to maintain intravenous line patency. Despite these orders, the Medication Administration Records (MARs) for November 2024 showed that staff administered one gram of Ertapenem Sodium intravenously every day at 9:00 a.m. from November 15 through 24, 2024, without documented evidence of flushing the catheter before or after medication administration. This was confirmed in an interview with the Director of Nursing and Assistant Director of Nursing on December 18, 2024, who acknowledged the lack of documentation for flushing the IV catheter according to the facility's policy.
Plan Of Correction
1. Resident 10's intravenous (IV) flush orders, before and after medications, were clarified with the Medical Director. Resident 10 had no ill effects. 2. Residents with IV flush orders were reviewed for accuracy. Registered Nurses were educated on clarifying before and after medication administration flush orders for IVs. 3. Director of Nursing or designee will audit residents with IV orders to ensure they include flush orders for before and after medication administration weekly times four and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by several deficiencies observed during a survey. In the B-wing medication cart, multi-dose containers of inhalers for a resident were not labeled with the date they were opened, contrary to the manufacturer's instructions. Additionally, an insulin pen for another resident, which was no longer prescribed, was not discarded as required. These lapses were confirmed by a Licensed Practical Nurse during the survey. Further deficiencies were noted in the medication room and C-wing medication cart. The medication refrigerator's temperature was not consistently monitored and documented on the night shift, with only six recorded checks over a 17-day period. This was confirmed by a Registered Nurse. Additionally, loose medications were found in the C-wing medication cart, indicating improper securing of medications. These findings were corroborated by interviews with nursing staff and the Assistant Director of Nursing, who acknowledged the lapses in medication management and storage.
Plan Of Correction
1. Resident 2's inhaler was discarded due to being opened without being dated. Resident 63's insulin pen was discarded due to being discontinued. Medication room fridge temperature was checked and marked to be within appropriate level at time of review. Medication carts were checked and loose pills removed. 2. Medication carts were checked for inhalers and insulin pens for date and active order. Licensed Staff educated on dating open inhalers, discarding discontinued insulin pens, completing daily medication room fridge temperature and removing loose pills from medication carts. 3. Admissions Director, who is a licensed staff member, or designee will audit medication carts for undated inhalers or discontinued insulin pens weekly times four weeks and monthly times two months. Admissions Director or designee will audit medication carts to ensure no loose pills in the cart weekly times four weeks and monthly times two months. Assistant Director of Nursing or designee will audit medication room fridge temperature log for completion weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Recurring Deficiencies in Quality of Care and Compliance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by the results of the current survey ending December 19, 2024. The survey identified repeated deficiencies in areas such as quality of care, specifically in following physician's orders, treatment of pressure ulcers, medication storage and labeling, and infection control practices. These deficiencies were previously cited in a survey ending January 11, 2024, and the facility had developed plans of correction that included audits and reporting to the QAPI committee. However, the current survey revealed that these plans were not successfully implemented, leading to ongoing non-compliance. The specific deficiencies included failure to follow physician's orders, inadequate treatment of pressure ulcers, improper storage and labeling of medications, and non-compliance with infection control practices. Despite the facility's plans to conduct audits and review results with the QAPI committee, these measures were ineffective in maintaining compliance with the relevant regulations. The repeated nature of these deficiencies indicates a systemic issue within the facility's quality assurance processes.
Plan Of Correction
1. The Quality Assurance and Performance Improvement committee reviewed current survey deficiencies and plan of correction including audits. 2. The Quality Assurance and Performance Improvement committee reviewed previous survey/complaint deficiencies to correct deficiencies and ensure that plans to effectively address recurring deficiencies. 3. The Quality Assurance and Performance Improvement committee was educated on the Quality Assurance and Performance Improvement Plan. 4. The Quality Assurance Performance Improvement committee will review previous survey/complaint deficiencies to ensure compliance.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2024. The regulation requires a minimum of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. The deficiency was identified through a review of nursing schedules and staffing information, which revealed that the facility did not meet these staffing ratios for several days across different shifts in November and December 2024. Specifically, the facility was found to be understaffed on the day shift for seven out of 21 days, on the evening shift for six out of 21 days, and on the overnight shift for 14 out of 21 days. For instance, on November 17, 2024, the facility had a census of 80 residents, requiring 8.00 NAs during the day shift, but only 7.45 NAs were available. Similar discrepancies were noted on other days, with the number of NAs falling short of the required numbers based on the facility's census data. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged that the facility did not meet the required staffing ratios on the specified days. No additional higher-level staff were available to compensate for these deficiencies, indicating a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met. 2. The facility will continue to take measures to adequately provide staff to meet the required Certified Nursing Assistant to resident ratios. When total certified nursing assistant to resident ratios is unable to be met, the facility will reevaluate the scheduling of new admissions. The Nursing Home Administrator or designee will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler who are responsible to maintain adequate staffing and staffing ratios. 3. The Nursing Home Administrator or designee will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents weekly times two weeks and monthly times two months. 4. The results will be reviewed at Quality Assurance Performance Improvement meetings until substantial compliance has been met.
