Riverside Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mckeesport, Pennsylvania.
- Location
- 100 8th Street, Mckeesport, Pennsylvania 15132
- CMS Provider Number
- 395719
- Inspections on file
- 36
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Riverside Health & Rehab Center during CMS and state inspections, most recent first.
A resident admitted for a short-term respite stay with multiple diagnoses, including C. diff and diabetes, did not have timely physician progress notes written, signed, and dated at each required visit. Wound care orders and documentation were entered as late entries, and this deficiency was confirmed by the DON during staff interviews.
Three residents admitted with chronic kidney disease or end stage renal disease requiring dialysis did not have their dialysis care needs included in their baseline care plans within 48 hours of admission, despite physician orders and facility policy. Staff interviews confirmed the omission of dialysis care from the initial care planning.
Three residents with chronic kidney disease or end stage renal disease did not have consistent or complete dialysis communication maintained between the facility and the dialysis provider, as required by policy. Multiple dialysis communication forms were incomplete or missing, and two residents were not care planned for dialysis services despite physician orders. The DON confirmed these lapses in required documentation and communication.
The facility did not keep the dish machine in the Main Kitchen in working order, resulting in staff using handwashing and disposable containers for meal service. The issue persisted for several days before being identified by the Dietary Manager, and both the drainage and disposal components of the dish machine were found to be non-operational.
The facility did not fully investigate injuries sustained by three residents, including falls and a skin tear of unknown origin. In each case, required documentation and investigation steps were incomplete, such as missing details on how injuries occurred, lack of staff statements, and absence of current transfer orders. The DON confirmed that the facility failed to respond appropriately to possible neglect and injuries of unknown origin.
Three residents with significant medical needs, including amputations, diabetes, and muscle weakness, reported extended delays in receiving assistance with ADLs such as toileting and incontinence care. Residents described waiting hours for help, with call lights going unanswered and staff failing to provide timely support. The DON confirmed the lack of adequate ADL assistance.
Two residents experienced falls due to staff not following established safety protocols, including failure to use required wheelchair leg rests and not utilizing a mechanical lift for transfers. In both cases, the residents sustained minor injuries, and facility leadership confirmed that staff did not adhere to care plans or transfer procedures.
A resident with severe cognitive impairment and multiple diagnoses experienced a fall resulting in a forehead injury. The facility did not notify the resident's representative of the incident at the time it occurred, and the representative only learned of the fall after observing a bruise during a visit. The administrator confirmed the failure to provide timely notification as required by facility policy.
A resident with a history of brain cancer and traumatic brain injury did not receive a physician-ordered follow-up MRI scan. Although the MRI was scheduled, the need for an escort was documented, and Ativan was ordered, the appointment was canceled without explanation and not completed as ordered. Staff interviews confirmed the failure to implement the physician's order.
The facility failed to notify physicians of elevated or decreased blood sugar levels and assess residents for hyperglycemia and hypoglycemia, resulting in immediate jeopardy for multiple residents. Despite having protocols in place, the facility lacked procedures for managing hyperglycemia, leading to inadequate documentation and follow-up on out-of-range blood sugar levels. Staff interviews revealed awareness of procedures, but lapses in documentation and communication contributed to the deficiency.
The facility failed to complete comprehensive MDS assessments within the required timeframe for several residents. According to the RAI User's Manual, these assessments should be completed no later than 14 days after admission. However, some residents had their assessments completed late or not at all. This issue was confirmed by the RNAC during an interview.
The facility failed to complete quarterly MDS assessments within the required timeframe for three residents. The RAI User's Manual mandates that these assessments be completed no later than 14 days after the ARD. However, one resident's MDS was completed late, another's was not completed at all by the required date, and a third resident's MDS was also completed late. The RNAC confirmed this failure during an interview.
The facility failed to update care plans for two residents to reflect their current medical needs. One resident receiving hospice services and another on continuous oxygen therapy did not have their care plans updated with relevant goals and interventions. The DON confirmed the oversight.
The facility's QAPI program failed to address deficiencies related to the documentation and notification of hypo/hyperglycemic events. Multiple residents experienced high or low blood sugar levels without proper documentation or timely notification to medical personnel. The Nursing Home Administrator and DON confirmed the facility's failure to maintain an effective Quality Assurance Committee, affecting 26 of 84 residents.
The facility failed to develop baseline care plans for four residents with diabetes mellitus, as required within 48 hours of admission. Despite their diagnosis, the care plans did not include necessary diabetes care and interventions. This deficiency was confirmed by the DON and ADON during an interview.
The facility failed to develop comprehensive care plans for five residents, as required by the RAI User's Manual and facility policy. The Section V CAA Summary, Question V0200, was not completed for these residents, who had significant medical conditions such as diabetes mellitus, chronic kidney disease, and dementia. Their care plans lacked goals and interventions related to diabetes mellitus, and the facility's leadership confirmed this deficiency.
The facility failed to maintain a comprehensive water management program to monitor and control Legionella bacteria, lacking specific testing protocols and a flow diagram of the water system. The absence of a Maintenance Director contributed to the deficiency, which violated CMS and ASHRAE guidelines.
A facility failed to transmit MDS assessments to the CMS QIES ASAP System within the required 14-day timeframe for a resident. The discharge tracking records for a resident were not completed and transmitted as mandated by the RAI User's Manual. The RNAC confirmed the oversight during an interview, acknowledging the failure to ensure timely transmission of MDS assessments.
