Ridgeview Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Curwensville, Pennsylvania.
- Location
- 30 Fourth Avenue, Curwensville, Pennsylvania 16833
- CMS Provider Number
- 395652
- Inspections on file
- 23
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Ridgeview Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to complete comprehensive admission MDS assessments within the required 14-day timeframe for 57 residents. Delays ranged from 15 to 216 days, with the Nursing Home Administrator confirming the issue. This deficiency indicates a systemic problem in timely assessments.
The facility failed to complete Quarterly MDS assessments within the required timeframe for 42 residents. The RAI User's Manual mandates that these assessments be completed every 92 days, but many were late, with some residents not having any assessment in the prior 92 days. The Nursing Home Administrator confirmed the non-compliance, violating state codes on clinical records and nursing services.
The facility failed to transmit MDS assessments to the CMS QIES ASAP System within the required 14 days for 31 residents. Specific cases included a resident with a hip fracture and another with renal failure and COVID, where necessary tracking records were not completed on time. The MDS validation report also showed late submissions for multiple residents, confirmed by the Nursing Home Administrator.
The facility failed to accurately complete MDS assessments for five residents, leading to deficiencies in documenting medication administration and vaccination status. Errors included not reflecting the administration of antipsychotic and hypoglycemic medications, as well as missing influenza vaccine documentation. These inaccuracies were confirmed through staff interviews.
The facility failed to follow physician's orders for medication administration for four residents. A resident with hypotension did not have blood pressure checked before receiving Midodrine. Another resident with diabetes had elevated blood sugar levels without physician notification. A resident with heart failure received Midodrine despite high blood pressure, and a resident with hypertension received Metoprolol without vital sign checks. These deficiencies were confirmed by facility staff.
The facility failed to discontinue unnecessary medications for two residents. One resident continued receiving Arixtra and insulin coverage despite a pharmacy recommendation to stop, while another resident was kept on a 14 mg nicotine patch without tapering as advised. These oversights were confirmed by facility staff.
A resident with cognitive impairment and anxiety was frequently administered Ativan without documented attempts of non-pharmacological interventions. The facility's records lacked evidence of such interventions before medication administration, as confirmed by the Nursing Home Administrator.
The facility did not comply with its policy to record dish machine temperatures for each meal, as required to ensure food safety. The policy specified wash and rinse temperatures of 150°F and 180°F, respectively. A review of logs from August to October 2024 showed missing entries, which was confirmed by the Dietary Manager.
A facility failed to assess a resident's ability to self-administer medication, as required by policy. The resident, who was cognitively intact but needed assistance for daily care, was left unsupervised with unlabeled pills. An LPN left the medication assuming the resident would take it, without observing or confirming the resident's ability to self-administer safely.
The facility failed to document the opportunity for residents and/or their representatives to formulate advance directives, as required by their policy. This deficiency was identified during a review of facility policies, clinical records, and staff interviews. For three residents reviewed, there was no documented evidence that they or their representatives were informed of their rights to develop advance directives, offered assistance, or had their directives reviewed annually. Despite the facility's policy, the Nursing Home Administrator could not produce any advance directives or documentation of the required processes for these residents.
A facility failed to provide a required notice to a resident after the end of Medicare coverage. The resident's Medicare coverage started and ended on specific dates, but there was no documented evidence of an Advance Beneficiary Notice of Noncoverage (ABN) being issued. The Director of Social Services was unaware of the need for the ABN.
The facility failed to provide written notification to residents and their legal guardians regarding hospital transfers. A resident with respiratory failure, another with uncontrolled bleeding, and a third with COPD were transferred without their responsible parties receiving written notice of the transfer and reasons. The Nursing Home Administrator confirmed the lack of notification, violating resident rights and discharge policy.
The facility failed to develop comprehensive care plans for two residents. One resident, with cognitive impairment and conditions including diabetes and dementia, lacked a care plan for anticoagulant medication use. Another resident, cognitively intact with a urinary tract infection, did not have a care plan for urinary catheter use. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to update care plans for two residents to reflect their current medical treatments. One resident's care plan inaccurately stated they were receiving a diuretic, while another's care plan did not reflect the discontinuation of an indwelling catheter. These discrepancies were confirmed through staff interviews and reviews of medical records.
