River's Bend Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisburg, Pennsylvania.
- Location
- 800 King Russ Road, Harrisburg, Pennsylvania 17109
- CMS Provider Number
- 395395
- Inspections on file
- 31
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at River's Bend Health & Rehab Center during CMS and state inspections, most recent first.
The facility failed to keep the environment free of accident hazards and to provide adequate supervision and assistive devices for two residents. One resident with dementia, mobility deficits, and on warfarin was found with bruising to the forehead and eye after striking her head on bed enabler bars that had been placed on her bed without assessment, consent, or a physician order. Another resident with osteoporosis and gait abnormalities fell in the shower when a shower chair slid backward during a transfer because only the front brakes were locked; the resident sustained a wrist ligament injury confirmed by imaging and required OT and a brace. A nurse aide later acknowledged forgetting to lock the back brakes, and the DON stated she expected shower chair brakes to be locked as appropriate.
A resident with dementia and chronic kidney disease lost an upper denture, which staff documented and searched for but could not locate. Despite a facility policy requiring referral for lost dentures within three days and existing care plan and MD orders for dental consults as needed, a dental referral was not made for over a month, and the resident was not seen by a dentist until later for an impression for a new denture. During this delay, SLP notes documented decreased PO intake, difficulty chewing, diet downgrades to puree and then mechanical soft, and ongoing complaints about inability to chew and dislike of the softer diet. The resident was observed eating without the denture and experienced notable weight loss over this period, while the DON acknowledged an expectation for timely dental consultations for missing dentures.
The facility failed to obtain informed consent and provide explanations of risks and benefits before administering psychotropic medications to three residents with dementia, depression, bipolar disorder, and anxiety disorders. Physician orders and care plans documented use of antidepressants, antipsychotics, antianxiety agents, and mood stabilizers, but the clinical records lacked any documentation of risk/benefit discussions or consent by the residents or their representatives. The DON and a regional clinical leader confirmed that no psychotropic medication consents were in place, and the written psychoactive medication policy did not require consent prior to initiating these drugs.
The facility did not follow its grievance policy or promptly resolve multiple residents’ complaints about missing, labeled clothing items. Several residents reported that grievances about lost pants, slacks, shirts, pajamas, socks, sweatshirts, and jeans were not resolved, with only some items ever returned and others still missing. Documentation showed that a concern form identified multiple residents’ missing clothing, and a subsequent notation stated the concern remained unresolved. During interviews, residents stated grievances were not always addressed, and the DON could not provide evidence of further efforts, follow-up, or replacement of the missing items for the residents who reported ongoing clothing losses.
The facility failed to ensure accurate MDS assessments for three residents. One resident receiving an antipsychotic had a psychiatry note documenting that a GDR was clinically contraindicated, but this was not coded in Section N0450 of the Quarterly MDS. Another resident with multiple psych diagnoses received antipsychotic, antidepressant, anticonvulsant, and diuretic medications per the MAR, yet the Annual MDS listed only antibiotic and insulin use, and a later Quarterly MDS did not reflect the documented contraindication to GDR. A third resident readmitted with Stage 2, Stage 3, and Stage 4 pressure ulcers had MDS assessments that incorrectly coded the Stage 4 ulcer as not present on admission, and later only documented a Stage 4 ulcer as not present on admission, despite clinical records showing all ulcers were present on admission.
Surveyors found that the facility did not update care plans to reflect significant changes in three residents’ needs and preferences. One resident’s care plan still listed antipsychotic and anticoagulant therapy after both medications had been discontinued. Another resident with a history of falls was using bilateral fall mats in bed, but this intervention was not documented in the care plan. A third resident with PVD and spinal stenosis repeatedly stated she was waiting to go home, yet her care plan did not address whether her goal was LTC or discharge, despite prior care conference notes documenting her desire to go home and her refusal of assisted living.
A resident with nonexudative age-related macular degeneration and other conditions reported being unable to see out of three-year-old glasses, while multiple optometry consults documented that recommended new spectacles, retinal specialist referrals, and eye drops were never implemented. Despite a contract requiring coordination of optometry services and a care plan identifying impaired vision with ophthalmologist/optometrist consults, the facility did not ensure scheduling of the retinal specialist or provision of new glasses over several consults, and the DON acknowledged that these recommendations had been missed.
Surveyors found that the facility did not follow its own policies or professional standards for food storage and labeling. In dry storage, an opened package of dried chicken gravy was not securely closed or dated. In the walk-in refrigerator and freezer, fresh sweet potatoes were undated and an open case of crescent rolls was stored on the floor. In first-floor nourishment areas, multiple containers of prepared foods brought in for residents were not labeled with resident identifiers or dates. On another floor, open containers of Med Pass 2.0 nutritional supplement were partially used and not date marked. The Food Service Director and Regional RD acknowledged these items should have been properly stored and labeled, and the NHA offered no further information when the issues were discussed.
A RN was observed administering medications consecutively to four residents without performing hand hygiene between residents, despite a facility policy requiring appropriate hand hygiene before preparing or administering medications. The DON stated she would expect the RN to complete hand hygiene as needed, indicating that the observed practice did not align with facility policy on infection prevention and control.
A resident with peripheral vascular disease and spinal stenosis, care planned as at risk for social isolation with an approach to provide an activity calendar, was found to have an in-room dry-erase board showing an incorrect month and year and a wall calendar left on a past month. The resident’s MDS documented a BIMS score indicating some cognitive function, yet the activity calendar and date information were not kept current. The NHA reported an expectation that nursing or activities staff would update these items, but this did not occur, resulting in a failure to support resident dignity and rights under facility policy and state nursing services regulations.
The facility failed to act promptly on repeated Resident Council concerns about confused, wandering residents entering other residents' rooms and disturbing them. Over several months, council minutes documented reports of residents entering rooms late at night, removing items, and roaming halls after being moved from a dementia unit, without documented resolution or follow-up. Individual and group interviews revealed that residents continued to experience confused residents entering their rooms daily, taking food and personal items, and in one case grabbing and pushing a resident's wheelchair, while staff response was described as minimal and largely limited to verbal redirection. Residents also reported suggesting the use of stop signs across doorways during council meetings but stated they had not received the signs or any response to this request.
Surveyors found that multiple resident rooms were not maintained in a clean and homelike condition, despite a facility policy requiring regular cleaning of visibly soiled environmental surfaces. Over several consecutive days, one resident’s tray table and floor remained dirty with spilled liquid and a discarded plastic cup, another resident’s floor stayed heavily soiled with a straw wrapper and pepper packet, and a third resident’s tray table remained heavily soiled with debris and liquid stains. The Nursing Home Administrator acknowledged ongoing issues with housekeeping oversight and stated that housekeeping services were expected to maintain a safe, clean, comfortable, and homelike environment.
Surveyors found that the facility did not provide required written notices of hospital transfers, bed-hold policies, or Ombudsman notifications for several residents. One resident with muscle weakness, dysphagia, and delusional disorders was transferred to the hospital without documented written bed-hold information. Another resident with dementia and atrial flutter was transferred without written notice of transfer or bed-hold policy, and this transfer was not included in the facility’s Ombudsman reporting. A third resident with a fractured pelvis, spinal stenosis, COPD, and Medicaid coverage was transferred and later returned, but there was no documentation of written transfer notice, bed-hold policy notice, or Ombudsman notification. Policy review showed the discharge policy lacked explicit requirements for written transfer notices to residents, representatives, and the Ombudsman, and staff confirmed they had no additional documentation to show these notices were provided.
A resident with dementia, muscle weakness, and lack of coordination had a care plan addressing wandering behaviors, including use of visual deterrents, removal from other residents’ rooms, and assessment of basic needs when wandering began. Surveyors observed the resident repeatedly wandering hallways, entering another resident’s room, handling and dropping that resident’s water cup, and closing other residents’ room doors while staff were present but did not redirect the resident or follow the planned interventions. No stop signs or other visual deterrents were in place on the resident’s hallway, and leadership confirmed these care plan elements had not been implemented, contrary to facility policy requiring staff to be familiar with and follow each resident’s plan of care.
A resident with osteoporosis, HTN, and gait/mobility abnormalities, care planned for assistance with ADLs and grooming and totally dependent for care, was observed on multiple occasions with noticeable facial hair on her chin despite facility policy that morning care and shaving be provided according to preference. Documentation showed the resident received scheduled bed baths, and the resident reported that staff did not always offer shaving, while the DON stated she expected dependent residents to receive ADL care and shaving on bathing days and as needed.
A resident with dementia and a UTI was readmitted from the hospital with an existing peripheral IV in the left antecubital area and an order for IV meropenem, but there were no physician orders for required flushing/locking agents, IV site changes, or dressing changes, contrary to facility policy. The IV dressing was observed intact but undated on multiple days, and hospital records did not show when the IV was started or last changed. The admission/readmission assessment did not document the IV access, and the baseline care plan did not address the resident’s active infection, enhanced barrier precautions, or IV site and related care. The DON and regional clinical leader acknowledged that appropriate IV-related orders and care plan elements should have been in place.
A resident with a gastrostomy, protein-calorie malnutrition, and dysphagia had physician orders for scheduled pump enteral feeding and a care plan addressing tube feeding and water flushes. Surveyors observed an enteral feeding bag hanging and infusing that was not labeled with hang time or date and bore a use-by date that had passed, despite package instructions limiting use to 48 hours after connection. Later the same morning, the same unlabeled, expired bag was still hanging, nearly empty, and an RN confirmed it was the bag she had disconnected from the pump, though she had not hung it. The RN also found two additional expired formula bags in the room, and the DON stated she expected tube feeding formulas in use to be labeled and not expired.
