Ridgeview Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shenandoah, Pennsylvania.
- Location
- 200 Pennsylvania Avenue, Shenandoah, Pennsylvania 17976
- CMS Provider Number
- 395929
- Inspections on file
- 54
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Ridgeview Healthcare & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep the environment free of accident hazards by leaving unsecured medications and medicated creams accessible in resident rooms. A cognitively intact resident approved for self-administration had an oral muscle relaxant pill left on a bedside table, and additional anticoagulant and antidepressant pills were found on the floor in another room. Another cognitively intact resident had an unlabeled hydrocortisone cream at the bedside with no physician order, and a third cognitively intact resident had zinc oxide ointment routinely left at the bedside, despite not being formally approved to self-administer. Staff, including LPNs and an RN supervisor, acknowledged that these medications and products should not have been left accessible, contrary to facility policies on medication administration and self-administration.
Two residents with cognitive impairments and complex medical conditions experienced significant, unaddressed weight loss due to the facility's failure to assess, monitor, and communicate changes in nutritional status. The facility did not follow its own policies for reweighing, notifying appropriate staff, or implementing interventions, and did not adequately evaluate contributing factors such as medication side effects and inconsistent intake.
Two residents had inaccurate MDS assessments: one was incorrectly documented as having received insulin injections during the look-back period, despite no evidence in the medication administration records, and another was not coded as edentulous on the MDS despite clinical records and observations confirming the absence of natural teeth.
A resident with Parkinson's disease and dementia became edentulous after multiple tooth extractions and was in the process of receiving full dentures. However, the facility did not develop or implement a care plan addressing the resident's dental status or outline steps and timelines for obtaining dentures, as confirmed by staff and clinical record review.
A resident with dementia and Parkinson's disease, identified as being at risk for falls, did not have physician-ordered non-skid strips applied to the floor as required. Observations and staff interviews confirmed the absence of these safety measures, indicating staff did not consistently follow the care plan and physician's orders.
The facility did not ensure timely payment for essential goods, services, and staff payroll, resulting in multiple outstanding vendor balances and returned payroll checks for 27 staff members. The NHA confirmed a lack of evidence for payments or formal agreements for overdue invoices, and administration did not have access to verify payment status.
A resident with multiple chronic conditions persistently refused hygiene care, including showers, toileting, and housekeeping, resulting in prolonged exposure to urine and feces and unsanitary room conditions. Staff did not implement alternative infection control strategies or individualized interventions, and the resident's mattress and linens were only replaced when permitted, approximately every three months. Facility leadership confirmed the ongoing unsanitary environment and lack of effective infection prevention measures.
A resident with COPD and dementia, but assessed as cognitively intact, was found with medication left at the bedside without documented assessment or approval for self-administration. Facility policy requires interdisciplinary team determination and documentation for self-administration, which was not completed in this case.
A resident was left in urine and feces-soaked linens that leaked onto the floor, creating a visibly soiled and foul-smelling environment. The unsanitary conditions persisted for several hours without intervention, as confirmed by a registered nurse and acknowledged by the facility administrator.
A resident with multiple health conditions was observed to have a fungal rash that was not assessed, documented, or addressed in the care plan. Staff noted the presence of multiple fungal areas but reported frequent refusals of skin assessments by the resident. There were no physician orders or care plan updates for the fungal rash, and the DON confirmed the lack of documentation and follow-up.
A resident with severe cognitive impairment and a history of falls experienced three falls within a day without additional safety interventions being implemented, despite ongoing confusion and medical instability. Separately, a cognitively intact resident was found with another resident's medications at his bedside after refusing them, and reported frequent medication administration errors. The DON and NHA confirmed that effective safety measures and medication security were not maintained.
The facility did not employ a full-time qualified director of food and nutrition services, as the dietary supervisor lacked required certification and had not completed the necessary program. After the resignation of the full-time RD, the facility relied on a corporate RD who provided only remote services, resulting in no on-site oversight, staff training, or direct observation of residents for nutritional assessments.
A cognitively impaired resident at Ridgeview Healthcare & Rehab Center was sexually abused by another resident, who was cognitively intact. The incident was witnessed by staff, who reported it immediately. The impaired resident, unable to consent due to severe cognitive impairment, was found with her brief removed and appeared distraught. Legal action is being pursued against the perpetrator.
The facility did not meet the required nurse aide to resident ratios on two shifts. On one evening shift, only 6.10 nurse aides were provided instead of the required 8 for a census of 88, failing the 1:11 ratio. On the same night shift, 5.10 nurse aides were provided instead of the required 5.87, failing the 1:15 ratio. No additional higher-level staff were available to compensate for this deficiency.
The facility did not meet the required LPN to resident ratios on three night shifts, failing to provide the minimum LPN staffing levels as per regulation. On three occasions, the number of LPNs was below the required level for the resident census, and no additional higher-level staff were available to compensate for this deficiency. The Nursing Home Administrator confirmed these staffing shortfalls.
The facility did not meet the required minimum of 3.2 hours of direct resident care per day, providing only 2.92 hours on a specific date. This was confirmed by the Nursing Home Administrator.
The facility failed to conduct a comprehensive assessment to determine necessary resources for resident care, lacking details on nurse staffing and activity needs for younger residents and those with mental health diagnoses. The activities program was inadequate, with residents expressing dissatisfaction. The facility relied heavily on agency staff, employing less than half of its required nursing staff.
The facility failed to provide a comprehensive activity program that meets the diverse needs and preferences of its residents, particularly affecting those under 60 and with mental health diagnoses. The activity program lacked variety and engagement, with residents expressing dissatisfaction over used bingo prizes and the absence of activities tailored to their interests. The Activity Director confirmed the lack of a dedicated budget and specific activities for younger or mentally ill residents.
The facility failed to prevent falls for two residents with cognitive impairments due to inadequate supervision and improper equipment use. One resident experienced multiple falls despite being at high risk, while another fell due to unlocked wheelchair brakes. Additionally, a resident reported being burned by fluctuating water temperatures in a shower room, highlighting a failure to maintain a safe environment.
The facility failed to comply with regulations by not ensuring timely payment for essential goods and services, as required by the 28 PA Code. Outstanding balances over 121 days were noted, and the Nursing Home Administrator confirmed the lack of evidence for payments or agreements. This non-compliance risks the health and safety of residents.
A resident reported the theft of his cellphone, identifying two agency nurse aides as alleged perpetrators. The facility failed to report the incident to local law enforcement, the State Licensing Agency, or the Local Area Agency on Aging within the required timeframes. The resident contacted law enforcement independently, leading to a police investigation. The facility's investigation lacked timely notifications and documentation, and a PB-22 form was not completed for the alleged perpetrators.
A facility failed to provide person-centered care for a resident requiring hemodialysis, specifically in managing their AV fistula. The resident's care plan lacked individualized interventions for monitoring, care, maintenance, or emergency management of the AV fistula, despite physician orders specifying dialysis days and care instructions. The DON confirmed the absence of a specific care plan for the AV fistula.
An LPN failed to adhere to infection control practices by administering medications to two residents using her ungloved hand, transferring pills into a plastic cup, and handing them to the residents. Additionally, a capsule was dropped on the medication cart, picked up with an ungloved hand, and given to a resident. The DON confirmed these actions breached infection control standards.
The facility failed to comply with Act 52 infection control requirements, as its policy did not include all necessary elements, such as a multidisciplinary committee. Infections were reported monthly instead of within the required 24-hour timeframe, as confirmed by the Infection Preventionist.
The facility failed to ensure timely payment for essential goods and services, with numerous outstanding balances overdue by more than 121 days. The Nursing Home Administrator confirmed the lack of evidence for payments or agreements, and the administration could not verify the status of these bills, demonstrating non-compliance with regulations.
The facility failed to maintain battery-powered emergency lighting on two floors. Observations revealed that emergency lights on the 3rd floor near a resident room and at the 2nd floor Nurse's station did not illuminate when tested. This was confirmed by the Facility Administrator and Facilities Manager.
The facility failed to maintain the sprinkler system, affecting two floors. Observations revealed a missing ceiling tile in the 1st floor Therapy Room and gaps around sprinkler escutcheons on the 3rd floor. These deficiencies were confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility did not secure an electrical panel on the first floor, leaving it unlocked and accessible to unauthorized persons. This was observed near the Game Room and confirmed by the Facilities Manager and Facility Administrator.