A resident choked on improperly pureed food, requiring the Heimlich maneuver, due to the facility's failure to provide the correct food consistency. Additionally, two residents using air mattresses did not have documented safety assessments, as confirmed by the Assistant DON.
A facility failed to timely address a pharmacy recommendation for a resident, resulting in a deficiency. The resident, who was cognitively intact and had diabetes, had a medication regimen review on June 4, 2024, suggesting changes to Allopurinol and Zoloft. The physician agreed, but the changes were delayed until July 6, 2024. This delay was confirmed by the Nursing Home Administrator.
The facility failed to properly label and store medications, including undated insulin pens, expired vials, and unsecured controlled drugs. Additionally, a resident was left with unsupervised and unlabeled medication, which she was unaware of. An LPN confirmed leaving the medication unsupervised, and the ADON acknowledged the error.
The facility's QAPI committee failed to address recurring deficiencies effectively, as evidenced by repeated issues in multiple surveys. Deficiencies included inaccurate MDS assessments, failure to create individualized care plans, and issues with quality of care, safety, drug storage, and food handling. Despite plans of correction involving audits and QAPI review, the facility did not maintain compliance, as shown in the latest survey.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds, as required by CDC and CMS guidelines. The resident, who had multiple wounds and an infection, did not have appropriate infection control measures in place, such as signage or the use of gowns and gloves during high-contact care activities. The Infection Preventionist confirmed the oversight, resulting in a deficiency.
A facility failed to offer an influenza vaccine to a resident, as required by their policy. Despite a request from the resident's representative and a policy mandating annual vaccination offers, there was no documentation that the resident was offered, received, or refused the vaccine since admission. This was confirmed by the Infection Control Nurse.
A facility failed to comply with state regulations by not paying employees' wages and vendor invoices on time, placing residents in immediate jeopardy. The facility owed $189,422.71 in unpaid wages, risking staff shortages and inadequate resident care. Additionally, $106,697.88 in vendor invoices were outstanding, affecting essential services like lab work, primary care, and elevator maintenance. This financial mismanagement led to significant risks to resident health and safety, as confirmed by staff and union representatives. The non-compliance with 28 PA Code 201.14(g) highlighted the facility's financial instability and its impact on care quality.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required time frame for 57 out of 138 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the facility did not adhere to this guideline, resulting in delayed assessments for numerous residents. Specific examples of these delays include Resident 6, whose admission MDS assessment was completed 16 days after admission, and Resident 10, whose assessment was completed 18 days after admission. Other residents experienced even longer delays, such as Resident 13, with a 27-day delay, and Resident 27, with a 29-day delay. The most significant delay was observed in Resident 118, whose assessment was completed 216 days after admission. The Nursing Home Administrator confirmed during an interview that the admission MDS assessments were not completed within the required time frames. This deficiency indicates a systemic issue in the facility's process for conducting timely assessments, affecting a significant portion of the resident population.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for 42 out of 138 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly assessment is due every 92 days, with the completion date being the Assessment Reference Date (ARD) plus 14 days. However, the facility did not adhere to these guidelines, resulting in late assessments for numerous residents. Specific instances of non-compliance include assessments for several residents being completed days after the required timeframe. For example, one resident's assessment with an ARD of June 27, 2024, was completed eight days late, while another resident's assessment with an ARD of July 5, 2024, was completed six days late. Additionally, two residents did not have any quarterly assessment completed in the prior 92 days, indicating a significant oversight in maintaining up-to-date clinical records. The Nursing Home Administrator confirmed during an interview that the admission MDS assessments were not completed within the required time frames. This failure to comply with the mandated assessment schedule is a violation of the 28 Pa. Code 211.5(f) Clinical Records and 28 Pa. Code 211.12(d)(5) Nursing Services, highlighting a systemic issue in the facility's assessment process.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14 days of completion for 31 out of 138 residents reviewed. This deficiency was identified through a review of the Resident Assessment Instrument, clinical records, and the MDS validation report, as well as staff interviews. Specific instances included Resident 37, who was transferred to the hospital for a hip fracture and readmitted to the facility, yet the required Discharge and Entry/reentry tracking records were not completed by the specified date. Similarly, Resident 84 was admitted to the hospital and returned with new admission orders, but the necessary tracking records were not completed in a timely manner. The MDS assessment validation report from iQIES further revealed that several MDS assessments were completed and submitted late for multiple residents, with specific examples including assessments for Residents 13, 15, 38, 43, 46, 71, 95, 96, 100, 110, 116, 122, 126, 127, 128, 133, 144, 146, 147, 148, and 154. These delays in submission were confirmed during an interview with the Nursing Home Administrator. The report highlights the facility's non-compliance with the requirement to transmit comprehensive MDS assessments within 14 days of the Care Plan Completion Date and other MDS assessments within 14 days of the MDS Completion Date, as outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual.