Surveyors found that the facility did not keep its medication error rate below 5%, identifying 4 errors in 26 observed medication administrations. Policy required nurses to verify correct medication, dose, and resident, yet one LPN gave a resident only 500 mcg of cyanocobalamin instead of the ordered 1000 mcg. Another RN gave a different resident 500 mcg of cyanocobalamin instead of 4000 mcg, substituted Senna Plus (senna with docusate) for ordered senna alone, and administered enteric-coated aspirin instead of the ordered chewable form. The DON acknowledged that medications should have been given in the ordered forms and dosages.
A resident with severe cognitive impairment and multiple medical conditions, identified as high risk for elopement, repeatedly exhibited exit-seeking behaviors and was not consistently supervised or provided with effective interventions. Despite documented incidents of wandering and attempts to leave, staff failed to verify the resident's whereabouts after a door alarm, resulting in the resident leaving the facility and being found by EMS near a public road with minor injuries. This failure also placed other at-risk residents in immediate jeopardy.
The facility did not conduct reference checks for five newly hired employees, violating its policy and Pennsylvania Code regulations. The absence of documentation for reference checks was confirmed by the Regional President of Operations and the NHA, who acknowledged the expectation for such checks during the hiring process.
The facility failed to ensure timely responses to Medication Regimen Reviews by the attending physician or prescriber for several residents. Recommendations made by the consultant pharmacist were not addressed, signed, or dated, and some were missing from records. Interviews with the DON highlighted expectations for timely responses, which were not met, indicating a systemic issue in medication management.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in reflecting their current health status. One resident with dysphagia and other conditions experienced significant weight loss, which was not documented accurately in the MDS. Another resident with congestive heart failure and dementia also had significant weight loss, but the MDS inaccurately coded the weight loss section. These inaccuracies were acknowledged by the NHA during an interview.
A facility failed to conduct an initial care plan meeting for a resident with anxiety and explosive disorder, as required by their policy. The policy mandates an interdisciplinary care plan within seven days of assessment and a meeting within 3-5 days of admission. The omission was confirmed by the Regional President of Operations and the DON, leading to a deficiency finding.
The facility failed to invite residents and/or their representatives to care plan meetings and did not ensure required interdisciplinary team participation. A resident with hypertension and depression was not invited to meetings, and another with heart failure had an outdated care plan. A third resident with dementia was not invited to meetings after admission. Documentation and team attendance were inadequate.
The facility failed to complete physician discharge summaries for two residents. One resident with congestive heart failure and diabetes was discharged home after rehabilitation, while another with dysphagia and chronic kidney disease was sent to the hospital. Both lacked completed discharge summaries, as confirmed by staff interviews.
Two residents in the facility did not receive care according to their physician orders and care plans. One resident, with dementia and other conditions, was observed without required heel boots and leg rests, despite documentation indicating otherwise. Another resident, with heart failure, was not wearing prescribed TED hose, contrary to records. Staff interviews revealed a lack of awareness and inaccurate documentation, highlighting deficiencies in care management.
A resident with limited mobility and multiple diagnoses was not wearing the prescribed wrist splint and edema glove, as observed in the common area. Facility staff confirmed the resident should have been wearing the equipment, indicating a failure to adhere to the care plan and facility policy.
A resident with anxiety and explosive disorder fell and hit their head, resulting in a bruise that staff failed to document until a surveyor noticed it days later. The facility did not conduct required neurological checks post-fall, and the incident report was delayed. The DON confirmed expectations for immediate documentation and assessments were not met.
A facility failed to maintain accurate dialysis communication records for a resident with end-stage renal disease. The required Dialysis Communication Tool, which includes pre-dialysis assessments, was not completed on several occasions, as confirmed by the DON. This deficiency was identified through a review of the resident's clinical records.
A facility failed to document the disposition of medications for a resident with end stage renal disease and hypertension who passed away from cardiac arrest. The discharge summary noted that the medications went with the resident, but no medication disposition form or progress notes were completed. The DON confirmed the absence of the required documentation.
The facility did not maintain food safety standards in the dish machine area, as the dish machine's final rinse temperature was too low and sanitizer was not connected. A Dietary Aide handled clean and dirty dishes without changing gloves or washing hands, violating facility policy.
The facility failed to maintain proper documentation and maintenance of its sprinkler system, lacking records for 5-year maintenance and failing to address a failed annual main drain test. Observations revealed obstructions and debris affecting the sprinkler system, with items laying across pipes and debris-covered sprinkler heads in the Laundry Room.
The facility failed to conduct required monthly and annual inspections and testing of its Essential Electrical System, including a 30-minute load bank test, a 90-minute load bank test, and a fuel quality test. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director.
The facility was found to lack a carbon monoxide detector in the Boiler/Generator Room, violating the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. Additionally, the 1st floor exit door in the Common Area required more than 30 pounds of force to operate, exceeding the NFPA 101 Means of Egress standards. These deficiencies were confirmed during an exit conference with the Administrator and Maintenance Director.
The facility failed to maintain hazardous area doors within allowed gap margins and ensure self-closing mechanisms, affecting fire safety compliance. Observations revealed excessive gaps in doors across multiple zones and a failure of the Kitchen Scullery door to self-close, confirmed by the Administrator and Maintenance Director.
The facility did not document monthly inspections of portable fire extinguishers for six months, as required by NFPA 10. This was confirmed by the Administrator and Maintenance Director during an exit conference, affecting the entire component of the facility.
The facility failed to maintain cross-corridor smoke barrier doors, affecting two smoke compartments. An observation revealed that the left leaf of the smoke barrier doors on the 2nd floor near a resident room did not close due to a faulty door closure. This was confirmed during an interview with the Administrator and Maintenance Director.
The facility failed to conduct fire drills on the 2nd shift every quarter, affecting the entire component. Documentation review revealed that fire drills were not performed for the 2nd shift during several quarters in 2024, including the 1st quarter on the 3rd shift, the 2nd quarter on the 1st, 2nd, and 3rd shifts, the 3rd quarter on the 1st, 2nd, and 3rd shifts, and the 4th quarter on the 3rd shift. This was confirmed during an interview with the Administrator and Maintenance Director.
The facility was found deficient in meeting operational standards, with incomplete life safety drawings lacking essential details and missing documentation for annual testing of carbon monoxide detectors and evacuation protocols, as required by the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act.
The facility failed to perform required owner's quick checks on the Kitchen's fixed chemical fire suppression system and did not conduct semi-annual cleaning of the Kitchen exhaust ductwork for a full year, affecting one of eight smoke zones.
The facility did not ensure that power receptacles were GFI protected within six feet of a water source in one of the smoke zones. Observations revealed non-GFI protected outlets behind an ice machine near a resident room and in the Boiler/Generator Room. This was confirmed by the Administrator and Maintenance Director.
The facility failed to document the required monthly and annual testing of battery back-up emergency lighting. A review revealed the absence of documentation confirming these tests, which was acknowledged by the Administrator and Maintenance Director. This deficiency impacts the entire emergency lighting system.
The facility failed to document the annual fire door inspection for eight smoke compartments. During a review, it was found that the required inspection records were missing. This was confirmed by the Administrator and Maintenance Director.
The facility failed to document the inspection and testing of electrical receptacles in Patient Care Areas. A review revealed missing documentation verifying that these inspections had been conducted, which was confirmed by the Administrator and Maintenance Director.
The facility failed to conduct and document required neurological checks for two residents after falls, as per their Neurological Checks Policy. One resident with Parkinson's Disease and anxiety disorder had multiple falls with initial checks but no follow-up documentation. Another resident with dementia and CHF also lacked documented follow-up checks after a fall. The NHA acknowledged the missing documentation.
A facility failed to maintain accurate records for controlled drugs, specifically lorazepam, for a resident with dementia and anxiety disorder. Alterations in medication records led to a loss of 20 tablets, and incomplete reconciliation sheets contributed to the oversight. The issue was identified when the pharmacy alerted the facility about the exhausted supply, revealing an additional diversion of 38 pills. The facility lacked a documented response or staff education on altering medication records.
The facility failed to properly store and label medications in three medication carts, with insulin products lacking opened dates and food improperly stored with medications. Loose pills and pill dust were found in the carts, and there was no cleaning schedule in place. The DON confirmed these issues violated facility policy.
The facility failed to notify residents, their representatives, and the Ombudsman of transfers, including the reason, date, location, appeal rights, and contact information. This deficiency was identified in six out of eleven resident records reviewed, with multiple instances of improper notification and documentation.
The facility failed to ensure that residents and their representatives received written notice of the bed-hold policy during hospital transfers. Seven residents with various medical conditions had multiple hospital transfers without proper documentation of the bed-hold policy being provided. Interviews with the NHA and DON confirmed that the facility's practice was not consistently documented.
The facility failed to ensure accurate resident assessments for two residents. One resident's MDS assessments did not reflect a documented clinical contraindication for a gradual dose reduction of antipsychotic medication, while another resident's MDS assessments failed to indicate a PTSD diagnosis despite clinical documentation.
Failure to Control Bed and Shower Equipment Hazards Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices, affecting two residents. One resident with dementia, muscle weakness, lack of coordination, and on daily warfarin had a room change and was later found with discoloration and bruising on the right forehead and eye. She reported bumping her head on the bed siderails/enabler bars. Her clinical record did not contain any assessment for safe use of enabler bars, no consent for their use, and no physician order authorizing them, despite her cognitive impairment and anticoagulant therapy. Subsequently, this resident was documented as unsteady on her feet, with non-reactive pupils and no response to physical stimuli, and she was sent to the emergency room for evaluation. The facility’s own incident report recorded that she had hit her head on the siderails and that she later returned from the hospital after testing. During interviews, the DON and Regional Director of Clinical Services confirmed there were no enabler assessments for this resident and acknowledged that the enablers were already on the bed after her move and should not have been there. These facts demonstrate that the resident’s environment included an unassessed and unauthorized enabler device that contributed to her head injury. Another resident with age-related osteoporosis, hypertension, and gait and mobility abnormalities sustained a fall in the shower room while attempting to transfer from a shower chair to a wheelchair. A staff member was present but was unable to stop the fall. The resident reported that as she stood up, the shower chair slid out, causing her to fall to the floor, later complaining of significant pain in the right hand, wrist, and forearm. Imaging showed scapholunate widening suggesting a ligamentous injury, and OT documentation noted severe pain and functional deficits requiring a wrist brace. The fall report and staff interview revealed that at the time of the fall only the front brakes of the shower chair were locked, the back brakes were not locked, and the aide assisting the resident admitted she forgot to lock the back brakes, despite the DON’s expectation that shower chair brakes be locked as appropriate.