The facility was found non-compliant with infection prevention regulations due to the absence of a designated Infection Preventionist (IP). The facility's policy did not mention the IP role, and during a survey, it was confirmed that no IP was employed after the previous one left. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of an IP and the incomplete infection prevention and control program.
A resident with a history of behavioral issues physically abused another resident, resulting in a concussion. The affected resident, who was cognitively intact, reported severe headache and vertigo, leading to a hospital visit and diagnosis. The facility's response included separating the residents and conducting neurological checks, but the investigation lacked witness statements.
The facility failed to implement effective infection control practices for COVID-19, leading to increased risk of virus transmission. COVID-19 positive residents were not isolated from negative roommates, and there was a lack of comprehensive testing and contact tracing. Observations showed inconsistent mask usage and communal dining despite guidelines to limit virus spread. The decision not to cohort COVID-19 positive residents was made by the Nursing Home Administrator, who lacked infection prevention credentials.
The facility failed to respond promptly to residents' requests for assistance, impacting their quality of life. Residents reported long wait times for care, particularly during night shifts and when staff called off. Despite grievances and Resident Council meeting discussions, issues persisted, with residents experiencing delays in receiving necessary assistance.
The facility failed to maintain a clean and orderly environment, with observations of unsanitary conditions such as stained curtains, broken blinds, and persistent foul odors. Interviews revealed that the Director of Maintenance acknowledged the urine smell issue, and a resident expressed dissatisfaction with the offensive odors, stating it violated her rights. The Nursing Home Administrator confirmed the facility's obligation to maintain cleanliness.
A facility failed to ensure LPNs were competent and trained to administer IV treatments, as required by state standards. A resident with osteomyelitis had a catheter nicked during a dressing change, leading to a leak. The facility's policies did not align with state requirements, and there was no evidence of staff education or competency evaluation for IV administration.
A facility failed to ensure timely physician visits for a resident with bipolar disorder and dementia. The resident's clinical record lacked documented physician visits and progress notes over several months, violating the requirement for visits every 30 days for the first 90 days after admission and at least every 60 days thereafter. This was confirmed by the DON.
A facility failed to attempt a gradual dose reduction of Quetiapine for a resident with bipolar disorder and dementia. The resident's clinical record lacked evidence of any dose reduction attempts or physician documentation justifying the continued dosage. The DON confirmed these findings during a survey.
The facility failed to provide food and beverages that matched resident preferences and planned menus, as observed during resident council meetings and interviews. Five residents expressed dissatisfaction with meals not matching the planned menus and the unavailability of preferred items like orange juice, salad dressing, and ketchup. A resident reported having to order food from outside due to the lack of preferred meal items. The food service director confirmed the unavailability of certain items and the lack of communication regarding food alternates.
The facility failed to consistently provide snacks to residents between dinner and breakfast, despite a policy to offer extra nourishment. Several residents reported that snacks were often unavailable, and staff did not always offer them, even when residents were in common areas. The Nursing Home Administrator could not explain the inconsistency between the policy and residents' experiences.
The facility failed to maintain sanitary conditions in the food and nutrition services department, leading to potential contamination and increased risk of food-borne illness. Observations included soiled floors, improperly labeled nutritional shakes, and unsanitary storage of food thickener scoops. The FSD confirmed these deficiencies.
The facility failed to ensure the Medical Director or a designated physician attended the quarterly QAPI Committee meetings for two out of four quarters. The absence was noted from March through July, missing five monthly meetings. This was confirmed by the administrator.
A facility failed to report an abuse allegation involving two residents to the State Survey Agency in a timely manner. One resident was struck by a bedside table pushed by another resident, resulting in a concussion. Despite the incident's severity, the required PB-22 form was not completed, and updated findings were not reported to local or state agencies. The oversight was confirmed by the RNM and NHA.
A resident reported being struck in the head by a bedside table pushed by her roommate, resulting in a concussion. The facility failed to conduct a thorough investigation as required by its abuse prevention policy, as no witness statements were obtained. The RN Unit Manager informed the NHA and DON but did not follow the policy's procedures.
A resident with osteomyelitis and anxiety fell while being transported to an appointment due to inadequate supervision. The resident attempted to back his wheelchair into a van independently, despite being instructed to wait for assistance. The incident occurred while a nurse aide and van driver were present but unable to prevent the fall.
A resident with multiple health conditions experienced a decline in bowel continence, but the facility failed to implement individualized interventions to address this issue. Despite assessments indicating frequent bowel incontinence, the care plan only included measures for bladder incontinence, with no actions taken to address the bowel function decline.
A facility failed to coordinate care between the facility and a Hospice Agency for a resident with dementia, diabetes, and atherosclerotic heart disease. The resident's care plan did not reflect necessary coordination for hospice services, as confirmed by the DON.
The facility failed to implement effective QAPI programs, as evidenced by incidents involving two residents. One resident experienced a head injury during repositioning, with discrepancies in staff accounts and no thorough investigation. Another resident's catheter was allegedly nicked by staff, leading to a hospital transfer, but no investigation was conducted. The facility did not demonstrate effective QAPI programs to ensure quality care and life outcomes.
A contracted registered dietitian, Employee 13, was not trained on the facility's abuse prohibition policy before starting work. The facility lacked documentation of such training, confirmed by the NHA.
The facility failed to maintain proper food storage practices, with dry storage temperatures consistently above the recommended range of 50 to 70 degrees Fahrenheit. The dietary manager acknowledged the issue, yet the temperatures remained between 72 and 78 degrees Fahrenheit throughout June. Additionally, inadequate ventilation was observed, as a hole cut in the wall for ventilation did not effectively ventilate the area, which felt warm and humid.
The facility failed to maintain safe and orderly bathroom facilities on the second and third floors. A resident reported a broken toilet seat in a shared bathroom, which was observed to be loose and posed a fall hazard. The toilet was also cracked with a dark substance in the cracks. Further inspections revealed unsecured toilet seats in other rooms and shower rooms. The Nursing Home Administrator confirmed the expectation for safe maintenance of toilet seats.
The facility failed to provide timely pressure-relieving measures for two residents with pressure sores. One resident developed a sore on her buttocks, and an air mattress ordered by the physician was not available. Another resident with a Stage III ulcer did not receive an air mattress despite recommendations, due to the facility's outstanding debt to the vendor.
Unsecured Medications and Topical Agents Left Accessible in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free from accident hazards by allowing unsecured medications to be accessible on two nursing units. Facility policies on administering medications and self-administration of medications require that medications be administered safely, only as prescribed, and that any medications permitted for self-administration be stored securely and not accessible to other residents. The policies also state that if safe storage in the resident’s room is not possible, medications must be stored on a central medication cart or in the medication room. Despite these policies, surveyors observed multiple instances where medications and medicated products were left unsecured in resident rooms. For one resident who was cognitively intact and had been assessed and approved for self-administration, surveyors observed an orange oblong pill partially obscured by papers on the bedside table. The resident stated the pill must have fallen out of her medication cup, and an LPN later identified and secured it as methocarbamol 750 mg, for which there was a current physician’s order. In another room, surveyors observed two pills and a clear medication cup on the floor near a bed. An LPN confirmed the medications should not have been on the floor and secured them. The Nursing Home Administrator later identified these pills as Eliquis 5 mg and sertraline 100 mg. For another cognitively intact resident, surveyors found a tube of hydrocortisone 1% cream at the bedside. The tube lacked instructions for use, dosage information, and labeling, and there was no physician order in the clinical record for this medication. A RN Supervisor confirmed the resident should not have had the hydrocortisone cream at the bedside. For a third cognitively intact resident, surveyors observed a tube of zinc oxide 20% ointment at the bedside, labeled with the resident’s name and room number. The resident reported that staff routinely left the ointment at the bedside for application, that she did not apply it herself but could if she chose to, and that staff routinely left medications at her bedside. The Nursing Home Administrator was informed that medicated creams and ointments were being left at bedsides accessible to residents who had no documented assessment or approval to self-administer medications.