Inaccurate MDS Assessments for Medications and Vaccinations
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, leading to deficiencies in documenting medication administration and vaccination status. For one resident, the MDS assessment did not reflect the administration of olanzapine, an antipsychotic medication, nor the attempt at a gradual dose reduction, despite physician's orders and medication administration records indicating otherwise. Another resident's MDS assessment lacked documentation of influenza vaccine status, with no evidence of the vaccine being offered, received, or refused since admission. Additionally, the facility did not accurately code the administration of hypoglycemic medications for two residents, as their MDS assessments failed to reflect the administration of Metformin and insulin, despite physician's orders and medication administration records confirming their use. Another resident's MDS assessment inaccurately documented the administration of Risperidone, an antipsychotic medication, and did not reflect a gradual dose reduction that had been ordered and administered. These inaccuracies were confirmed through staff interviews, including with the Nursing Home Administrator.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for four residents, leading to deficiencies in care. Resident 67, who was cognitively intact and diagnosed with hypotension, had specific orders for Midodrine administration based on blood pressure readings. However, staff did not obtain or document the resident's blood pressure before administering the medication, as confirmed by the Nursing Home Administrator. Resident 97, who was cognitively impaired and diagnosed with diabetes, had orders to receive Insulin Lispro for blood sugar levels over 400 mg/dl, with a requirement to notify the physician. Despite multiple instances of elevated blood sugar levels, there was no documented evidence that the physician was notified, as confirmed by the Assistant Director of Nursing. This oversight occurred on several dates in August, September, and October. Resident 100, who was cognitively intact and diagnosed with heart failure, had orders to hold Midodrine if the systolic blood pressure exceeded 130 mmHg. The Medication Administration Record showed that the medication was administered despite blood pressure readings above the specified threshold. Similarly, Resident 311, diagnosed with hypertension, had orders to hold Metoprolol if the systolic blood pressure was below 100 or heart rate was below 60, but staff failed to obtain these vital signs before administration. These deficiencies were confirmed through interviews with the Nursing Home Administrator.
Failure to Discontinue Unnecessary Medications for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary drugs, as evidenced by the cases of two residents. Resident 74, who was cognitively intact and diagnosed with diabetes, continued to receive Arixtra, a blood thinner, and fingerstick monitoring with sliding scale insulin coverage despite a pharmacy recommendation to discontinue these medications. The recommendation was made on August 10, 2024, but the physician did not act on it until September 15, 2024, resulting in the resident receiving unnecessary medication for 36 days. This delay was confirmed by the Nursing Home Administrator during an interview. Similarly, Resident 81, who was also cognitively intact and had diagnoses including atrial fibrillation and peripheral vascular disease, was prescribed a 14 mg nicotine patch for smoking cessation without a stop date. The pharmacy recommended tapering the patch and adding a stop date, which the CRNP agreed to on September 28, 2024. However, there was no evidence that these recommendations were implemented, and the resident continued to receive the 14 mg patch beyond the recommended period. This oversight was confirmed by the Infection Control Nurse, who acknowledged that the pharmacy's recommendations were not followed as agreed.