Failure to Obtain Timely Dental Services After Loss of Denture
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in obtaining timely dental services after the loss of an upper denture, contrary to its own Dental Services Policy requiring referral within three days for lost or damaged dentures. The resident, who had dementia and chronic kidney disease, was documented on December 22, 2025, as having a missing upper denture that could not be located despite staff searching her room. Her care plan included an intervention to obtain a dental consult as needed, and there was a physician order allowing dental visits as needed. However, no dental referral was made until January 23, 2026, more than a month after the denture was reported missing, and the resident was not seen by a dentist for an impression for a new upper denture until February 2, 2026. During this period, multiple speech therapy notes documented that the resident had decreased meal intake and difficulty chewing due to the missing denture, leading to a downgrade to a puree diet, which she refused, and then to a mechanical soft diet. The resident repeatedly complained about her inability to chew mechanical soft textures and expressed to staff and family that she disliked the softer diet and wanted dentures so she could eat regular food again. Observations showed her eating without her upper denture, and interviews with the Speech Language Pathologist confirmed that the resident continued to voice a desire for new dentures. Weight records showed a decrease from 191.6 pounds on January 9, 2026, to 184.2 pounds on March 2, 2026, after the denture went missing. The DON stated she would expect residents to receive timely dental consultations for missing dentures.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents or their representatives of the risks and benefits of psychotropic medications and did not obtain consent prior to administering these medications for three residents reviewed. The facility’s Psychoactive Medication Policy, last reviewed on April 30, 2025, did not contain any expectation for obtaining consent before starting psychoactive medications. For one resident with major depressive disorder and dementia, physician orders showed Trazodone 75 mg three times daily for depression starting February 13, 2026, and Lorazepam 0.5 mg twice daily for anxiety starting December 16, 2025. The care plan documented psychotropic drug use beginning July 9, 2024, but the medical record contained no documentation of an explanation of risks and benefits or consent for these medications. The DON confirmed that appropriate notifications were not made prior to starting psychotropic medications for this resident. Another resident with dementia and depression had multiple psychotropic medication orders, including quetiapine, Rexulti, mirtazapine, and trazodone, with corresponding care plan focuses on antipsychotic and antidepressant use. However, the medical record lacked documentation of any explanation of the risks and benefits of these psychotropic medications or consent from the resident or representative, and the DON and Regional Director of Clinical Services stated there were no psychotropic medication consents for this resident. A third resident with bipolar disorder, anxiety disorder, depression, and dementia had orders for aripiprazole, bupropion, and escitalopram, and a care plan focus on psychotropic drug use including antidepressant, antipsychotic, and mood stabilizer medications. Review of this resident’s record also failed to show any explanation of risks and benefits or consent for psychotropic medication use, and staff confirmed that no psychotropic medication consents were available. These findings were cited under 28 Pa. Code 201.29(a) Resident rights and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Timely Resolve Resident Grievances About Missing Clothing
Penalty
Summary
The facility failed to make prompt efforts to resolve resident grievances related to missing clothing, as required by its grievance policy and resident rights regulations. The written policy, last revised May 8, 2025, states that grievance reviews must be completed within 30 days and that any resident rights violation must be corrected within 10 days or referred to the State Department of Health if it cannot be corrected within that timeframe. During a Resident Council group interview, multiple residents reported that grievances were not always resolved timely or at all. Residents specifically reported missing clothing items for which grievances had been filed but that had not been found or replaced. One resident reported missing a pair of pants since January 2026, and another reported missing three pairs of brand-new slacks and two shirts, stating that staff took them from his room and never returned them. Review of a Concern Form dated November 11, 2025, showed that several residents had reported not getting their clothes back, despite most items being labeled with their names. The missing items included a sweat suit and sports bras for one resident, pajama sets and gripper socks for another, sweatshirts and dress pants for a third, and a new pair of jeans for a fourth. Documentation of the resolution dated November 13, 2025, indicated the concern was not resolved, as only some laundry was returned and other items were still being searched for, leaving the residents dissatisfied. In a subsequent interview, the DON was unable to provide any additional information on further efforts to locate the missing clothing, whether the items had been replaced, or whether any follow-up or grievance documentation existed for the residents who reported missing clothing during the Resident Council meeting. These findings demonstrate that the facility did not follow its own grievance policy time frames or ensure timely resolution of the residents’ grievances regarding missing clothing.
Inaccurate MDS Coding for Medications and Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for three residents. For one resident with dementia and depression who was receiving an antipsychotic (Rexulti) daily, a psychiatry consult documented that a gradual dose reduction (GDR) should not be attempted because the benefits outweighed the risks. However, the resident’s Quarterly MDS for the specified assessment reference date did not indicate in Section N, question N0450, that the physician had documented a GDR as clinically contraindicated. For another resident with bipolar disorder, anxiety disorder, depression, and dementia who was receiving antipsychotic, antidepressant, anticonvulsant, and diuretic medications, the Annual MDS for the specified assessment reference date documented only antibiotic and insulin use in Section N, despite the Medication Administration Record showing administration of the other medications during the reference period. In addition, this same resident had a psychiatry consult stating that no GDR of the antipsychotic should be attempted because benefits outweighed risks, but the Quarterly MDS did not indicate that the physician had documented a GDR as clinically contraindicated in Section N0450. Another resident with hypertension and obesity was readmitted after a hospital stay and was noted in the clinical record to have Stage 2, Stage 3, and Stage 4 pressure ulcers present upon admission. The resident’s Quarterly MDS with one assessment reference date documented in Section M that the Stage 2 and Stage 3 pressure ulcers were present upon admission, but coded the Stage 4 pressure ulcer as not present upon admission. A subsequent Quarterly MDS with a later assessment reference date documented only that a Stage 4 pressure ulcer was not present upon admission. During interviews, the Regional Director of Clinical Services and the DON confirmed that these MDS assessments for all three residents were not coded accurately and that the MDS should be an accurate reflection of each resident’s status.
Failure to Review and Revise Care Plans for Medication Changes, Fall Interventions, and Discharge Goals
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans in response to changes in residents’ conditions and needs for three of 32 residents. Facility policy required an interdisciplinary plan of care to be established and updated as indicated for every resident. For one resident with dementia and atrial flutter, the care plan continued to list focuses of psychotropic drug use and cardiovascular anticoagulant therapy that began in July 2025, even though the antipsychotic medication had been discontinued on January 8, 2026, and the anticoagulant medication had been discontinued on December 31, 2025. The DON confirmed that the care plan should have been revised when these medication changes occurred. Another resident with repeated falls and muscle weakness was observed lying in bed with fall mats on both sides of the bed, but the care plan, initiated in January 2024 for a history of falls, did not include the use of bilateral fall mats as an intervention. The DON stated that the care plan should have included this intervention. A third resident with peripheral vascular disease and spinal stenosis was observed lying in bed and repeatedly stating that she was waiting for a family member to take her home. Her care plan did not indicate whether her goal was to remain for LTC or be discharged to another level of care, despite care conference notes documenting that she wanted to go home alone, had been educated that her physician felt this was unsafe, and had declined assisted living. The DON acknowledged that this resident’s care plan should have reflected her choice for discharge or LTC at the facility.
Failure to Implement Vision Service Recommendations and Provide Updated Eyeglasses
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident received proper treatment and assistive devices to maintain vision, despite an existing contract with a vision services company. The contract, effective December 14, 2018, required the company to arrange optometry services, including eye exams, medical eye evaluations, and fitting and ordering of eyeglasses, while the facility was responsible for coordinating necessary physician documentation. One resident with diagnoses including nonexudative age-related macular degeneration, dysphagia, and delusional disorders reported during an interview that his glasses were three years old and that he was unable to see out of them. His comprehensive care plan identified impaired vision with an intervention for ophthalmologist/optometrist consults as per orders. Clinical record review showed multiple vision consults with unimplemented recommendations. A consult dated November 26, 2024, documented bilateral nonexudative age-related macular degeneration and recommended scheduling a retinal specialist consult and obtaining new spectacles to maximize visual function. A February 5, 2025, consult recorded that the resident had not received the glasses from the November order, had not seen a retinal specialist, and was not receiving any prescribed eye drops, and again requested scheduling of the retinal specialist consult. A June 17, 2025, consult noted the resident still had not received new glasses or seen the retinal specialist and again requested scheduling for evaluation and treatment of possible choroidal neovascular membranes. During an interview, the DON acknowledged that the recommendations from the initial and February consults were missed, including during current facility ownership, and stated it was her expectation that contracted service recommendations be implemented or addressed by the physician if there was disagreement.
Failure to Properly Store and Label Food and Nutritional Supplements
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store and serve food and beverages in accordance with professional standards and the facility’s own policies. The facility’s policy on food brought in from outside required containers to be labeled with the food item name, resident name, date, and stored in an appropriate refrigerator, and the dry food storage policy required food to be stored six inches off the floor and opened items to be kept in sealed, covered containers. During observation of the dry storage room, surveyors found one package of dried chicken gravy that was not securely closed or date marked. In the walk-in refrigerator, a plastic container of fresh sweet potatoes was observed without a date. In the walk-in freezer, a case of crescent rolls was found open on the floor with one tray removed from the case. The Food Service Director acknowledged at the time of each observation that these items were not stored or labeled as required. Further observations in nourishment refrigerators on both the first and second floors showed additional failures to follow food storage and labeling standards. In the first-floor nourishment refrigerator, surveyors observed a plastic container of soup, a Styrofoam container of French fries with cheese sauce, a Styrofoam container with a chicken fajita, and a plastic container of taco salad, none of which were marked with a resident identifier or date, contrary to the facility’s policy for outside food. In the second-floor nourishment refrigerator, two 32-ounce containers of Med Pass 2.0 nutritional supplement were open, partially used, and not date marked. The Regional RD confirmed that the Med Pass containers should have been dated when opened. When these concerns were discussed with the NHA, no additional information was provided.
Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented infection control policies related to hand hygiene during medication administration. Facility policy titled "General Dose Preparation and Medication Administration," revised November 15, 2024, requires staff to complete appropriate hand hygiene prior to preparing or administering medications. On March 10, 2026, at 9:41 AM, a Registered Nurse (Employee 2) was observed administering medications consecutively to Resident 92, Resident 100, Resident 93, and Resident 12 without performing hand hygiene at any time during the observation. In an interview on March 3, 2026, at 12:15 PM, the Director of Nursing stated she would expect Employee 2 to complete hand hygiene as needed. This failure to follow the facility’s hand hygiene policy during a medication pass constituted noncompliance with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Failure to Maintain Accurate Room Calendar and Information Board for Resident at Risk of Social Isolation
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in a manner that enhanced a resident’s dignity and honored resident rights. Facility policy titled “Resident Rights and Facility Responsibilities,” revised September 3, 2020, states that the facility will comply with all resident rights and communicate these rights in a language residents and their representatives understand. For one resident with diagnoses including peripheral vascular disease and spinal stenosis, surveyors observed on March 9, 2026, that the dry-erase board in the resident’s room displayed the wrong month and year, indicating February 2026 when it was actually March 2026. Additionally, a wall calendar in the same room was left open to July 2025, rather than the current month. Review of the resident’s clinical record showed a care plan problem for psychosocial well-being, identifying the resident as at risk for social isolation related to admission to the facility, with an approach to provide an activity calendar initiated on July 31, 2025. The resident’s Quarterly MDS dated February 2, 2026, documented a BIMS score of 12, indicating the resident had some cognitive capacity for memory and orientation. During an interview, the Nursing Home Administrator stated that she would expect nursing or activities staff to update the dry-erase board and ensure the calendar displayed the correct month. The failure to maintain accurate date information and an up-to-date activity calendar in the resident’s room occurred despite the existing care plan and facility policy, resulting in a deficiency under 28 Pa. Code 211.12(d)(1)(5) related to nursing services and resident dignity.
Failure to Act on Resident Council Concerns About Wandering Residents Entering Rooms
Penalty
Summary
The facility failed to honor residents' rights to have their views considered and acted upon regarding ongoing concerns about confused, wandering residents entering other residents' rooms. Facility policy stated that the Activity Director would attempt to accommodate resident recommendations and provide follow-up to the Resident Council, and that resident issues would be documented and forwarded to the Administrator for appropriate follow-up. Resident Council minutes over three consecutive months documented repeated concerns: in December, residents reported confused residents going into other rooms late at night with no resolution documented; in January, residents again reported wandering and removal of items from rooms, with a documented plan for staff education and purposeful rounding; and in February, the minutes did not show any review or follow-up of the prior wandering concern to determine if it had been resolved. Residents later reported that they had suggested using stop signs across doorways during a council meeting but had not received any response or implementation. Multiple resident interviews corroborated that the problem persisted. One resident reported that residents moved from the dementia unit to another hall were confused, roamed hallways, entered her room, and became more agitated and hostile when redirected; she described an incident where a confused resident grabbed her wheelchair from behind and began pushing her until staff intervened. Other residents reported that confused residents roamed into their rooms, attempted to take items that did not belong to them, and took food from meal trays. A bedbound resident stated that a confused resident frequently entered her room, appeared to mistake her for a family member, and took her snacks, and she had not completed a grievance form. In a group interview, several residents stated that wandering residents entered their rooms daily, hit and stole from residents, and that staff response was limited to telling the wandering residents to move on. Residents also reported that, despite raising these issues monthly since December and suggesting stop signs for doors, they had not received the signs or any substantive response from administration, demonstrating a failure to act promptly on resident council concerns about quality of life and wandering behaviors.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in accordance with its own environmental cleaning and disinfection policy. The policy, last reviewed July 2, 2026, states that proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection and that household surfaces, including floors, tabletops, resident care areas, dining rooms, common areas, shared shower rooms and bathrooms, hair salons, and activity areas, should be cleaned regularly, when spills occur, and when surfaces are visibly soiled. Despite this policy, surveyors observed multiple resident rooms over several days with visibly soiled surfaces and debris that remained unaddressed. In one resident’s room, on three separate observations on March 9, 10, and 11, the tray table was dirty with spilled liquid and the floor was dirty with a discarded plastic cup, with conditions remaining consistent from day to day. In another resident’s room, observed on March 9, 10, and 11, the floor appeared heavily soiled and had a straw wrapper and a pepper packet on the floor, again unchanged across days. A third resident’s room was observed on March 10 and 11 with a tray table that was heavily soiled with debris and spilled liquid stains on both days. During an interview, the Nursing Home Administrator acknowledged that there had been issues with oversight in the housekeeping department and stated an expectation that the facility provide housekeeping services necessary to maintain a safe, clean, comfortable, and homelike environment.
Failure to Provide Required Written Transfer Notices and Bed-Hold Information
Penalty
Summary
Surveyors determined that the facility failed to provide required written notices related to hospital transfers and bed-hold policies for multiple residents. Review of the facility’s Discharge Planning Policy, last reviewed February 3, 2026, did not include the requirement to provide written notice of a transfer to the resident, the resident’s representative, or a representative of the Office of the State Long-Term Care Ombudsman. The Bed Hold Letter Policy, dated March 24, 2025, described internal tracking and notification processes for Medicaid bed-hold days but did not demonstrate that residents or their representatives actually received written bed-hold information at the time of transfer. Staff interviews with the DON, the Regional Director of Clinical Services, and the Nursing Home Administrator confirmed that no additional documentation could be produced to show that these notices were provided. Record review showed that one resident with muscle weakness, dysphagia, and delusional disorders was transferred to the hospital and there was no documentation that a written copy of the facility’s bed-hold policy was provided to the resident or representative. Another resident with dementia and atrial flutter was transferred to the hospital without documented written notice of the transfer or the facility’s bed-hold policy, and the facility’s Ombudsman reporting records for that month did not include this resident. A third resident with a fractured pelvis, spinal stenosis, COPD, and Medicaid as the payor source was transferred to the hospital and later returned, but the clinical record lacked evidence of written notice of the transfer, written notice of the bed-hold policy, or notification to the Ombudsman. The Nursing Home Administrator acknowledged that the facility did not have proof that these required notices and notifications were provided.
Failure to Implement Care Plan Interventions for Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive care plan for a resident with dementia, muscle weakness, and lack of coordination. The resident’s care plan, initiated on January 27, 2026, identified behavioral symptoms of wandering throughout hallways and occasionally into other residents’ rooms. Planned interventions included providing visual deterrents such as stop signs, warning signs, arrows, or do not enter signs; removing the resident from other residents’ rooms and unsafe situations; and assessing for comfort measures and basic needs when wandering began. Facility policy required that all staff caring for a resident be familiar with and follow the resident’s plan of care. Surveyor observations on multiple days showed that these interventions were not carried out. On March 9, 2026, the resident was observed wandering from room to room, entering another resident’s room, picking up that resident’s Styrofoam water cup, and dropping it on the floor, while three nurse aides were present in the hallway and did not intervene or redirect the resident. One nurse aide acknowledged seeing the incident and later stated that the resident always wanders room to room and made no attempt to redirect her. On March 10, 2026, during an activity near the nurse’s station, the resident was again observed wandering the hall and closing open resident room doors without redirection from a nurse and a nurse aide present. Additionally, during observations from March 9–12, 2026, no visual deterrents such as stop signs or warning signs were present on the hallway where the resident resided, and the Regional Director of Clinical Services confirmed that such signs had not been placed despite the care plan requirements.
Failure to Provide Necessary Shaving and Grooming for Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received necessary services to maintain grooming and personal hygiene, specifically shaving. Facility policy on AM care stated that morning care would be offered daily to promote comfort, cleanliness, grooming, and wellbeing, with showers or baths scheduled according to resident preference and shaving provided as desired. The resident had diagnoses including age-related osteoporosis, hypertension, and abnormalities of gait and mobility, and her care plan identified ADL/self-care/mobility deficits with an intervention for personal hygiene/grooming assistance of one staff member. Physician orders reflected a preferred bathing schedule of Tuesdays and Fridays on day shift. Surveyor observations of the resident on three separate days showed a quarter-inch presence of facial hair on her chin. Point-of-care documentation indicated the resident received a bed bath on a Tuesday and required total dependence for care. During interview, the resident stated she preferred bed baths in her room and reported that staff did not always offer to shave her. The DON stated that the resident had been shaved and that she would expect ADL care to be provided to dependent residents and shaving to be offered on bathing days and as needed. These findings demonstrated that the resident did not consistently receive shaving as part of her ADL care despite her dependence and facility policy expectations.