Failure to Assess and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to properly assess, evaluate, and monitor the nutritional status of two residents who experienced significant weight loss. For one resident with dementia and COPD, there was a documented pattern of frequent loose stools attributed to medication side effects and rectal prolapse. Despite ongoing documentation of these symptoms and a notable weight loss of 14 pounds (11%) over 90 days, there was no evidence that the physician or nurse practitioner evaluated or addressed the repeated episodes of loose stools, nor were adjustments made to the medication regimen. The resident's meal intake was inconsistent, and although nutritional supplements were provided, the underlying causes of weight loss were not adequately investigated or managed by the clinical team. For another resident with Alzheimer's Disease and adult failure to thrive, a significant weight loss of 19.2 pounds (10.53%) was recorded over a one-month period. The facility did not reweigh the resident within 24 hours as required by policy, nor did they notify the physician, resident representative, or Dining Services Director of the weight loss. There was also no documentation that the resident's nutritional status was reviewed or that any interventions were recommended by the Dining Services Director or other members of the multidisciplinary team. These deficiencies were confirmed through staff interviews and review of facility records, which showed a lack of timely assessment, notification, and intervention in response to significant changes in residents' weights. The facility did not follow its own policies regarding weight monitoring, assessment, and communication, resulting in inadequate evaluation and support for residents experiencing significant weight loss.
Inaccurate MDS Assessments for Medication and Dental Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident, the quarterly MDS assessment indicated that the resident received an insulin injection during the seven-day look-back period. However, a review of the medication administration records for the relevant months showed no documented evidence that the resident received any insulin injections during that period. This discrepancy was confirmed by the Regional Nurse Consultant and the Registered Nurse Assessment Coordinator during an interview. For another resident, the annual MDS assessment did not accurately reflect the resident's dental status. The resident was observed to be edentulous, and dental consults documented the extraction of teeth and the process of obtaining dentures. Despite this, the MDS assessment did not indicate that the resident was edentulous, as required. The Regional Nurse Consultant confirmed that the MDS assessment was not accurate regarding the resident's dental condition.
Failure to Develop and Implement Comprehensive Dental Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing the dental needs of a resident who was admitted with diagnoses including Parkinson's disease and dementia. The resident became edentulous following the extraction of seven teeth, as documented in a dental consult. Subsequent dental consults indicated the fabrication and trial of full upper and lower dentures, but there was no documentation of the results of the denture trial or a clear plan for obtaining dentures. Despite the resident's significant dental changes and ongoing dental interventions, the clinical record did not contain a care plan reflecting the resident's edentulous status or a timeline and actions for obtaining dentures. Interviews with facility staff confirmed that the resident's comprehensive care plan did not address these dental needs, and it was acknowledged that the facility is responsible for ensuring care plans include all identified problems and necessary services.
Failure to Apply Physician-Ordered Non-Skid Strips for Fall Prevention
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not ensuring the consistent application of physician-ordered preventative safety measures for a resident. The resident, who had diagnoses including dementia and Parkinson's disease and was assessed as having moderately impaired cognition, had a physician's order for non-skid strips to be placed on the floor on the door side of the bed due to a history of multiple falls and an identified risk for falls. The resident's care plan also included this intervention. During observations on two separate occasions, it was noted that the non-skid strips were not present on the floor as ordered. This absence was confirmed by a Registered Nurse Supervisor. Further, interviews with the Regional Nurse Consultant and Nursing Home Administrator confirmed that staff had not consistently followed the physician's order for the application of non-skid strips for the resident's safety.
Failure to Ensure Timely Payment for Essential Goods, Services, and Payroll
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. A review of the accounts payable ledger revealed multiple outstanding balances exceeding 121 days past due for essential vendors, including pest management, nurse staffing agencies, food suppliers, medical director services, ambulance services, and utility providers. The Nursing Home Administrator (NHA) confirmed that the facility's owners had not provided evidence of payments or formal payment agreements for these overdue invoices, and facility administration did not have direct access to billing or payment records to verify if any past-due bills had been settled. Additionally, the NHA confirmed that 27 staff members received payroll checks that were returned due to insufficient funds, although the corporate office later reissued the checks and covered associated fees. The failure to pay for critical staffing, food services, medical supplies, and essential utilities was identified as noncompliance with regulations requiring financial solvency to prevent operational disruptions that could jeopardize resident health and safety.
Failure to Implement Infection Control for Resident Refusing Care
Penalty
Summary
The facility failed to implement effective infection prevention and control practices for a resident who required assistance with activities of daily living (ADLs), including toileting, bathing, and bed maintenance. The resident, who had multiple diagnoses such as morbid obesity, respiratory failure, COPD, diabetes, and heart disease, consistently refused hygiene care, including showers, toileting, and perineal care, as well as housekeeping services. Despite these refusals, staff did not develop or implement alternative infection control strategies or individualized behavioral interventions. The resident was observed multiple times sitting in urine- and feces-soaked linens, with bodily fluids leaking onto the floor and a strong foul odor present in the room. The mattress and linens were only replaced when the resident permitted, which occurred approximately every three months. Clinical records and care plans documented persistent refusals of care and noted the resident's behavior as a potential infection risk and skin integrity concern. Staff were directed to offer care every two hours and as needed, but records showed the resident refused all scheduled care and skin assessments over an extended period. Facility leadership confirmed the unsanitary conditions and acknowledged that staff did not know how to address the situation. There was no evidence that the facility maintained a sanitary environment or implemented effective infection prevention and control measures for the resident, resulting in prolonged exposure to urine and feces and an unsanitary living environment.
Failure to Assess and Document Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for one resident. According to facility policy, residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, with this determination documented in the medical record and care plan. However, a review of the clinical record for a resident with diagnoses including COPD and dementia, but who was assessed as cognitively intact, revealed no documentation that the resident had been assessed or approved to self-administer medications. During observation, three red gelcap pills were found on the resident's bedside table, later identified as Docusil oral capsules 100 mg. The DON confirmed that there was no documented evidence supporting the resident's ability to safely self-administer medication and acknowledged that the medication should not have been left at the bedside. This failure to follow policy and ensure proper assessment and documentation led to the deficiency.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Facility staff failed to provide adequate housekeeping services, resulting in a resident being left in urine and feces-soaked linens that had leaked onto the floor in their room. The floor beneath and around the bed was visibly soiled with brown and yellow liquid, emitting a strong, foul odor that was noticeable from the hallway. This unsanitary condition persisted for over four hours, as confirmed by a subsequent observation with a registered nurse, during which no corrective action had been taken. The Nursing Home Administrator acknowledged the failure to maintain a clean and sanitary environment, which compromised the resident's dignity and well-being.
Failure to Assess, Document, and Care Plan for Fungal Rash
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for one resident with diagnoses including congestive heart failure and morbid obesity. The resident was cognitively intact and receiving wound care for a pressure wound and incontinence-associated dermatitis. Despite documentation of these conditions, an observation revealed the presence of a fungal rash under the resident's left axilla, which was not previously assessed or documented in the clinical record. The resident's care plan did not address this fungal rash, and there were no physician orders for its assessment or treatment. Staff interviews confirmed that the resident had multiple fungal areas, but the resident often refused skin assessments. During an attempted assessment, the resident refused further examination. The Director of Nursing confirmed that there was no documentation of assessment, treatment, or care planning for the fungal rash. This lack of assessment, documentation, and care planning was not in accordance with professional standards and facility policy, as required by state regulations.
Failure to Prevent Falls and Medication Errors
Penalty
Summary
The facility failed to implement effective safety measures and provide sufficient staff supervision to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident, who had dementia and chronic kidney disease, experienced three falls within a 24-hour period. Despite being identified as high risk for falls and exhibiting confusion, fever, and altered mental status, the clinical record did not show that any additional safety interventions were put in place after each fall. The resident ultimately required one-to-one supervision only after the third fall, just prior to being sent to the emergency department for evaluation and treatment of sepsis and other acute conditions. Additionally, the facility did not maintain a safe environment for three other residents. During an observation, a cognitively intact resident was found with a cup containing five pills on his bedside table, which he stated were not his and had been left there after he refused them days earlier. The resident reported that he was frequently given his roommate's and neighbor's medications by mistake. The medications were later confirmed by the DON to belong to another resident, and the nurse on duty acknowledged that the resident should not have had medications at his bedside. Interviews with the DON and NHA confirmed that the facility did not implement additional or effective safety measures to mitigate the risk of falls for the resident who fell multiple times, and that it is the facility's responsibility to ensure a safe environment free of accident hazards, including preventing medication errors and ensuring proper medication security.