Failure to Document Non-Pharmacological Interventions Before Administering Ativan
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering anti-anxiety medication to a resident. The resident, who was cognitively impaired and diagnosed with anxiety, was prescribed Ativan as needed for mild anxiety and shortness of breath. Despite the requirement to attempt non-medication interventions first, the clinical records showed no evidence of such attempts before administering Ativan on multiple occasions in September and October 2024. The resident's Medication Administration Records indicated frequent administration of Ativan without documented non-pharmacological interventions. An interview with the Nursing Home Administrator confirmed the absence of documentation for non-medication interventions prior to administering the medication. This oversight was a violation of the facility's protocol and state regulations, as staff were expected to document any non-medication interventions attempted.
Failure to Record Dish Machine Temperatures
Penalty
Summary
The facility failed to adhere to its policy regarding the recording of dish machine temperatures, which is crucial for ensuring food safety. The policy, dated January 16, 2024, required dietary aides to record the wash and rinse temperatures of the dish machine for each meal period, with specified temperatures of 150 degrees Fahrenheit for washing and 180 degrees Fahrenheit for rinsing. However, a review of the Dish Machine Temperature Log from August 21 to October 21, 2024, revealed significant gaps in documentation, indicating that proper temperatures were not consistently recorded for each meal. This lapse was confirmed during an interview with the Dietary Manager, who acknowledged the incomplete temperature logs and the staff's failure to record the necessary data as required by the facility's policy.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to determine if a resident was safe to self-administer medications, as required by their policy. The policy, dated January 16, 2024, states that self-administration is permitted only when the interdisciplinary team has determined it is clinically appropriate and safe. However, for Resident 69, who was cognitively intact but required assistance for daily care needs and had multiple diagnoses including stroke, anxiety, depression, and hypertension, no such assessment was completed. This oversight was confirmed by the Nursing Home Administrator during an interview. On October 21, 2024, an observation revealed that Resident 69 was left unsupervised with a medicine cup containing 11 unlabeled pills on her over-bed table. The resident was unaware of the pills and had forgotten to take them. An LPN admitted to leaving the medication in the resident's room without observing her take it, assuming she would take them when she sat up. This action was contrary to the facility's policy, as there was no assessment confirming the resident's ability to self-administer medication safely.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to document the opportunity for residents and/or their representatives to formulate advance directives, as required by their policy. This deficiency was identified during a review of facility policies, clinical records, and staff interviews. The facility's policy, dated January 16, 2024, mandates that upon admission, residents or their representatives should be provided with information about their rights to accept or refuse medical treatment and to formulate advance directives. If a resident has not established advance directives, the staff should offer assistance, document the offer, and record the resident's decision to accept or decline assistance in the medical record. Additionally, the policy requires that advance directives be reviewed annually with the resident during the assessment process and documented in the medical record. For three residents reviewed, there was no documented evidence that they or their representatives were informed of their rights to develop advance directives, offered assistance, or had their directives reviewed annually. Resident 37 was cognitively impaired with diagnoses including diabetes and dementia, while Residents 40 and 53 were cognitively intact with various medical conditions such as chronic kidney disease, peripheral vascular disease, COPD, atrial fibrillation, and cerebral infarction. Despite the facility's policy, the Nursing Home Administrator could not produce any advance directives or documentation of the required processes for these residents, indicating a failure to comply with the established procedures.
Failure to Provide Medicare Coverage Notice
Penalty
Summary
The facility failed to provide the required notice to a resident or their representative after the end of Medicare coverage. Specifically, for one of the three residents reviewed, Medicare coverage began on August 2, 2024, and the last covered day was September 16, 2024. Despite the discontinuation from Medicare Part A coverage, there was no documented evidence that the resident received an Advance Beneficiary Notice of Noncoverage (ABN). An interview with the Director of Social Services revealed that the ABN was not issued because she was unaware of the form and its necessity.