Failure to Follow IV Therapy Standards and Care Planning for Resident with UTI
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and its own policies for a resident receiving IV antibiotic therapy. Facility policies required that vascular access devices used for intermittent infusions be flushed with prescribed flushing/locking agents to maintain patency, that short peripheral IV catheter dressings be changed at least every seven days or sooner if compromised, that dressings be labeled with the date, time, and nurse’s initials, and that peripheral catheter sites be assessed before and after intermittent infusions and at least once every shift when not in use. Resident 66, who had dementia and a urinary tract infection, was readmitted from the hospital with an existing IV access line in the left antecubital area. Physician orders included meropenem 1 g IV twice daily over three hours, but there were no corresponding orders for any flushing/locking agent, IV access site changes, or dressing changes. Observations on two separate days showed the IV dressing was intact but lacked any date, and hospital records did not document when the IV site was started or when the dressing was last changed. The facility’s admission/readmission observation for this resident documented a urinary tract infection and that orders were reviewed with the physician, but it did not document the presence of the IV access site. The baseline care plan also did not include the resident’s current infection requiring enhanced barrier precautions, the IV access site, or the care required for that site. During interviews, the DON and the Regional Director of Clinical Services confirmed that there should have been orders in place for a flushing agent, IV access site changes, and dressing changes upon readmission, and that the baseline care plan should have included the infection, isolation precautions, and IV access site. These omissions resulted in care that did not follow facility policy or professional standards for managing peripheral IV therapy for this resident.
Expired and Unlabeled Enteral Feeding Formula Used for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident receiving enteral feeding, in accordance with its Enteral Feeding Tube Policy. The policy stated that licensed clinicians with demonstrated competence may administer enteral feedings and provide tube/site care. The resident involved had diagnoses including gastrostomy status, unspecified protein-calorie malnutrition, and dysphagia, and had physician orders for pump feeding to begin in the evening with a specified rate and total volume, and an order to take down the tube feeding each morning. The resident’s comprehensive care plan identified nutritional issues related to dysphagia, protein-calorie malnutrition, and the need for a feeding tube, with an intervention to provide tube feeding supplement with water flushes as ordered. Surveyor observations on one morning showed that the resident’s enteral feeding bag was hanging and infusing, but the bag was not labeled with a hang time or date. The same bag displayed a use-by date that had already passed and instructions stating it should be used for a maximum of 48 hours after connection when proper technique is followed. A later observation the same morning found the same unlabeled, nearly empty bag still hanging, though not infusing, with the same expired use-by date. An RN confirmed that this was the same bag she had disconnected from the pump and stated she had not hung it the previous day. During the interview, she became aware the formula was expired and located two additional expired formula bags in the resident’s room. The DON stated she would expect tube feeding formulas in use to be labeled with a hang time and date and not be expired.
Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors in 26 medication administration opportunities, resulting in a 15.83% error rate. Facility policy on General Dose Preparation and Medication Administration, revised November 15, 2024, required nurses to verify that the medication administered is the correct medication, at the correct dose, for the correct resident. Review of Resident 66’s current physician orders showed an order for Cyanocobalamin (Vitamin B-12) 1000 mcg daily starting March 6, 2026, but observation on March 10, 2026, at 9:41 AM revealed that an LPN administered only 500 mcg of Cyanocobalamin to this resident. Review of Resident 93’s current physician orders showed Cyanocobalamin 4000 mcg daily, Aspirin 81 mg chewable tablet, and Senna 8.6 mg twice daily, but observation at the same time revealed that an RN administered Cyanocobalamin 500 mcg, Aspirin 81 mg enteric-coated instead of chewable, and Senna Plus 8.6 mg-50 mg (Senna 8.6 mg with docusate 50 mg) instead of Senna alone. In an interview, the Director of Nursing stated she would have expected the medications to be given in the form and dosages ordered, confirming that the observed administrations did not comply with physician orders and facility policy. These findings demonstrate that the facility did not ensure adherence to its own medication administration policy and physician orders during observed medication passes, resulting in multiple dose and formulation discrepancies for the residents involved and a medication error rate exceeding the regulatory threshold.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate interventions, supervision, and safety measures to prevent the elopement of a resident who was identified as being at high risk for elopement and exhibited exit-seeking behaviors. The resident, who had diagnoses including alcohol abuse, encephalopathy, congestive heart failure, lack of coordination, and muscle weakness, was admitted from the hospital and assessed as high risk for elopement shortly after admission. Despite repeated documentation of confusion, unsteady gait, agitation, and multiple attempts to leave the unit, the resident was not consistently provided with the necessary supervision or interventions to prevent elopement. Nursing progress notes documented frequent exit-seeking behaviors, including attempts to open exit doors and wandering near the ambulance entrance. Staff redirected the resident multiple times, and recommendations were made to move the resident away from the exit area and to increase monitoring. However, these interventions were not consistently implemented. On the day of the incident, the resident was last seen in his room, but after a door alarm sounded, staff assumed he was with another staff member and did not verify his whereabouts. A head count was not performed, and the resident was able to leave the facility undetected. The resident was later found by EMS staff laying on the ground near a public road with abrasions to his hands and feet. The incident placed additional residents, who were also identified as being at risk for elopement, in immediate jeopardy due to the lack of effective supervision and safety measures. Staff interviews and facility documentation confirmed that facility policy and procedures for elopement prevention were not followed, and the necessary interventions were not in place at the time of the incident.
Failure to Conduct Reference Checks for New Employees
Penalty
Summary
The facility failed to ensure that residents were protected from potential abuse by not obtaining reference checks from previous or current employers for five employees. The facility's policy, titled Pennsylvania Resident Abuse, mandates that reference checks from two prior employers should generally be attempted before hiring a new employee. However, upon reviewing the personnel files of Employees 2, 3, 4, 5, and 6, it was found that no reference checks were documented for any of these employees. Interviews with the Regional President of Operations and the Nursing Home Administrator confirmed the absence of documentation for reference checks. The Nursing Home Administrator acknowledged that reference checks are expected to be attempted or completed during the hiring process. This oversight is a violation of several Pennsylvania Code regulations, including those related to the responsibility of the licensee, management, resident rights, and resident care policies.
Failure to Respond to Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRRs) were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for four residents. The facility's policy required that any irregularities identified by the pharmacist should be addressed by the attending physician or prescriber no later than their next scheduled visit to the facility. However, for Resident 49, multiple recommendations made by the consultant pharmacist over several months were not responded to, signed, or dated by the attending physician or prescriber. Resident 62's electronic medical record showed a delay in the physician's response to a pharmacist's recommendation, taking nearly two months to address it. Additionally, a recommendation made in October 2024 could not be located by the facility. Similarly, Resident 70's records indicated that the attending physician or prescriber failed to respond to recommendations made in June, July, and October 2024. For Resident 119, a recommendation made in August 2024 was also missing from the facility's records. Interviews with the Director of Nursing (DON) revealed an expectation that pharmacy recommendations should be responded to within two to four weeks. However, the facility was unable to provide documentation of timely responses or locate certain recommendations, indicating a systemic issue in adhering to the policy and ensuring proper medication management for the residents.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in reflecting their current health status. Resident 85, diagnosed with dysphagia, gastro-esophageal reflux disease, and hypertension, experienced a significant weight loss, which was not accurately documented in the Minimum Data Set (MDS) assessments. The MDS with an assessment reference date of October 7, 2024, did not reflect the resident's most current weight or the significant weight loss. Additionally, a physician's note dated November 14, 2024, indicated protein calorie malnutrition (PCM) due to refusal to eat, yet the MDS dated November 15, 2024, failed to mark the diagnosis of PCM. Similarly, Resident 125, with diagnoses of congestive heart failure and dementia, experienced a 13% weight loss since admission and a 5.2% loss since October 3, 2024. However, the MDS dated November 6, 2024, inaccurately coded the weight loss section as "No or unknown," failing to reflect the resident's actual weight loss. These inaccuracies in the MDS assessments were acknowledged by the Nursing Home Administrator during an interview, who stated that the facility expects accurate coding of resident assessments.
Failure to Provide Initial Care Plan Meeting
Penalty
Summary
The facility failed to provide a resident and/or their representative with a summary of the baseline care plan within 48 hours of admission, as required by their policy. The policy mandates that an interdisciplinary care plan be established and updated for every resident in accordance with state and federal regulations. The comprehensive care plan should be developed within seven days after the completion of the comprehensive assessment (MDS) and involve an interdisciplinary team, including the attending physician, a registered nurse, a nurse aide, and a member of the food and nutrition services staff. Additionally, the facility's Advance Care Planning Meeting Protocol requires a meeting with the resident and/or their representative within 3-5 days of admission to discuss pertinent information regarding the resident's wishes. In the case of Resident 72, who was admitted with diagnoses including general anxiety disorder and intermittent explosive disorder, no initial care plan meeting was held to provide the resident and/or their representative with the baseline or comprehensive plan of care. This omission was confirmed by the Regional President of Operations and the Director of Nursing, who acknowledged that the facility's expectation was for an initial care plan meeting to be conducted in accordance with the facility's policy. As of March 26, 2025, the resident's clinical record showed no evidence of such a meeting, leading to the deficiency finding.
Deficiencies in Care Plan Meetings and Documentation
Penalty
Summary
The facility failed to invite residents and/or their representatives to care plan meetings and did not ensure the participation of required interdisciplinary team members in these meetings. For Resident 14, who has diagnoses including hypertension and major depressive disorder, the facility did not document his attendance or invitation to care plan meetings held in February 2025 and September 2024. Only two members of the interdisciplinary team attended the February 2025 meeting, and there were no documented meetings between September 2024 and February 2025. Resident 49, diagnosed with heart failure and vascular dementia, had a care plan that was not reviewed or revised in a timely manner. The care plan included a focus on oxygen therapy, which was no longer supported by an active physician's order since October 2024. The Nursing Home Administrator acknowledged that the care plan should have been updated to reflect the current needs and orders for Resident 49. For Resident 58, who has dementia, severe protein-calorie malnutrition, and Parkinson's disease, the facility did not invite her or her representative to care plan meetings after the initial meeting post-admission. The February 2025 meeting documentation did not show any invitation to the resident or her representative, and only two interdisciplinary team members attended. The Director of Nursing confirmed the lack of invitation and expected participation of all team members in care conferences.