Lack of Qualified Food and Nutrition Services Leadership and On-Site RD Oversight
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services and did not ensure that a registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department. The individual appointed as dietary supervisor did not possess the necessary regulatory qualifications, as she was not a Certified Dietary Manager (CDM) and had not completed the required CDM program, with no clear timeline for certification provided. Additionally, after the resignation of the full-time RD, the facility relied solely on a corporate dietitian who provided services remotely, with all dietary documentation and assessments completed off-site. There was no on-site supervisory oversight, staff training, direct observation of residents for nutritional assessments, or monitoring of meal service by the RD during this period.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
Ridgeview Healthcare & Rehab Center was found to be non-compliant with federal and state regulations regarding the freedom of residents from abuse, neglect, and exploitation. The facility failed to protect a cognitively impaired resident, identified as Resident 2, from sexual abuse by another resident, identified as Resident 3. Resident 2, who suffers from Huntington's Disease and dementia, was unable to consent to or initiate sexual behavior due to severe cognitive impairment. Despite this, Resident 3, who is cognitively intact, engaged in inappropriate sexual conduct with Resident 2, which was witnessed by staff members. The incident occurred when two nurse aides, Employee 2 and Employee 3, entered Resident 2's room and observed Resident 3 performing oral sex on Resident 2. The aides immediately reported the incident to the registered nurse on duty, Employee 1. Resident 2 was found lying on her mattress with her incontinence brief removed, and when asked if someone had hurt her, she moaned "yes." A body audit revealed no physical signs of abuse, but the resident was sent to the hospital for a rape kit examination. The state police were notified, and an investigation was initiated. Interviews with the staff confirmed that Resident 2 could not have removed her brief or initiated the interaction due to her cognitive and physical limitations. Resident 3 admitted to the act but claimed that Resident 2 had initiated the interaction, which was not possible given her condition. Legal records indicate that Resident 3 is facing charges of indecent assault on a person with mental disabilities. The facility's failure to protect Resident 2 from abuse was confirmed by the Nursing Home Administrator during the survey.
Plan Of Correction
This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. 1. The facility will complete an assessment of current residents to identify residents that are at risk for engaging in or being victimized by sexual aggression. Residents that are identified as being at risk will have their individual care plans reviewed and updated with appropriate interventions. This assessment will be conducted upon admission, quarterly, after any significant change and post resident to resident aggression. 2. The facility will review and revise the current facility Abuse Prevention Policy to ensure compliance with federal and state regulations. 3. Facility will conduct re-education for staff across all departments and disciplines on: the facility abuse and prevention policy, recognizing, preventing and reporting sexual abuse. This re-education will include competency testing of staff. 4. Facility will conduct audits of residents to ensure a sexual aggression assessment has been conducted and appropriate interventions have been care planed. Audits will be conducted weekly x4, then monthly x 4. The facility will also conduct an audit of incidents. The purpose of this audit will be to identify any trends in recurring issues that need to be addressed through additional education and/or policy revisions. This audit will be conducted weekly x4, then monthly x 4. All results will be reported to the QAPI Committee.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two shifts out of 21 reviewed, as determined by a review of nurse staffing records and staff interviews. On January 19, 2025, during the evening shift, the facility provided only 6.10 nurse aides instead of the required 8 for a census of 88 residents, failing to meet the 1:11 ratio. Additionally, on the same date during the night shift, the facility provided 5.10 nurse aides instead of the required 5.87 for the same census, failing to meet the 1:15 ratio. No additional higher-level staff were available to compensate for this deficiency on the mentioned dates.
Plan Of Correction
1. Facility cannot retroactively correct the failure to meet the ratio requirements of the Certified Nursing Aides as identified in the outlined PA-2567. 2. Education given to the Nurse Scheduler and Director of Nursing on the Certified Nursing Aides ratio requirements. 3. Facility is actively recruiting Certified Nurses Aides through outside marketing sources; utilizing outside Nurse Agency to supplement Certified Nursing Aides; and daily staffing meetings being conducted in attempts to maintain State Mandated ratios for Certified Nursing Aides. 4. The Administrator will audit the staffing schedules to ensure the appropriate number of Certified Nursing Aides are scheduled to achieve compliance. Audits will occur three times per week for one week; weekly for four weeks and monthly for four weeks. The results of the audits will be submitted to the QA Committee.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three separate night shifts out of 21 reviewed. Specifically, on January 15, 19, and 21, 2025, the facility did not provide the minimum LPN staffing levels required by regulation. On January 15, the facility had 2.20 LPNs instead of the required 2.28 for a census of 91 residents. On January 19, there were 1.33 LPNs instead of the required 2.20 for a census of 88 residents. On January 21, the facility had 2.03 LPNs instead of the required 2.25 for a census of 90 residents. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN to resident ratios on these dates.
Plan Of Correction
1. Facility cannot retroactively correct the failure to meet the ratio requirements of the LPN's as identified in the outlined PA-2567. 2. Education given to the Nurse Scheduler and Director of Nursing on the LPN's ratio requirements. 3. Facility is actively recruiting LPN's through outside marketing sources; utilizing outside Nurse Agency to supplement LPN's; and daily staffing meetings being conducted in attempts to maintain State Mandated ratios for LPN's. 4. The Administrator will audit the staffing schedules to ensure the appropriate number of LPN's are scheduled to achieve compliance. Audits will occur three times per week for one week; weekly for four weeks and monthly for four weeks. The results of the audits will be submitted to the QA Committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day. A review of the facility's staffing levels revealed that on January 19, 2025, the facility provided only 2.92 hours of direct care nursing per resident, which is below the mandated minimum. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 22, 2025, who acknowledged the facility's failure to meet the required nursing care hours consistently.
Plan Of Correction
1. Facility cannot retroactively correct the failure to meet the overall PPD requirements of the nursing staff as identified in the outlined PA-2567. 2. Education given to the Nurse Scheduler and Director of Nursing on the overall PPD requirements for nursing staff. 3. Facility is actively recruiting Certified Nurses Aides and Licensed Practical Nurses through outside marketing sources; utilizing outside Nurse Agency to supplement Certified Nursing Aides and Licensed Practical Nurses; and daily staffing meetings being conducted in attempts to maintain State Mandated PPD requirements. 4. The Administrator will audit the staffing schedules to ensure the facility is staffed appropriately to reach the mandated State PPD. Audits will occur three times per week for four weeks and weekly for four weeks. The results of the audits will be submitted to the QA Committee.
Inadequate Facility Assessment and Activities Program
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for resident care during both routine operations and emergencies. The assessment provided was not tailored to the specific needs of the residents, lacking detailed information on nurse staffing requirements, including staffing levels, use of agency staff, recruitment and retention plans, and emergency contingency plans. The facility had a census of 90 residents, with 18 under the age of 60 and 80-85 with mental health diagnoses, yet the assessment did not address the specific activity needs of these populations. Additionally, the facility's activities program was inadequate, failing to meet the cognitive, functional, and recreational needs of its residents, particularly the younger residents and those with mental health diagnoses. Residents expressed dissatisfaction with the activities program, noting that Bingo prizes were used items and there was no designated activity budget. The facility relied heavily on agency staff for over 60% of its nursing needs and employed less than half of its required nursing staff, which was confirmed by the Nursing Home Administrator. These deficiencies have the potential to negatively affect the quality of care and quality of life for all residents.
Plan Of Correction
1. Ridgeview Healthcare and Rehabilitation Center's Facility Assessment was updated to include the identified areas as outlined in the statement of deficiencies from the annual survey ending December 20, 2024. 2. Regional Administrator educated NHA & IDT team on importance of maintaining the Facility Assessment accurately to reflect current environment of the facility. 3. Updates to Ridgeview Healthcare and Rehabilitation Center's Facility Assessment will be completed upon changes within the organization or at least annually. 4. Ridgeview Healthcare and Rehabilitation Center's Facility Assessment will be reviewed monthly at the QA Committee meeting for three months and at least annually thereafter.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs, interests, preferences, and functional abilities of its residents, particularly affecting four residents out of a sample of 18. The deficiency was identified through clinical record reviews, resident council meeting minutes, and interviews with residents and staff. The facility's activity program was criticized for lacking variety and engagement, with specific concerns about the use of 'bingo bucks' for prizes, which were often used items. Additionally, the facility did not have a dedicated budget for activities, and the Activity Director, who started in August 2024, confirmed that there were no specific activities for younger residents or those with mental health needs. The report highlighted that the activity preferences for some residents had not been reviewed for over a year, indicating a lack of personalized care planning. The facility's activity calendars for the months leading up to the survey showed a lack of variety and programming for younger residents, despite a significant portion of the resident population being under 60 and having mental health diagnoses. Interviews with residents revealed dissatisfaction with the current activities, describing them as boring and not aligned with their interests or preferences. The facility's failure to develop and implement a comprehensive activity program that addresses the diverse needs of its residents, including those with higher cognitive functioning and younger residents, was a significant factor in the deficiency.