Failure to Notify Residents and Guardians of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their legal guardians regarding the reasons for hospitalization, as required by regulations. Specifically, three residents were transferred to the hospital without their responsible parties receiving written notice of the transfer and the reasons for it. Resident 12 was admitted to the hospital with respiratory failure, Resident 74 with uncontrolled bleeding, and Resident 106 with chronic obstructive pulmonary disease. The Nursing Home Administrator confirmed that no written notices were provided to the residents or their responsible parties at the time of transfer, which is a violation of the residents' rights and discharge policy as per 28 Pa. Code 201.25 and 28 Pa. Code 201.29(f)(g).
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which is a requirement according to their policy for Comprehensive Person-Centered Care Plans. For Resident 37, who was cognitively impaired and had diagnoses including diabetes and dementia, there was no care plan developed to address her treatment needs related to the use of anticoagulant medication, Enoxaparin. This oversight was confirmed by the Nursing Home Administrator during an interview. Similarly, for Resident 84, who was cognitively intact and had a urinary tract infection, there was no care plan developed to address his treatment needs related to the use of a urinary catheter. Despite nurse aide documentation indicating that catheter care was provided each shift, the care plan did not include the use of a urinary catheter before the resident was discharged to the hospital. This deficiency was also confirmed by the Nursing Home Administrator.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that the care plans for two residents were updated to reflect their current care needs. For Resident 33, a quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and not receiving a diuretic medication. However, the resident's care plan inaccurately stated that they were receiving a diuretic. A review of the Medication Administration Record (MAR) and current physician's orders confirmed that there was no order for a diuretic, and an interview with the Nursing Home Administrator confirmed the care plan was not revised accordingly. Similarly, Resident 81's care plan was not updated to reflect changes in their medical treatment. An admission MDS assessment showed that the resident was cognitively intact and had an indwelling catheter. A nurse's note later indicated that the resident was ordered to trial discontinuing the catheter, and a review of the Treatment Administration Record (TAR) and current physician's orders confirmed there was no order for an indwelling catheter. Despite this, the care plan still indicated the presence of an indwelling catheter, as confirmed by the Nursing Home Administrator.
Failure to Ensure Proper Food Consistency and Safety Assessments
Penalty
Summary
The facility failed to provide the correct consistency of food to a resident who required a mechanically-altered diet. The resident, who was cognitively intact, had a physician's order for a pureed texture diet with nectar consistency liquids. However, on one occasion, the resident choked on a chunk of chicken during lunch, necessitating the Heimlich maneuver by a licensed practical nurse. A speech therapist confirmed that the pureed chicken was not the proper consistency and contained chunks, which led to the choking incident. Additionally, the facility did not complete safety assessments for two residents who used air mattresses. Both residents were cognitively intact and required assistance with mobility. They had pressure ulcers and were using air mattresses as part of their care plan. However, there was no documented evidence that the use of air mattresses was assessed for potential safety hazards before being placed on their beds. The Assistant Director of Nursing confirmed the lack of safety assessments for these residents, acknowledging that such assessments should have been conducted.
Delayed Response to Pharmacy Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a pharmacy recommendation for a resident, leading to a deficiency. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and had a diagnosis of diabetes. A pharmacy medication regimen review conducted on June 4, 2024, recommended changes to the resident's medication, specifically adjusting Allopurinol dosage and the timing of Zoloft administration. Although the physician agreed to these recommendations, the changes were not implemented until July 6, 2024, over a month later. This delay was confirmed by the Nursing Home Administrator during an interview on October 23, 2024, acknowledging that the pharmacy medication regimen reviews were not addressed in a timely manner for the resident.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by several deficiencies observed during the survey. In the Walnut hall medication cart, a Lantus insulin Solostar pen for a resident was found opened and undated, which was confirmed by an LPN. Additionally, in the Maple hall medication cart, two expired multi-dose vials of insulin, Novolog and Lantus, were not discarded after 28 days of being opened, as confirmed by the same LPN. Furthermore, the medication room on the East Wing lacked a separately-locked, permanently-affixed compartment in the refrigerator for controlled drugs, as a narcotic box containing Dronabinol was found unsecured and not permanently affixed. The report also highlighted an incident involving a resident who was cognitively intact and required assistance for daily care needs. This resident was found with an unsupervised medicine cup containing 11 unlabeled pills on her overbed table, which she was unaware of and had forgotten to take. An LPN admitted to leaving the medication in the resident's room without supervision, assuming the resident would take them upon sitting up. The Assistant Director of Nursing confirmed that medications should not have been left unsupervised and unlabeled at the bedside.