Failure to Complete Physician Discharge Summaries
Penalty
Summary
The facility failed to ensure that a physician's discharge summary was completed for two residents who were reviewed for discharge. Resident 57, who had diagnoses including congestive heart failure and type two diabetes mellitus, was admitted for rehabilitation and discharged home after reaching rehabilitation goals. However, as of March 26, 2025, no physician's summary was completed for Resident 57's stay from January 16, 2025, to February 5, 2025. This was confirmed during a staff interview with the Director of Nursing, who stated that it is the facility's expectation for physician summaries to be completed for discharged residents. Similarly, Resident 137, who had diagnoses including dysphagia, chronic kidney disease, and hypertension, was admitted for rehabilitation after a hospital stay and was discharged after being sent directly to the hospital following an outside appointment. As of March 26, 2025, no physician's summary was completed for Resident 137's stay from December 2, 2024, to January 10, 2025. The Nursing Home Administrator confirmed during an interview that they were unable to locate a physician discharge summary for Resident 137, reiterating the facility's expectation for such summaries to be completed.
Failure to Adhere to Physician Orders and Care Plans
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents, leading to deficiencies in their care. Resident 61, diagnosed with dementia, generalized osteoarthritis, and hypertension, had physician orders for specific positioning and protective equipment, including bilateral heel boots while in bed and leg rests on her Broda chair. Observations revealed that Resident 61 was not wearing the heel boots on multiple occasions, despite documentation indicating otherwise. Additionally, the leg rests were missing from her Broda chair, contrary to her care plan. Staff interviews revealed a lack of awareness and inability to locate the required equipment, with inaccurate documentation noted by the staff responsible for her care. Resident 105, diagnosed with congestive heart failure, major depressive disorder, and hypertension, had physician orders for TED hose to be worn on her lower extremities to manage edema. Observations on consecutive days showed that Resident 105 was not wearing the TED hose, despite documentation indicating they were in place. The Nursing Home Administrator confirmed that the TED hose should have been applied as per the physician's order and that the documentation was inaccurate. The deficiencies highlight a failure in the facility's management and adherence to resident care policies, as evidenced by the inaccurate documentation and lack of compliance with physician orders for both residents. The Director of Nursing acknowledged the issues and indicated a need for investigation and adherence to care plans, but the report does not detail any corrective actions taken to address these deficiencies.
Failure to Provide Prescribed Mobility Equipment
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received the appropriate services and equipment to maintain or improve mobility. The resident, identified as having multiple diagnoses including contracture, depression, dementia, dysphagia, diabetes mellitus, and metabolic encephalopathy, had physician orders for a left wrist cock-up splint and a left edema glove to be worn during the day and removed at night. These orders were intended to prevent further contracture and facilitate participation in activities. However, during an observation, the resident was found in the common area without the prescribed splint and glove. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that the resident should have been wearing the splint and glove at the time of the observation. The facility's policy on splint issuance required a provider's order and therapist evaluation, with the splint schedule documented in the care plan. Despite these protocols, the resident was not wearing the necessary equipment, indicating a lapse in adherence to the care plan and facility policy.
Failure to Document and Assess After Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assessment following an accident involving a resident who was reviewed for falls. The resident, who has a history of general anxiety disorder and intermittent explosive disorder, sustained a witnessed fall and struck their head on the bed footboard, resulting in a bruise above the right eye. However, the bruise was not documented by staff until it was pointed out by a surveyor several days later. The facility's policy requires neurological checks after any head trauma, but there was no documentation of such assessments being conducted for this resident following the fall. Additionally, the incident investigation report for the fall was not created until two days after the event, and the progress note by the witnessing registered nurse was not entered until a week later. The Director of Nursing confirmed that it was the facility's expectation for fall investigation reports to be completed immediately after a fall and for neurological assessments to be conducted as per policy. The delay in documentation and failure to perform required assessments indicate a lapse in the facility's adherence to its own policies and procedures regarding fall management and resident safety.
Incomplete Dialysis Communication Records
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident requiring dialysis services. The facility's Hemodialysis Care Policy mandates that a Dialysis Communication Tool be completed and sent with the resident to dialysis, documenting pre-dialysis assessments such as vital signs, weight, medications, and other pertinent information. However, for Resident 54, who has diagnoses including Parkinson's disease and end-stage renal disease, the facility did not complete the required dialysis communication forms on several specified dates in February and March 2025. During an interview, the Director of Nursing confirmed the absence of these forms for the specified dates and acknowledged the expectation that such forms should be completed on dialysis days. The deficiency was identified through a review of Resident 54's clinical records, which revealed missing documentation for the dialysis communication forms on the specified dates, despite existing physician orders and care plans requiring their completion.
Failure to Document Medication Disposition for Deceased Resident
Penalty
Summary
The facility failed to provide documentation of the actual disposition of medications for a resident, identified as Resident 136, who had diagnoses including end stage renal disease and hypertension. The resident was found unresponsive and passed away due to cardiac arrest, as noted in a discharge summary dated February 15, 2025. The discharge summary indicated that the resident's medications went with them, but there was no completed medication disposition form or progress notes documenting the disposition of medications. During an interview, the Director of Nursing confirmed the absence of the medication disposition form and acknowledged that it should have been completed.
Failure to Maintain Food Safety Standards in Dish Machine Area
Penalty
Summary
The facility failed to adhere to professional standards for food safety in the dish machine area during an observed meal service. The dish machine was in use with a final rinse cycle temperature of 142 degrees Fahrenheit, which is below the required temperature for a hot temperature dish machine. Additionally, the sanitizer solution was not connected to the dish machine as the tubing was found on the floor instead of being placed in the sanitizer bucket. This indicates a failure to ensure that the dish machine was operating within the necessary specifications for effective sanitation. Furthermore, Employee 7, a Dietary Aide, was observed handling both clean and dirty dishes without changing gloves or performing hand hygiene between tasks. This practice contravenes the facility's policy, which requires staff to wash hands thoroughly before moving from handling dirty dishes to clean ones. Interviews with the Registered Dietitian and Food Service Director confirmed these lapses, highlighting a lack of compliance with established procedures for dish machine operation and hand hygiene in the dish room.
Deficiencies in Sprinkler System Maintenance and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and maintenance of its sprinkler system, as evidenced by the absence of 5-year sprinkler gauge replacement/calibration and internal pipe and valve inspection records. During a review of documentation, it was confirmed that the facility lacked these critical maintenance records. Additionally, the facility did not address the failure of the annual main drain test due to low water pressure, which was identified on August 28, 2024. This failure was confirmed during an interview with the Administrator and Maintenance Director. Further observations revealed physical obstructions and debris affecting the sprinkler system. Multiple items, such as wires and flex conduits, were found laying across the sprinkler pipes in various locations throughout the facility. Additionally, several sprinkler heads in the Laundry Room were covered with debris, which could impede their functionality. These issues were confirmed during an exit conference with the facility's Administrator and Maintenance Director.
Plan Of Correction
The 5-year sprinkler inspection report was located with last inspection performed on June 30, 2021. Results posted in Life Safety Book. The failed main drain test performed on August 28, 2024 due to low water pressure will be followed up to make necessary repairs as recommended by a qualified sprinkler company. The sprinkler company will be at the facility on April 1, 2025 to provide the facility with a remedy and work will be scheduled as soon as possible thereafter. Items laying across sprinkler pipes in the following areas have been removed from the sprinkler pipes: 1st floor, above ceiling by Resident Room D15 1st floor, above ceiling by Resident Room C1 2nd floor, above ceiling by Physical Therapy 2nd floor, above ceiling by Resident Room F18 The Maintenance Director will spot check other areas above the ceiling throughout the facility on a monthly basis to check for items laying on sprinkler pipes. After any vendor work above the ceiling, the Maintenance Director or NHA will inspect the area before the vendor leaves the facility. The sprinkler heads in the laundry area have been cleaned and will be inspected monthly by the NHA or designee. The Maintenance Director was re-educated on the need to maintain documentation so that it is easily retrievable; to follow up with repairs to any failed inspections and to not have anything laying across sprinkler pipes. The Maintenance Director or designee will audit inspection reports for timeliness and follow up repairs weekly for four weeks and then monthly for 3 months and report the results to the facility's QAPI committee. The NHA or designee will audit inspection reports on a quarterly basis to make sure recommended repairs are completed and that all inspection reports are timely and filed in the Life Safety Book.
Failure to Perform Essential Electrical System Maintenance
Penalty
Summary
The facility failed to perform the required monthly and annual inspections and testing of its Essential Electrical System (EES), which is crucial for maintaining power supply in critical situations. During a document review and interview conducted on March 13, 2025, it was revealed that the facility did not conduct the necessary monthly 30-minute load bank test using the transfer switches, nor did it perform the annual 90-minute load bank test and the annual fuel quality test. These tests are essential to ensure the generator and associated equipment can supply power within 10 seconds, as required by NFPA standards. The deficiency was confirmed during an exit conference with the Administrator and Maintenance Director, where it was acknowledged that the facility had not adhered to the maintenance and testing schedule mandated by NFPA 101, NFPA 110, and NFPA 111. The lack of compliance with these standards indicates a failure to ensure the reliability of the emergency power system, which is critical for the safety and well-being of the residents in the event of a power outage.
Plan Of Correction
The generator will be run for 30 minute load bank using the transfer switches monthly and will be run for 90 minute load bank annually. An annual fuel quality test will be performed on the generator on April 3, 2025 and the fuel sample will be taken on the same date. The Maintenance Director was re-educated on the need to run the generator 30 minutes monthly under load and annually for 90 minutes under load as well as have a fuel quality test performed annually. The NHA or designee will audit the generator logs monthly 30-minute testing and semi-annually for the 90 minute testing and that all documentation is filed in the Life Safety Book.