LPN Staffing Deficiencies in November and December 2024
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on specific days in November and December 2024. On November 17, 2024, the facility had a census of 80 residents, necessitating 2.00 LPNs during the day shift, but only 1.91 LPNs were available. Similarly, on November 23, 2024, with a census of 79 residents, 1.98 LPNs were required, yet only 1.47 LPNs were present. This indicates a shortfall in staffing levels during the day shift on these dates. Additionally, the facility did not meet the required staffing ratios during the overnight shift on December 17 and 18, 2024. On December 17, with a census of 82 residents, 2.05 LPNs were needed, but only 2.03 LPNs were available. On December 18, with a census of 81 residents, 2.03 LPNs were required, but only 2.00 LPNs were present. The Nursing Home Administrator confirmed these deficiencies, and no additional higher-level staff were available to compensate for the shortfall.
Plan Of Correction
1. The facility will continue to take measures to adequately provide staff to ensure the needs of the residents are met. 2. The facility will continue to take measures to adequately provide staff to meet the required Licensed Practical Nurses to resident ratios on all shifts. When total Licensed Practical Nurses to resident ratios is unable to be met, the facility will reevaluate the scheduling of new admissions. The Nursing Home Administrator or designee will provide education on minimum staffing ratios to the Registered Nurse Supervisor and Scheduler who are responsible to maintain adequate staffing and staffing ratios. 3. The Nursing Home Administrator or designee will audit daily schedules to ensure minimum number of staff are scheduled to meet the needs of the residents weekly times two weeks and monthly times two months. 4. The results will be reviewed at Quality Assurance Performance Improvement meetings until substantial compliance has been met.
Failure to Notify Resident's Representative of Hospital Transfer and Medication Changes
Penalty
Summary
The facility failed to ensure proper notification of a resident's representative regarding significant changes in the resident's condition and treatment. Specifically, the facility did not inform the resident's representative about the resident's transfer to the hospital on November 9, 2024, after the resident exhibited altered behavior and was diagnosed with status epilepticus. Additionally, there was no documented evidence that the resident or their representative was notified about changes in medication orders, including the administration of Keppra and Pantoprazole, on November 24 and November 26, 2024, respectively. The resident in question had moderate cognitive impairment and required assistance with daily care needs, with diagnoses including epilepsy and a gastrointestinal stromal tumor. The Director of Nursing confirmed that the notifications were not made, which is a violation of the facility's policy on residents' rights. This policy mandates immediate notification of the resident, consultation with the resident's physician, and notification of the resident's representative when there is a significant alteration in treatment or a decision to transfer the resident from the facility.
Plan Of Correction
1. Resident 1 was notified of changes, and it was documented in point click care which is an electronic medical record keeping system utilized by the nursing home. 2. Education to licensed staff including agency to be completed on notification and documentation. 3. Audits will be conducted daily X 5, then weekly X 4 until compliance is met. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.
Failure to Accommodate Resident Toileting Preferences During Meals
Penalty
Summary
The facility failed to reasonably accommodate the toileting preferences of two residents, leading to a deficiency in resident care. Resident 1, who has a diagnosis of Malignant Carcinoid Tumor of the Stomach and experiences frequent bowel incontinence, reported that she is not toileted during meals due to an infection control policy. This policy prevents staff from assisting residents with toileting until after meal trays are distributed and collected. As a result, Resident 1 often becomes incontinent during mealtimes, which she finds distressing and inappropriate given her medical condition. Similarly, Resident 2, who is cognitively intact and suffers from frequent urinary tract infections, expressed that she is unable to use the bathroom during meal service, sometimes waiting up to an hour. This resident uses a bedpan when in bed and a toilet with assistance when in a wheelchair. Staff interviews confirmed that they were instructed not to toilet residents during meals for infection control reasons. The Director of Nursing and the Nursing Home Administrator acknowledged the policy but stated that toileting needs during meals would be addressed on a case-by-case basis, although this was not reflected in the residents' experiences.
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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