Repeated Deficiencies in Quality Assurance Processes
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in multiple surveys. The deficiencies included inaccurate Minimum Data Set (MDS) assessments, failure to create individualized plans of care, and issues related to quality of care, safety/accidents, labeling and storing drugs and biologicals, and food procurement/storage/preparation. These deficiencies were initially identified in a State Survey and Certification survey ending in November 2023 and a complaint visit in May 2024. Despite developing plans of correction that included quality assurance systems, the facility did not maintain compliance with the cited nursing home regulations. The facility's plans of correction involved completing audits and reporting the results to the QAPI committee for review. However, the current survey ending in October 2024 revealed that the QAPI committee did not successfully implement these plans to ensure ongoing compliance. Specific deficiencies were cited under F641 for inaccurate MDS assessments, F656 for individualized plans of care, F684 for quality of care, F689 for safety/accident hazards, F761 for labeling/storing drugs and biologicals, and F812 for food procurement/storage/preparation. The repeated nature of these deficiencies indicates a failure in the facility's quality assurance processes.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the CDC and CMS, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for a resident with chronic wounds. Resident 81, who was cognitively intact and required assistance with care needs, was admitted with arterial and pressure ulcers and had a diagnosis of peripheral vascular disease. The resident's care plan indicated actual skin breakdown and an infection in the left toe. Despite these conditions, the facility did not implement EBP, which includes the use of gowns and gloves during high-contact care activities for residents with chronic wounds or indwelling medical devices. Observations revealed that there was no signage at the entrance or within Resident 81's room to indicate that infection control measures were in place. The resident had multiple wounds, including unstageable pressure ulcers and wounds with purulent drainage, which required antibiotic treatment. The Infection Preventionist confirmed that EBP should have been in place for Resident 81 due to the chronic wounds, but it was not implemented, leading to a deficiency in infection control practices.
Failure to Offer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered and/or received the influenza immunization, as required by their policy. The policy, dated January 16, 2024, mandates that all residents and employees without contraindications be offered the influenza vaccine annually between October 1 and March 31. A quarterly Minimum Data Set (MDS) assessment for the resident, dated September 11, 2024, indicated cognitive impairment and lacked influenza vaccine information. An informed consent form, dated October 31, 2023, showed that the resident's representative requested the vaccine. However, a review of the immunization records revealed no documentation that the resident was offered, received, or refused the vaccine since admission on July 20, 2023. This was confirmed by the Infection Control Nurse during an interview on October 22, 2024.
Non-Compliance with State Regulations Due to Unpaid Wages and Vendor Invoices
Penalty
Summary
The facility in question failed to comply with state regulations and codes by not paying their employees' wages and vendor invoices in a timely manner, placing the residents in immediate jeopardy. The facility owed $189,422.71 in unpaid wages to employees, leading to a significant risk of staff walking off the job and leaving residents without adequate care. Additionally, vendor invoices totaling $106,697.88 were outstanding, including payments to essential service providers like a lab, primary care associates, and an elevator corporation, which could impact the quality of care provided to residents. The Immediate Jeopardy situation was identified on February 28, 2024, when it was discovered that the facility had not paid its employees for the payroll due on February 23, 2024. The facility's accounts payable ledger showed significant outstanding balances to various vendors, indicating a pattern of financial mismanagement. The failure to meet these financial obligations jeopardized the health and safety of the residents, as confirmed by interviews with staff members and the union president, who expressed concerns about staffing shortages due to unpaid wages. The facility's non-compliance with state regulations, specifically 28 PA Code 201.14(g), regarding timely payment of bills incurred in the operation of the facility, led to the Immediate Jeopardy situation. The lack of financial responsibility and failure to prioritize essential payments put the residents at risk of serious harm or even death. The facility's inability to meet its financial obligations not only impacted employee morale and retention but also raised concerns about the continuity and quality of care provided to the residents.
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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