Plan Of Correction
1. R-18, R-16 & R-19 will be interviewed by Activity Director to identify their interest in activity programs and bingo prizes. 2. Activity department will discuss activity planning during resident council meetings to engage feedback from residents on the activities they do or do not like. 3. Activity Director has been reeducated on planning activities to meet the needs, interests, preferences and functional abilities of the current resident population. 4. NHA/designee will meet monthly with residents to ensure their activity preferences are being addressed and planned as able into the activity calendars. A summary of each meeting will be submitted to the QA Committee monthly.
Inadequate Supervision and Environmental Safety in LTC Facility
Penalty
Summary
The facility failed to implement effective interventions and provide adequate supervision to prevent repeated falls for two residents. Resident 52, who has severe cognitive impairment due to Huntington's disease, experienced multiple falls despite being identified as at high risk. The interventions in place, such as using a call light, were not suitable given the resident's cognitive limitations. The facility did not provide sufficient staff supervision or document effective interventions to prevent these falls, as evidenced by multiple incidents where the resident was found on the floor. Resident 49, who has moderate cognitive impairment and is dependent on staff for wheelchair mobility, fell in the dining room when attempting to sit back down in a wheelchair that rolled away. The staff failed to ensure the wheelchair locks were engaged, which directly contributed to the fall. The facility did not provide documented evidence that measures were taken to ensure the locks were engaged prior to the incident, compromising the resident's safety. Additionally, the facility failed to maintain a safe environment in a third-floor shower room, where a resident reported being burned by fluctuating water temperatures. The maintenance director acknowledged an issue with the facility's boiler, and the water temperature was found to be inconsistent. Staff did not check water temperatures before resident showers, and there was no assessment to determine if residents could safely shower independently. This oversight led to a resident experiencing discomfort and potential harm during a shower.
Plan Of Correction
1. R-52, R-49, R-78 & R-48 still reside in the facility. R-41 discharged to another SNF. 2. IDT Team met for R-52 and her individual care plan has been updated for safety interventions. R-49 is able to unlock his breaks independently; Fall(s) attributed to the acute onset and surgical intervention of Acute Appendicitis, Anti-rollback mechanism added to wheelchair. R-78 & R-48 are not independent in the shower room for showers. After residents were assessed by therapy, no resident was deemed to be an independent shower. 3. Fall prevention & safety education provided to staff. Facility will audit the last two weeks of residents falls to ensure appropriate interventions are in place. Outside plumber identified an issue with the main mixing valve on the water heater and replaced. Staff educated on taking water temperatures prior to showering of residents. 4. CNA/Nursing staff will complete purposeful rounding and complete tool five days/week for four weeks, then weekly for two months. Audit of shower temps to be completed three times per week for four weeks and weekly for two months. DON/designee will round three times per week for four weeks with audits submitted to the QA Committee for three months.
Non-compliance with Timely Payment Regulations
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. According to the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), a facility owner is required to pay bills in a timely manner for services essential to the health and safety of residents. A review of the facility's accounts payable ledger revealed multiple outstanding balances as of December 20, 2024, that were greater than 121 days beyond the terms of payment. These included significant amounts owed to various service providers such as Allstate Pest Management, Concept Medical, and General Healthcare Resources, among others. During an interview, the Nursing Home Administrator confirmed that the facility owners had not provided evidence of payments or payment agreements for the outstanding invoices. Furthermore, the facility administration did not have access to billing or payment records and could not verify whether the listed bills had been paid. This lack of timely payment for essential goods and services demonstrates non-compliance with the regulations, which require facilities to pay bills promptly to prevent jeopardizing the health and safety of residents.
Plan Of Correction
1. January 1, 2025 the company obtained a new accounts payable company. The facility administrator will work with the new company designee to research accuracy of the listed vendors. There are no goods or services that are being withheld from the residents due to the status of the AP liabilities of Ridgeview Healthcare and Rehabilitation Center. 2. The Administrator will receive an AP/Aging report monthly and review the report that bills are paid in a timely manner and continued vital services are rendered for resident care. 3. The Regional Administrator will educate the Administrator on reviewing the monthly vendor AP/Aging report to ensure vital resident services are not interrupted. 4. Administrator/designee will maintain documentation of the monthly review of the AP/Aging reports and implement a monthly accounts payable call to ensure current services for vital goods and vendors are not interrupted and being provided. Results of the monthly accounts payable call will be submitted to the QA Committee for three months for any changes or recommendations.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to timely report an alleged misappropriation of resident property involving a resident who was cognitively intact, as indicated by a BIMS score of 15. The resident reported the theft of his cellphone in November to the facility staff, identifying two agency nurse aides as the alleged perpetrators. Despite the resident's prompt notification, the facility did not report the incident to local law enforcement, the State Licensing Agency, or the Local Area Agency on Aging within the required timeframes as outlined in their abuse policy. The facility's investigation lacked documented evidence of timely notifications to the appropriate authorities, and a PB-22 form was not completed within five working days for the alleged perpetrators. The resident independently contacted law enforcement, which initiated a police investigation. The facility's administrator confirmed the failure to adhere to the established reporting procedures, which delayed the investigation and response to the resident's allegation.
Plan Of Correction
This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. 1. Facility conducted an immediate investigation upon learning about the allegation. Local police were notified, and the facility replaced the alleged stolen phone, which the resident did not accept. Facility subsequently did report this event to the DOH on 12/20/2024. 2. Facility will audit last 30 days of grievances to ensure facility has made appropriate reports of any alleged misappropriation of resident property. 3. IDT team will be educated on reporting requirements of alleged misappropriation of resident property. 4. NHA/Designee will conduct audits of grievances to ensure any allegation of misappropriation of resident property has been timely reported to the DOH. Audits will be conducted three times per week x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. All results will be reported to the QAPI Committee.
Deficiency in Person-Centered Dialysis Care
Penalty
Summary
The facility failed to provide person-centered care for a resident who required hemodialysis, specifically in the management of their arteriovenous (AV) fistula. The resident, who was admitted with end-stage kidney disease and dependent on dialysis, had a right arm AV fistula for dialysis access. Physician orders specified dialysis days and times, as well as instructions for the care of the AV fistula, including checking for bruit and thrill daily and using an emergency kit at the bedside. However, these orders did not detail specific care for the AV fistula. The resident's care plan included general interventions related to dialysis access but lacked individualized interventions for the monitoring, care, maintenance, or emergency management of the AV fistula site. During an interview, the Director of Nursing confirmed the absence of a care plan that included emergency measures or planned care specific to the AV fistula for this resident. This oversight was identified as a deficiency in providing appropriate dialysis care and services.
Plan Of Correction
1. R-60's Dialysis care plan was updated. 2. Care plans for other residents with Dialysis have been reviewed and addressed accordingly. 3. Quarterly review of care plans for Dialysis residents will occur to ensure individualized care plans. 4. Monthly audit of Dialysis resident's care plans to ensure accuracy for three months. Audits will be submitted to the QA Committee for three months.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration for two residents. On December 19, 2024, at 9 A.M., an LPN administered over-the-counter medications to a resident by pouring pills into her ungloved hand, transferring them into a plastic medication cup, and handing the cup to the resident. The medications included Vitamin B1, Vitamin B12, and a multi-vitamin. At 9:05 A.M., the same LPN repeated this practice with another resident, administering a multi-vitamin and Vitamin B1. Additionally, the LPN dropped a capsule on the top of the medication cart, picked it up with her ungloved hand, placed it into a plastic medication cup, and provided it to the resident. During an interview on December 20, 2024, the Director of Nursing confirmed that these practices constituted a breach of infection control standards during medication administration. The facility's failure to follow proper infection control practices placed residents at increased risk of infection and compromised their safety.
Plan Of Correction
1. R-57 & R-34 had no ill effects from incorrect handling of the OTC/vitamins during the medication pass on December 19, 2024. 2. Employee 1 received 1:1 education on proper medication handling and administration of any OTC/vitamin. Education to remaining LPN/RN's on proper medication handling and administration of any OTC/vitamin. 3. Audit(s) will be conducted on correct medication administration of OTC/vitamins three times per week for 4 weeks; weekly times 4 weeks and randomly for 4 weeks. 4. Results of the medication audits will be submitted to the QA Committee for three months.