Facility Lacks Carbon Monoxide Detector and Exceeds Door Force Requirement
Penalty
Summary
The facility was found to be non-compliant with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act due to the absence of an installed carbon monoxide detector in the Boiler/Generator Room. This deficiency was confirmed during an observation and interview conducted on March 13, 2025, at 12:12 PM, and further verified during the exit conference with the Administrator and Maintenance Director at 1:45 PM the same day. Additionally, the facility failed to maintain the required maximum force to operate exit discharge doors, as observed on March 13, 2025, at 11:35 AM. The 1st floor exit door in the Common Area required more than 30 pounds of force to set in motion, which is not in compliance with NFPA 101 Means of Egress standards. This issue was also confirmed during the exit conference with the Administrator and Maintenance Director.
Plan Of Correction
The 1st floor exit door, at the Common Area, will be repaired or adjusted so that the door opens with a force of less than 30 pounds. A Time Limited Waiver is being requested for this citation due to the construction of the metal framed glass door and metal threshold may require extensive work to make the repair or possibly a new door.
Deficiencies in Hazardous Area Door Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining the integrity of hazardous area doors, as observed during a survey on March 13, 2025. Specifically, the doors in four out of eight smoke zones exceeded the allowed gap margins. The affected areas included the Kitchen Scullery door, Main Kitchen door, Elevator Machinery Room door, and multiple Soiled Utility Room doors on both the 1st and 2nd floors. The gaps in these doors ranged from exceeding 1/8 inch to 3/16 inch, which is beyond the permissible limits for maintaining fire safety standards. Additionally, the Kitchen Scullery door on the 1st floor was observed to fail in self-closing, which is a requirement for hazardous area doors to ensure containment in case of a fire. These observations were confirmed during an exit conference with the Administrator and Maintenance Director, indicating a lapse in the facility's adherence to fire safety protocols as outlined in NFPA 101 standards.
Plan Of Correction
The 1st floor, Kitchen, Scullery door, top, exceeded 3/16 inch will be adjusted or repaired using approved hardware so gap does not exceed 3/16 inch. The 1st floor, Main Kitchen door, top and latch side, exceeded 3/16 inch will be adjusted or repaired using approved hardware so gap does not exceed 3/16 of an inch. The 1st floor, Elevator Machinery Room door, top and latch side, exceeded 1/8 inch will be adjusted or repaired using approved hardware so that the gap does not exceed 1/8 inch. The 1st floor, C Hall Soiled Utility Room door #1, top, exceeded 1/8 inch will be adjusted or repaired using approved hardware so that the gap does not exceed 1/8 inch. The 1st floor, C Hall Soiled Utility Room door #2, top and latch side, exceeded 1/8 inch will be adjusted or repaired using approved hardware so that the gaps do not exceed 1/8 inch. The 2nd floor, Soiled Utility Room door, by Infectious Control Room, top and latch side, exceeded 1/8 inch will be adjusted or repaired using approved hardware so that gaps do not exceed 1/8 inch. The kitchen scullery door will be repaired to make self-closing. Other doors to hazardous areas throughout the facility will be checked for proper gaps and adjusted or repaired using approved hardware as necessary. The Maintenance Director was re-educated on the need to maintain doors so that gaps are within acceptable range. The NHA or designee will audit door to hazardous areas for proper gaps monthly. A Time Limited Waiver is being requested until July 31, 2025 due to some doors may have to be replaced and the availability of the doors may take up to six months to obtain.
Failure to Document Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to provide documentation verifying that monthly inspections of portable fire extinguishers were conducted, as required by NFPA 10, Standard for Portable Fire Extinguishers. This deficiency was identified during a document review on March 13, 2025, which revealed that inspections were not performed for six months: January 2025, February 2025, July 2024, October 2024, November 2024, and December 2024. During an exit conference on the same day, the Administrator and Maintenance Director confirmed the failure to conduct these monthly inspections, affecting the entire component of the facility.
Plan Of Correction
All portable fire extinguishers have been inspected by the Maintenance Director or designee. Our extinguisher vendor will be contacted to perform an annual inspection, and the Maintenance Director will maintain monthly documentation of quick checks. The Maintenance Director has been re-educated on the requirement to perform a monthly inspection of all portable fire extinguishers. The NHA or designee will audit the portable fire extinguishers for sign-off of inspection monthly on a quarterly basis.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain the cross-corridor smoke barrier doors, which affected two of the eight smoke compartments within the component. During an observation on March 13, 2025, at 12:00 PM, it was noted that the left leaf of the cross-corridor smoke barrier doors on the 2nd floor, near Resident Room H18, did not close properly due to a faulty door closure. This deficiency was confirmed during an interview at the exit conference with the Administrator and Maintenance Director on the same day at 1:45 PM.
Plan Of Correction
The closer on the left leaf of the cross corridor smoke barrier doors near Resident Room H18 will be repaired or replaced to allow the door to close. All cross corridor doors have been inspected to see if they close. The Maintenance Director has been re-educated on the importance of checking that smoke barrier doors close fully. The Maintenance Director or designee will inspect cross corridor smoke doors for proper closing and smoke resistance each month. The NHA or designee will audit the cross-corridor doors for self-closing and smoke resistance quarterly.
Failure to Conduct Quarterly Fire Drills on 2nd Shift
Penalty
Summary
The facility failed to conduct fire drills on the 2nd shift every quarter, which affects the entire component. Upon reviewing documentation on March 13, 2025, it was revealed that the facility did not perform fire drills for the 2nd shift during several quarters in 2024. Specifically, fire drills were not conducted for the 1st quarter on the 3rd shift, the 2nd quarter on the 1st, 2nd, and 3rd shifts, the 3rd quarter on the 1st, 2nd, and 3rd shifts, and the 4th quarter on the 3rd shift. This deficiency was confirmed during an interview with the Administrator and Maintenance Director at the time of the exit conference.
Plan Of Correction
The facility will conduct a fire drill on 2nd shift on March 31, 2025. Fire drills will be performed on each shift quarterly. The Maintenance Director was re-educated on the need to have a fire drill on each shift quarterly. The Safety Committee will develop a schedule of monthly fire drills and audit quarterly for completion.
Deficiencies in Life Safety Drawings and Carbon Monoxide Protocols
Penalty
Summary
The facility failed to meet the minimum standards for operation as required by the Department and other state and local agencies. During a document review and observation, it was found that the facility's portable life safety drawings were incomplete. Specifically, they lacked compartment labeling, resident room capacities, firewall boundaries, smoke wall boundaries, and hazardous areas. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director. Additionally, the facility did not have documentation of annual testing and inspection of installed carbon monoxide detectors, as required by the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. The absence of documentation verifying evacuation and alarm protocols was also noted. These deficiencies were confirmed during an interview with the Administrator and Maintenance Director.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. The portable life safety drawings will be updated with compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, and hazardous areas. Annual inspection of installed carbon monoxide detectors will be tested and inspected. A copy of the annual inspection will be kept in the Life Safety Book. Evacuation and alarm protocols will be put in place in accordance with the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. A copy of the protocols will be placed in the Emergency Preparedness Plan of the facility and in the Life Safety Book. A carbon monoxide detector is installed in the Boiler/Generator Room within 15 feet of the fuel burning Boiler and Generator. Copies of the life safety drawings will be checked for accuracy and updated accordingly. All carbon monoxide detectors will be identified for inspection. Evacuation and alarm protocols will be reviewed by the Maintenance Director or designee for any needed adjustments. Placement of carbon monoxide detectors will be reviewed to ensure proper placement within 15 feet of fuel burning equipment. The Maintenance Director was re-educated on the need to have accurate portable life safety drawings reflecting compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, and hazardous areas; the need for annual inspection and testing of carbon monoxide detectors; the need for evacuation and alarm protocols regarding carbon monoxide alarms; and the need for carbon monoxide detectors in boiler and generator rooms. The Maintenance Director or designee will review the drawings for any changes monthly for three months. The Maintenance Director or designee will review the documentation of carbon monoxide annual inspection and present at QAPI and ensure annual inspection is available at the time of the Life Safety survey. The Maintenance Director or designee will review alarm and evacuation protocols at QAPI and at least annually. The Maintenance Director or designee will review proper placement of carbon monoxide detectors within 15 feet of fuel burning equipment.
Failure to Perform Fire Safety Checks and Cleanings
Penalty
Summary
The facility failed to perform the required owner's quick checks on the Kitchen's fixed chemical fire suppression system. This deficiency was identified during a document review and interview conducted on March 13, 2025, between 8:45 AM and 10:45 AM. The absence of these checks was confirmed during an exit conference with the Administrator and Maintenance Director on the same day at 1:45 PM. The lack of these checks indicates a failure to adhere to the necessary safety protocols for fire suppression systems in the facility's kitchen. Additionally, the facility did not conduct the semi-annual cleaning of the Kitchen exhaust ductwork for a full year. Documentation reviewed during the survey showed that the last cleaning cycle was completed on April 8, 2024. This oversight was also confirmed during the exit conference with the Administrator and Maintenance Director on March 13, 2025. The failure to perform these cleanings as required affects one of the eight smoke zones within the component, indicating a lapse in maintaining the necessary fire safety standards.
Plan Of Correction
The maintenance Director performed a quick check on the Kitchen's fixed chemical suppression system on March 28, 2025, and documentation placed in the Life Safety Book. The kitchen exhaust and ductwork cleaning was completed on April 8, 2024, and September 20, 2024. The next cleaning of the ductwork is scheduled for May 5, 2025, due to a scheduling conflict. The Maintenance Director was re-educated on the need to perform quick checks on the Kitchen's fixed chemical suppression system monthly. The Maintenance Director and Food Service Director were re-educated on the need to schedule kitchen exhaust duct cleaning every 6 months. The NHA or designee will audit that quick checks are being completed, and reports are received and filed in the Life Safety Book. Audits will be conducted quarterly. The Maintenance Director or designee will ensure that the Kitchen exhaust duct cleaning is performed on a semi-annual basis. Inspection reports will be filed in the Life Safety Book. The NHA or designee will audit that inspections are timely on a quarterly basis.