Non-compliance with Act 52 Infection Control Requirements
Penalty
Summary
The facility failed to comply with the requirements of Act 52 regarding its infection control plan. The deficiency was identified through a review of the facility's infection prevention and control policy, which was last reviewed in October 2024. The policy was intended to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of diseases and infections. However, it was found that the facility's infection control policy and procedures did not include all the necessary requirements mandated by Act 52. Specifically, the facility did not establish a multidisciplinary committee with representatives from various groups, as required by the Act, to oversee the infection control plan. During an interview, the Infection Preventionist confirmed that the facility's infection control policy did not meet the requirements of Act 52. It was revealed that infections were reported to the state agency at the end of each month, rather than within the required 24-hour timeframe. This reporting method was based on the Infection Preventionist's previous practice at another facility, which did not align with the current regulatory requirements. No evidence was provided during the survey to confirm the facility's compliance with Act 52, leading to the identification of this deficiency.
Plan Of Correction
1. The Infection Preventionist is now reporting any HAI (Healthcare Associated Infections) to the PA-PSRS system within 24 hours of confirmation. 2. Education provided to the Infection Preventionist on reporting requirements on HAI's to the PA-PSRS system. 3. The DON/designee will audit the HAI's submission timeframe weekly for four weeks and monthly for two months. 4. Results of the audits will be submitted to the QA Committee for three months.
Failure to Ensure Timely Payment for Essential Services
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. A review of the facility's accounts payable ledger revealed numerous outstanding balances as of December 20, 2024, with amounts overdue by more than 121 days. These unpaid bills included essential services and supplies from various vendors such as Allstate Pest Management, Geisinger Medical Center, and Nutro Co, among others. The total outstanding amount was substantial, with significant debts owed to entities like Total Plan Concepts and the West Mahanoy Township Tax Collector. During an interview, the Nursing Home Administrator confirmed that the facility owners had not provided evidence of payments or payment agreements for the outstanding invoices. Furthermore, the facility administration did not have access to billing or payment records, preventing them from verifying whether the listed bills had been paid. This lack of payment for essential goods and services demonstrates non-compliance with regulations requiring facilities to pay bills in a timely manner to prevent jeopardizing the health and safety of residents.
Plan Of Correction
1. January 1, 2025 the company obtained a new accounts payable company. The facility administrator will work with the new company designee to research accuracy of the listed vendors. There are no goods or services that are being withheld from the residents due to the status of the AP liabilities of Ridgeview Healthcare and Rehabilitation Center. 2. The Administrator will receive an AP/Aging report monthly and review the report that bills are paid in a timely manner and continued vital services are rendered for resident care. 3. The Regional Administrator will educate the Administrator on reviewing the monthly vendor AP/Aging report to ensure vital resident services are not interrupted. 4. Administrator/designee will maintain documentation of the monthly review of the AP/Aging reports and implement a monthly accounts payable call to ensure current services for vital goods and vendors are not interrupted and being provided. Results of the monthly accounts payable call will be submitted to the QA Committee for three months for any changes or recommendations.
Failure to Maintain Emergency Lighting
Penalty
Summary
The facility failed to maintain battery-powered emergency lighting in two locations, affecting two of four floors. During an observation on December 11, 2024, between 10:28 a.m. and 10:43 a.m., it was noted that the battery back-up emergency lights did not illuminate when tested. Specifically, at 10:28 a.m., Emergency Light #10 on the 3rd floor near Resident room 308 failed to function. Similarly, at 10:43 a.m., Emergency Light #21 at the Nurse's station on the 2nd floor also did not illuminate. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:15 a.m.
Plan Of Correction
This plan of correction is the center's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provision of Federal and State Law. 1. Batteries in Emergency Lights #10 & #21 were replaced. 2. Whole house test of Emergency Lights completed and addressed accordingly. 3. Education to the Maintenance Director and Maintenance staff on ensuring testing and maintenance of the Emergency Lights in the facility. 4. Weekly testing of Emergency Lights for 4 weeks; monthly testing of Emergency Lights for 2 months. Results of audit(s) to be submitted to the QA Committee Meeting monthly.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the sprinkler system, which provides fire protection, in two instances affecting two of four floors. On December 11, 2024, at 10:19 a.m., an observation on the 1st floor in the Therapy Room revealed a missing ceiling tile near the windows. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager. Additionally, between 10:27 a.m. and 10:32 a.m., observations on the 3rd floor identified two issues: a sprinkler head in the Shower Room was not sealed into the escutcheon, creating a gap, and a gap was also found around the sprinkler escutcheon in the ceiling near the Bathing Room corridor. These sprinkler deficiencies were also confirmed during the exit interview.
Plan Of Correction
1. The missing ceiling tile in the therapy gym was replaced. The ceiling tiles around the escutcheon(s) located in the 3rd floor shower room and 3rd floor corridor outside the bathing room were corrected to eliminate the gap identified. 2. A one-time facility audit conducted to ensure no gaps were identified around other escutcheons in the facility. 3. Education to the Maintenance Director and Maintenance staff to ensure no gaps are present around any escutcheons in the facility. 4. A monthly audit will be completed for three months to ensure no gaps are present around the escutcheons in the facility. Results of audit(s) to be submitted to the QA Committee Meeting monthly.
Unlocked Electrical Panel on First Floor
Penalty
Summary
The facility failed to maintain the security of electrical panels on the first floor, as observed on December 11, 2024. During the inspection, it was noted that a corridor wall-mounted recessed electrical panel near the Game Room was left unlocked, making it accessible to unauthorized persons. This observation was confirmed during an exit interview with the Facilities Manager and the Facility Administrator.
Plan Of Correction
1. The electric panel on the 1st floor, outside the movie room, was locked. 2. A one-time audit performed to ensure that the electric panels are appropriately locked. 3. Education to the Maintenance Director and Maintenance staff to ensure that the electrical panels are appropriately locked unless the panel is being accessed by appropriate personnel. 4. Audits will be completed monthly for three months to ensure that electrical panels are locked when not being accessed. Results of the audit(s) will be submitted to the QA Committee Meeting monthly.
Absence of Designated Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with regulatory requirements for infection prevention and control due to the absence of a designated Infection Preventionist (IP). The facility's Infection Control Policy, last reviewed on June 3, 2024, did not mention the need or role of an IP. During a survey conducted on September 10, 2024, it was revealed that the facility did not employ an IP, as confirmed by the Director of Nursing. The previous IP had left the facility on August 7, 2024, and since then, no individual had been appointed to fulfill the role. The Nursing Home Administrator confirmed that the facility's infection prevention and control program was not being completed as required by regulations.
Resident Abuse Leading to Concussion
Penalty
Summary
The facility failed to protect a resident, identified as Resident 29, from physical abuse by another resident, Resident 2, resulting in a concussion. Resident 29, who was admitted with severe morbid obesity and major depressive disorder, was cognitively intact with a BIMS score of 15. Resident 2, also cognitively intact with a BIMS score of 15, had a history of behavioral issues, including physical and verbal abuse. An incident occurred where Resident 2 pushed a bedside table, striking Resident 29 in the head, leading to complaints of headache and vertigo. Following the incident, Resident 29 was assessed with no visible injuries initially but later reported severe headache and vertigo, prompting a visit to the emergency department. The hospital diagnosed Resident 29 with a concussion, and she received pain management treatment. The facility's initial response included separating the residents and conducting neurological checks, but the investigation lacked witness statements from staff or other residents. Interviews with staff and residents confirmed the altercation and the subsequent room change for Resident 29. The Nursing Home Administrator acknowledged the facility's responsibility to prevent abuse among residents. The deficiency highlights a failure to ensure a safe environment, as outlined in the facility's Abuse Prevention Policy, which prohibits abuse by anyone, including other residents.
Failure to Implement Effective COVID-19 Infection Control Practices
Penalty
Summary
The facility failed to implement effective infection control practices for cohorting residents with respiratory infections and testing for COVID-19, which increased the risk of COVID-19 transmission among residents. The facility's policy, aligned with CDC guidelines, required testing of symptomatic individuals and those with close contact with confirmed cases, as well as isolation of COVID-19 positive residents. However, the facility did not adhere to these guidelines, as evidenced by COVID-19 positive residents being cohorted with COVID-19 negative roommates, and a lack of comprehensive testing logs for staff and residents. During the survey, it was observed that COVID-19 positive residents were not isolated according to the facility's policy. For instance, several residents who tested positive for COVID-19 continued to share rooms with COVID-19 negative roommates. Additionally, there was no documentation of contact tracing for residents or staff, and the facility's infection control logs did not record any symptoms displayed by residents or staff. Observations also revealed that residents and staff were not consistently wearing masks, and communal dining was conducted despite instructions to close the dining/activity room to limit virus spread. Interviews with facility staff, including the Infection Preventionist and the Nursing Home Administrator, confirmed that the facility did not move COVID-19 positive residents or their negative roommates, citing a belief that cohorting was no longer required. The decision not to cohort was made by the Nursing Home Administrator, who lacked medical and infection prevention credentials, during the absence of the Infection Preventionist and the Director of Nursing. This decision was based on previous experience at another facility, rather than current CDC guidelines or the facility's own policy.
Delayed Response to Resident Requests
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, negatively impacting their quality of life. This deficiency was identified through clinical record reviews, resident interviews, and Resident Council meeting minutes. Several residents, all cognitively intact, reported long wait times for staff assistance, particularly during night shifts and when staff called off. Residents expressed frustration and embarrassment due to delays in receiving care, such as changing incontinence pads or receiving help to the bathroom. Resident Council meeting minutes from February, March, and May 2024 highlighted ongoing concerns about delayed responses to call bells and long wait times for nursing staff assistance. Grievances were filed regarding these issues, but residents continued to report dissatisfaction with the timeliness of care. Interviews with residents revealed specific instances where they waited excessively for assistance, with some residents resorting to unsafe self-transfers or walking to the nurses' station due to unmet needs. The Nursing Home Administrator acknowledged that all residents should be treated with dignity and respect but could not explain the cause of the untimely staff responses. The deficiency was further supported by resident interviews, where they consistently reported long wait times, especially during periods of understaffing or when agency staff were on duty. These delays in care were reported to affect residents' dignity and quality of life, as they were left waiting for essential assistance.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment in two nursing halls, as evidenced by multiple observations of unsanitary conditions. Observations included an unlabeled urine collection graduate hanging on a grab assist bar, a call bell cord with black and brown stains, and a persistent foul urine smell in several resident rooms. Additionally, window blinds were found to be broken, privacy curtains were stained, and the first-floor spiritual area was littered with dead insects, dirt, and debris. The dining and activity areas were also found to have dust and debris on fan blades, dirty air conditioner filters, and stained window sills. Interviews with staff and residents further highlighted the issues, with the Director of Maintenance acknowledging the persistent urine smell due to residents urinating on the floor, which had seeped into the tiles. A resident, who was cognitively intact, expressed dissatisfaction with the offensive odors, stating it was against her rights to live in such conditions. The Nursing Home Administrator confirmed the facility's obligation to maintain a clean environment, yet the observations and interviews indicate a failure to uphold this standard.
Deficiency in IV Administration Competency and Training
Penalty
Summary
The facility failed to ensure that staff were competent and trained in accordance with the professional standards of the State nursing practice act to administer IV treatments. This deficiency was identified for one resident, Resident 148, who was receiving intravenous therapy. The facility's policies did not verify the scope of practice and competency requirements with the State Nurse Practice Act and did not provide for inservice instruction and supervised practice for LPNs as required. The policies also failed to list and describe the intravenous fluids that could be administered by LPNs. Resident 148 was admitted with diagnoses including osteomyelitis of the left ankle and foot and anxiety. A physician order required monitoring of the resident's right subclavian CVC tunnel catheter every shift and administration of Daptomycin intravenously. However, there was no indication that the catheter site was monitored on one occasion, and an LPN administered the antibiotic. An incident occurred where the resident's catheter was nicked during a dressing change, leading to a leak. The resident was sent to the emergency room, where a small linear laceration to the catheter was confirmed. Interviews with facility staff revealed that LPNs should not have been administering medications through intravenous lines, including PICC or CVC lines. The Director of Nursing confirmed the lack of documented evidence of educational programs for LPNs regarding intravenous administration as required by the State nursing practice act. The facility also failed to initiate an investigation into the resident's allegation about the catheter being nicked by staff, and there was no documented evidence of staff education or competency evaluation regarding intravenous administration.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen timely by a physician, as required by regulations. A review of the clinical record for a resident, who was admitted with diagnoses including bipolar disorder and dementia, revealed a lack of documented physician visits and progress notes from November 28, 2023, through May 23, 2024. There was no evidence that the resident's attending physician visited the resident once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, as mandated. This deficiency was confirmed during an interview with the Director of Nursing on July 26, 2024.
Failure to Attempt Gradual Dose Reduction of Psychoactive Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychoactive medication for a resident diagnosed with bipolar disorder and dementia. The resident was admitted with a physician's order for Quetiapine (Seroquel), an antipsychotic medication, to be administered at bedtime for mania and bipolar disorder. During a survey, it was found that there was no documented evidence of any attempts to reduce the dose of Seroquel since the initial prescription. Additionally, there was no physician documentation providing resident-specific information to justify why a dose reduction was clinically contraindicated or why the current dosage was necessary. The Director of Nursing confirmed the lack of attempts at GDR and the absence of supporting documentation.
Failure to Provide Preferred Foods and Beverages
Penalty
Summary
The facility failed to provide food and beverages that accommodated resident preferences and planned menus, as evidenced by observations, resident council meeting minutes, and interviews with residents and staff. During a group meeting, five residents expressed dissatisfaction with the meals served, noting that they did not match the planned menus and that preferred items were often unavailable. Specific concerns included the lack of salad dressing, sugar packets, salt, and orange juice, as well as the absence of hamburgers and condiments like ketchup. One resident, who is a vegetarian, reported having to order food from outside the facility due to the unavailability of her preferred meal items. Resident 50, a cognitively intact individual, expressed dissatisfaction with the food served, often opting for cold cereal and milk instead of the planned meal. She noted that orange juice, one of her preferred beverages, had been unavailable for a month, and she had not been receiving bananas, which she liked. The resident also mentioned the facility's lack of ketchup and her preference for hamburgers and mashed potatoes, which were rarely served. These issues were corroborated by the food service director, who confirmed the unavailability of certain items and the lack of communication regarding food alternates. The food service director acknowledged that commonly consumed items like orange juice, ketchup, bananas, and lettuce should be sourced locally when not available from the bulk supplier. However, the facility failed to inform residents of menu changes, preventing them from making alternate selections that honored their preferences. The deficiency was further highlighted by the facility's inability to provide preferred foods and beverages as planned, impacting the residents' satisfaction with their meals.
Inconsistent Provision of Snacks to Residents
Penalty
Summary
The facility failed to consistently provide snacks as desired by residents, as evidenced by the experiences of several residents who reported not being offered snacks between dinner and breakfast. The facility's policy, which was last reviewed on June 3, 2024, states that residents should be served extra nourishment to provide energy. However, the scheduled mealtimes revealed a gap exceeding 14 hours between dinner and breakfast, during which residents were not consistently offered snacks. Interviews with residents indicated that snacks were often unavailable, and staff did not always offer them, even when residents were in common areas like the activity room. Multiple residents, including those with intact cognitive abilities as indicated by their BIMS scores, reported that the facility frequently ran out of snacks or failed to offer them. Some residents resorted to purchasing their own snacks due to the inconsistency. The Nursing Home Administrator was unable to explain the discrepancy between the facility's policy and the residents' reports. The deficiency was identified under 28 Pa. Code 211.12 (d)(3)(5) Nursing Services, highlighting the facility's failure to meet the nutritional needs and preferences of its residents.
Unsanitary Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the food and nutrition services department, several unsanitary practices were observed. The floor area leading into the kitchen was patched with a concrete-type substance and was heavily soiled. Additionally, 22 thawed nutritional shakes were found in the walk-in cooler without a labeled thaw date, contrary to manufacturer instructions that require consumption within 14 days of thawing. Further observations revealed an open container of Thick-it with plastic scoops improperly stored with handles in direct contact with the thickener, and no evidence was provided that the scoops were washed and sanitized after each use as required. The dishroom floor under the dishwasher and along the wall extending to the two-compartment sink was heavily soiled with dirt and grime. The Food Service Director confirmed these unsanitary conditions and acknowledged that the department was to be maintained in a sanitary manner.
Medical Director Absence at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director or a designated physician attended the quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two out of four quarters from January 2024 through July 2024. A review of the QAPI Committee's monthly meeting sign-in sheets revealed that the Medical Director or another physician was absent from the meetings held from March 2024 through July 2024, missing a total of five monthly meetings. This deficiency was confirmed during an interview with the administrator on July 26, 2024, at 12:00 PM, who acknowledged the absence of a physician at the facility's QAPI meetings on a quarterly basis.