Failure to Maintain GFI Protection Near Water Sources
Penalty
Summary
The facility failed to maintain power receptacles with Ground Fault Interruption (GFI) protection within six feet of a water source in one of the eight smoke zones. During an observation conducted on March 13, 2025, between 11:42 AM and 12:10 PM, it was noted that outlets were not GFI protected in specific locations. These locations included the 2nd floor behind the ice machine by Resident Room F5 and in the Boiler/Generator Room by the boiler lines on the exterior wall, where three outlets were identified. This deficiency was confirmed during an interview with the Administrator and Maintenance Director at the time of the exit conference on the same day.
Plan Of Correction
The outlet on the 2nd floor, behind the ice machine, by Resident Room F5 was replaced with a GFI protected outlet. The 3 outlets in the Boiler/Generator Room, by the boiler lines exterior wall were replaced with GFI protected outlets. The Maintenance Director was re-educated on the need for GFI protected outlets within six feet of a water source. A facility wide inspection for GFI outlets will be conducted and whenever an outlet is replaced to ensure GFI protection within six feet of a water source.
Lack of Documentation for Emergency Lighting Testing
Penalty
Summary
The facility failed to provide documentation verifying the testing of battery back-up emergency lighting, which is required to be tested monthly for 30 seconds and annually for 90 minutes. This deficiency was identified during a document review conducted on March 13, 2025, between 8:45 AM and 10:45 AM. The review revealed that the facility lacked the necessary documentation to confirm that these tests had been conducted within the previous twelve months. During an exit conference on the same day at 1:45 PM, the Administrator and Maintenance Director confirmed the absence of documentation verifying the testing of battery back-up lighting fixtures. This deficiency affects the entire component of the facility's emergency lighting system.
Plan Of Correction
Battery back-up lighting annual 90 minute test will be performed on 4/2/25. Going forward, the lighting will be tested monthly for 30 seconds and annually for 90 minutes. Record of testing will be maintained in the Life Safety Book. All battery back-up lighting has been identified for testing. The Maintenance Director has been re-educated on the need to test the back up lighting monthly for 30 seconds and annually for 90 minutes. The NHA or designee will audit the recording of testing monthly and the documentation is filed in the Life Safety Book.
Lack of Documentation for Annual Fire Door Inspection
Penalty
Summary
The facility failed to provide documentation of the annual fire door inspection for eight smoke compartments. During a document review on March 13, 2025, it was discovered that the facility did not have records of the required annual inspection for fire-rated doors. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation.
Plan Of Correction
The fire rated doors in the eight smoke compartments have been inspected by the Maintenance Director. All fire rated doors inspections will be documented and repairs done as needed. Documentation of the inspections will be placed in the Life Safety Book. The Maintenance Director has been re-educated on the need to perform annual inspections on all fire-rated doors. The NHA or designee will audit the door inspections of fire doors to make sure the annual inspection was completed.
Lack of Documentation for Electrical Receptacle Inspections
Penalty
Summary
The facility failed to provide documentation verifying that electrical receptacles in Patient Care Areas had been subjected to inspection and testing. This deficiency was identified during a document review conducted on March 13, 2025, between 8:45 AM and 10:45 AM. The review revealed a lack of documentation confirming that the required testing and inspection of electrical receptacles had been performed. During an exit conference on the same day at 1:45 PM, the Administrator and Maintenance Director confirmed the absence of such documentation, affecting the entire component of the facility's electrical systems in Patient Care Areas.
Plan Of Correction
The electrical receptacles in Patient Care Areas have been inspected. All facility receptacles will be inspected. The Maintenance Director has been re-educated on the requirement to inspect all electrical receptacles in Patient Care Areas. The NHA or designee will audit the inspection results semiannually for proper documentation and placement in the Life Safety Book.
Failure to Conduct and Document Neurological Checks Post-Fall
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents, resulting in a deficiency. Resident 1, diagnosed with Parkinson's Disease and generalized anxiety disorder, experienced multiple falls, including one on October 11, 2024, where she hit her head on a bedside table. Although initial neurological checks were conducted and found to be within normal limits, no further checks were documented as required by the facility's Neurological Checks Policy. Similarly, Resident 1 had two unwitnessed falls on October 27, 2024, with initial checks performed but no subsequent checks documented. Resident 2, diagnosed with dementia and congestive heart failure, also experienced an unwitnessed fall on October 2, 2024. While neurological checks were completed at the time of the fall, no additional checks were documented afterward. The Nursing Home Administrator acknowledged the absence of documentation for the required neurological checks, which is a violation of the facility's policy and professional standards of practice.
Failure to Accurately Record and Reconcile Controlled Drugs
Penalty
Summary
The facility failed to maintain an accurate system for recording the disposition of controlled drugs, specifically lorazepam, for a resident diagnosed with dementia and anxiety disorder. The Controlled Medication Utilization Record for this resident showed alterations in the recorded number of remaining pills, indicating a loss of 20 tablets. The alterations were made using different ink colors, making some numbers illegible. Despite these discrepancies, staff continued to document administrations without identifying the potential diversion of medication. Additionally, the facility's controlled medication shift reconciliation sheets were incomplete for several days, further contributing to the oversight. The issue was only identified when the pharmacy alerted the facility that the resident's supply of lorazepam should not have been exhausted. An investigation revealed an additional diversion of 38 pills, with missing documentation for a period in May. The facility lacked a documented response or staff education regarding the alteration of controlled medication records. Interviews with the Nursing Home Administrator confirmed that staff were expected to report any alterations in controlled substance counts, but this expectation was not met.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles, as observed in three medication carts on B Hall, C Hall, and G Hall. The G Hall medication cart contained several insulin products, including prefilled pens and multidose vials, that lacked opened dates, contrary to the facility's policy requiring such labeling. Additionally, a prefilled insulin pen had a sticker covering critical manufacturer information. The Director of Nursing confirmed these labeling deficiencies during the observation. Further observations revealed improper storage practices in the C Hall medication cart, where food was found stored alongside multi-dose medication containers. Both the C Hall and B Hall medication carts contained loose medication pills and pill dust, indicating a lack of cleanliness and organization. The Nursing Home Administrator admitted that the facility did not have a current medication cart cleaning schedule, and it was unclear whose responsibility it was to maintain the carts. The Director of Nursing confirmed that food should not be stored in medication carts and that medications should be labeled with opened dates as per policy.
Failure to Notify Residents and Representatives of Transfers
Penalty
Summary
The facility failed to notify residents, their representatives, and the Office of the State Long-Term Care Ombudsman of resident transfers in writing, including the reason for the transfer, date of transfer, location of transfer, statement of the resident's appeal rights, and contact information for the Ombudsman. This deficiency was identified in six out of eleven resident records reviewed. The facility's policy did not adequately document the required notification and appeals information for emergency transfers, and the practice of obtaining signatures from two staff members did not ensure that residents or their representatives were properly informed. Resident 20 was transferred to the hospital on multiple occasions without proper notification to the resident or their representative. The facility's records lacked documentation that the Notice of Transfer or Discharge was provided to Resident 20 or their representative, and the resident was not included in the Ombudsman notification for January 2024. Similar issues were found with Resident 34, who was transferred to the hospital on several dates without proper notification, and the resident was also not included in the Ombudsman report for January 2024. Other residents, including Residents 76, 81, 97, and 184, experienced similar deficiencies. Their clinical records revealed that Notices of Transfer or Discharge were not properly addressed or signed by the residents or their representatives, and there was a lack of documentation in the progress notes to indicate that the information was provided. Additionally, some residents were not included in the Ombudsman notifications for their respective transfer dates. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these deficiencies and the facility's failure to adhere to its policy and documentation requirements.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to ensure that residents and their representatives received written notice of the facility's bed-hold policy at the time of transfer to a hospital or therapeutic leave. This deficiency was identified through clinical record reviews, policy reviews, and staff interviews. Specifically, seven out of eleven resident records reviewed did not have documentation that the bed-hold policy was provided to the residents or their representatives during hospital transfers. The residents involved had various medical conditions, including chronic systolic congestive heart failure, chronic obstructive pulmonary disease, dementia, end-stage renal disease, and Alzheimer's disease, among others. For Resident 20, the clinical record revealed two instances of hospital transfers on January 29, 2024, and February 27, 2024, without documentation that the bed-hold policy was provided to the resident or their representative. Similarly, Resident 34's record showed three hospital transfers on August 11, 2023, January 24, 2024, and April 3, 2024, with no documentation of the bed-hold policy being provided. Resident 59 was admitted to the hospital on January 29, 2024, and again, there was no documentation that the bed-hold policy was communicated to the resident or their representative. Other residents, including Resident 76, Resident 81, Resident 97, and Resident 184, also had multiple hospital transfers without proper documentation of the bed-hold policy being provided. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility's practice was to review the bed-hold policy with the resident or their representative and have it signed by two staff members during emergent transfers. However, this practice was not consistently documented in the progress notes, leading to the identified deficiency.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident status for two residents. For Resident 77, the clinical record revealed diagnoses including vascular dementia, delusional disorder, and depression. The Quarterly MDS assessments for Resident 77 on multiple dates indicated that the resident was receiving antipsychotic medication on a routine basis without a documented gradual dose reduction or a clinical contraindication for such a reduction. However, the clinical record contained documentation from the physician and a consultation note indicating that a gradual dose reduction was clinically contraindicated, which was not reflected in the MDS assessments. This discrepancy was confirmed during an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), who acknowledged the inaccuracies in the MDS coding for Resident 77. For Resident 87, the clinical record revealed diagnoses including PTSD, anxiety, and bipolar disorder. Despite these diagnoses, the Admission MDS and subsequent MDS assessments failed to indicate the PTSD diagnosis. The clinical record included a hospital referral and a PsychoGeriatric Services Evaluation that documented the PTSD diagnosis and the plan for continued psychology services. The NHA confirmed during an interview that the MDS assessments for Resident 87 were modified to reflect the PTSD diagnosis, acknowledging that the initial assessments were inaccurately coded.
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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