Failure to Report Resident Abuse Timely and Accurately
Penalty
Summary
The facility failed to timely and accurately report an allegation of resident abuse involving Resident 29 and Resident 2 to the State Survey Agency. According to the facility's Abuse Prevention Policy, all allegations of abuse must be reported to local and state agencies within the required time frames. An incident occurred where Resident 29 reported being struck in the head by a bedside table pushed by Resident 2. Initially, Resident 29 was assessed with no visible injuries, but later complained of severe headache and vertigo, leading to a hospital visit where she was diagnosed with a concussion. Despite the severity of the incident and the subsequent diagnosis, the facility did not complete the required PB-22 form or report the updated findings to any local or state agencies. Employee 12, the Registered Nurse Unit Manager, confirmed that while the incident was reported to the police and an incident report was written, no witness statements were obtained, and the necessary follow-up reporting was not conducted. This oversight was confirmed by the Nursing Home Administrator during an interview.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving Resident 29, who reported being struck in the head by a bedside table pushed by her roommate, Resident 2. Resident 29, who is cognitively intact with a BIMS score of 15, was admitted with severe morbid obesity and major depressive disorder. Following the incident, Resident 29 was diagnosed with a concussion after visiting the emergency department. The facility's policy mandates immediate and thorough investigations of abuse allegations, including obtaining signed statements from witnesses, which was not adhered to in this case. The incident report dated July 20, 2024, noted the altercation but lacked witness statements from staff or other residents, contrary to the facility's abuse prevention policy. Employee 12, the RN Unit Manager, acknowledged contacting the police and informing the NHA and DON but did not collect witness statements. The NHA could not provide evidence of a comprehensive investigation, indicating a failure to implement the facility's abuse prohibition policy. This deficiency was cited under F600 and F609, and relevant state codes were referenced.
Inadequate Supervision Leads to Resident Fall During Transport
Penalty
Summary
The facility failed to provide adequate supervision to prevent an avoidable fall during the transport of a resident. The resident, who was independently mobile in a wheelchair and had diagnoses including osteomyelitis and anxiety, was being transported to an appointment. During the transport process, the resident's wheelchair flipped backward while attempting to enter the transport van, resulting in the resident falling onto the floor of the van and hitting his head. The incident occurred despite the presence of a nurse aide and a van driver, who were responsible for assisting the resident. The incident report and staff interviews revealed that the resident attempted to back his wheelchair into the van by himself before the van driver could assist, leading to the fall. The van driver had instructed the resident to wait for assistance, but the resident proceeded independently. The nurse aide was standing next to the lift but was not in a position to prevent the fall. The facility's investigation concluded that the supervision provided was inadequate to prevent the resident from attempting to move backward into the van, resulting in the fall.
Failure to Address Decline in Bowel Continence
Penalty
Summary
The facility failed to implement individualized interventions to address a resident's decline in bowel continence, which was necessary to restore normal bowel function to the extent possible. The resident, who was admitted with diagnoses including Parkinson's disease, COPD, multiple sclerosis, chronic respiratory failure, and hypertension, was initially assessed as always continent of bowels according to the Quarterly Minimum Data Set Assessments. However, a subsequent assessment noted a decline, indicating frequent bowel incontinence. Despite this decline, the facility's plan of care only addressed bladder incontinence with a check and change every two hours, and no measures were implemented to address the resident's bowel incontinence. The Director of Nursing confirmed that the only program in place was for bladder incontinence, and no attempts were made to address the bowel function decline. This lack of action was in violation of the facility's nursing services and resident care policies.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure coordination of care and services between the facility and the Hospice Agency for a resident. The resident, who was admitted to the facility with diagnoses including dementia and diabetes, was later admitted into hospice services for atherosclerotic heart disease. However, the resident's care plan, which was last revised in March 2024, did not reflect the necessary coordination of services between the facility and the Hospice Agency to meet the resident's daily care needs and specific needs related to their terminal diagnosis. This lack of coordination was confirmed during an interview with the director of nursing.
Failure to Implement Effective QAPI Programs
Penalty
Summary
The facility failed to demonstrate the implementation of ongoing QAPI programs, particularly in investigating and analyzing the root cause of adverse events involving two residents. Resident 32, who has a history of chronic obstructive pulmonary disease, bilateral below-knee amputations, diabetes, and other conditions, experienced an incident where his head was bumped against the headboard during repositioning. Despite the incident being documented, there was no evidence of a thorough investigation or QAPI review to determine the root cause of the incident. Discrepancies in staff witness statements and the resident's account were not addressed, and there was no documentation on the method used for boosting the resident or why assistance was required despite the care plan indicating the use of enablers for bed mobility. Resident 148, diagnosed with osteomyelitis and anxiety, had a physician order for monitoring a subclavian CVC tunnel catheter and administering Daptomycin. An adverse event occurred when the catheter was flushed, and fluid was noted in the dressing, leading to a hospital transfer. The resident alleged that the catheter was nicked by staff, which was confirmed by emergency room documentation. However, the facility did not initiate an investigation into the incident to determine the root cause of the catheter laceration or address the resident's allegations. The facility's lack of effective QAPI programs was evident in both cases, as there was no documented evidence of investigations into the adverse events or corrective actions taken. The deficiencies highlight a failure to ensure quality of care and life outcomes through proper incident investigation and documentation.
Failure to Train Employee on Abuse Prevention Policies
Penalty
Summary
The facility failed to provide abuse prevention training to a contracted registered dietitian, identified as Employee 13, who began working at the facility on May 20, 2024. During an interview on July 25, 2024, Employee 13 stated that she had not received training on the facility's abuse prohibition policy prior to assuming her duties. A review of employee personnel records confirmed the absence of documentation indicating that Employee 13 was trained on the facility's abuse prohibition policies and procedures as part of staff orientation. On July 26, 2024, the Nursing Home Administrator confirmed that there were no written records to show that Employee 13 had been trained on the facility's abuse prevention and prohibition policies or procedures.
Improper Food Storage Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage of food, which increased the risk of food-borne illness. During a tour of the dietary department, it was observed that the dry food storage area had a thermometer reading of 78 degrees Fahrenheit, which is above the recommended range of 50 to 70 degrees Fahrenheit. The dietary manager acknowledged that the temperature was too warm, yet it was incorrectly considered within an acceptable range. A review of the facility's dry storage temperature chart for June 2024 showed that the temperatures consistently ranged from 72 to 78 degrees Fahrenheit, never falling within the recommended parameters. Additionally, the facility attempted to ventilate the dry storage area by cutting a hole in the wall leading to an outside room. However, there was no effective ventilation to the outside, and the area felt warm and slightly humid. This lack of proper temperature control and ventilation in the dry storage area failed to prevent microbial growth, which is essential for increasing storage life and decreasing the potential for food-borne illness.
Unsafe and Poorly Maintained Bathroom Facilities
Penalty
Summary
The facility failed to provide necessary housekeeping and maintenance services to ensure a safe and orderly environment on the second and third floor units. During an observation and interview with a resident, it was reported that the toilet seat in the resident's shared bathroom was broken and had been in this condition for a long time. The toilet seat was observed to be very loose, moving from side to side, and posed a potential fall hazard. Additionally, the porcelain of the toilet was cracked underneath the seat, with a dark substance accumulated inside these cracks. Further observations during a tour of resident bathrooms revealed that several toilet seats in other rooms and shower rooms on both the second and third floors were also not secured properly, shifting off the base and moving from side to side. An interview with the Nursing Home Administrator confirmed that resident toilet seats should be maintained in a safe and orderly manner.
Failure to Provide Timely Pressure-Relieving Measures
Penalty
Summary
The facility failed to provide timely pressure-relieving measures for two residents with pressure sores, leading to deficiencies in care. Resident 3 developed a pressure sore on her right buttocks, and although a physician ordered an air mattress on the same day, it was not available for use by June 26, 2024. This delay in providing the necessary equipment contributed to the lack of appropriate care for the resident's pressure sore. Resident 2, who was readmitted after hip surgery, had a Stage III pressure ulcer on his left buttock. Despite recommendations from the wound care team to use an air mattress since May 30, 2024, the physician did not order it until June 25, 2024, and it was still unavailable by June 26, 2024. The facility's inability to obtain the air mattresses was due to an outstanding debt to the vendor, which hindered the provision of essential care for the residents' pressure sores.
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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