The facility failed to maintain documentation for required emergency lighting tests, lacking records for both the annual 90-minute test and monthly 30-second testing. This deficiency affects the entire facility, as confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain its fire alarm system according to NFPA standards, lacking documentation for a two-year smoke detector sensitivity test and a semiannual visual inspection. This was confirmed by the Facility Administrator and Maintenance Director, affecting the entire facility.
The facility failed to maintain its automatic sprinkler system, lacking documentation for the semiannual inspection and having sprinkler heads covered in dust and lint. These deficiencies were confirmed by the Facility Administrator and Director of Maintenance.
The facility did not conduct the required monthly inspections of portable fire extinguishers, as observed on a specific date. This deficiency was confirmed in an interview with the Facility Administrator and Maintenance Director.
The facility failed to conduct and document eleven out of twelve required fire drills, as per NFPA 101 standards. Documentation was missing for the first and second shifts of the first quarter and all shifts for the second, third, and fourth quarters. Interviews with the Facility Administrator and Maintenance Director confirmed the lack of documentation for the previous twelve months.
The facility failed to maintain hazardous area enclosures as required by NFPA 101 standards. A penetration was found in the ceiling of the Janitor's closet in the Memory Care Unit, affecting one of eight smoke compartments. This deficiency was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to properly install and maintain kitchen equipment and hoods, affecting one of eight smoke compartments. A gas-fired oven was not tethered to prevent movement from the ventilation hood and gas connection. Additionally, the facility missed required semi-annual hood cleanings, fire suppression system inspections, and did not document monthly visual inspections. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility failed to ensure that corridor doors properly latched, affecting three smoke compartments. Observations revealed that doors to Patient Laundry, room 507, and Soiled Utility did not latch, with the latter being obstructed by tape on the striker plate. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain and inspect its emergency generator system, lacking documentation for required tests and inspections, including weekly checks and a 4-hour load test within the last three years. This deficiency affects the entire facility, as confirmed by the Facility Administrator and Maintenance Director.
Riverside Health and Rehab Center was found deficient in its Emergency Preparedness Plan for not including updated and accurate contact information for residents and their physicians. This was confirmed by the Facility Administrator and Maintenance Director during a survey, highlighting a failure to comply with 42 CFR 483.73 requirements.
The facility failed to maintain documentation of staff training and testing for its Emergency Preparedness (EP) Training Program. An interview and documentation review revealed the absence of records for an annual tabletop exercise, and the deficiency was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain battery-operated carbon monoxide alarms as required by the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act. Observations revealed that the facility did not perform the annual battery replacement, testing, and cleaning of the alarms, and lacked documentation of Carbon Monoxide Evacuation and Alarm protocols. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility did not meet the required staffing levels for nurse aides during a daylight shift. On a specific day, the facility was required to provide one nurse aide per 10 residents but failed to do so, providing only 64.00 hours of coverage instead of the required 73.60 hours. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to investigate incidents of possible neglect and abuse for two residents. One resident rolled out of bed during care, and another alleged neglect after sitting in urine for hours. The DON did not complete required investigations or reports for these incidents.
A resident with rheumatoid arthritis did not receive prescribed Hydroxychloroquine for several days due to unavailability, despite the order being sent to the pharmacy and the Nursing Supervisor being informed. The ADON confirmed this significant medication error.
Failure to Ensure Timely Physician Documentation at Each Visit
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a physician wrote, signed, and dated progress notes at each required visit for a resident. Clinical record review showed that the resident, who was admitted for a seven-day respite stay with diagnoses including C. difficile, diabetes, and high blood pressure, was seen by a wound doctor who provided specific wound care orders. However, the wound note was entered as a late entry several days after the visit, and the corresponding physician orders were also entered on the same later date. Interviews with staff, including the Director of Nursing, confirmed that the physician did not timely document progress notes at each visit as required. The resident was discharged on the same day the late entry and orders were recorded. This failure to ensure timely physician documentation was found for one of two residents reviewed during the survey.
Failure to Include Dialysis Care in Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans that addressed dialysis care and necessary interventions for three residents who required dialysis services. Clinical record reviews showed that each of these residents was admitted with diagnoses of chronic kidney disease or end stage renal disease, both requiring regular dialysis treatments as ordered by their physicians. Despite these documented needs and orders for dialysis three times a week, the baseline care plans completed within 48 hours of admission did not include dialysis care or related interventions for these residents. Facility policy requires that a baseline care plan be developed within 48 hours of admission to address the resident's immediate needs. However, the baseline care plans for the affected residents did not reflect their dialysis requirements, as confirmed by review of the care plans and by staff interviews, including with the Director of Nursing. This omission resulted in the residents' immediate care needs not being accurately addressed in their initial care planning.
Failure to Maintain Consistent Dialysis Communication and Care Planning
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for three residents who required such services. Review of facility policy indicated that both pre- and post-dialysis processes require documentation and communication between the facility and the dialysis provider. However, for three residents with chronic kidney disease or end stage renal disease, multiple dialysis communication forms were found to be incomplete or missing information from either the dialysis center or the facility. Additionally, two of these residents were not care planned for dialysis services as required, despite having physician orders for regular dialysis treatments. Clinical records showed that the affected residents had significant medical histories, including severe kidney disease, hypertension, heart failure, diabetes, and dementia. The documentation lapses included missing or incomplete dialysis communication forms on several dates for each resident, and in some cases, the absence of a care plan addressing dialysis needs. The DON confirmed that the facility did not ensure consistent dialysis communication for these residents, as required by facility policy and state regulations.
Failure to Maintain Operable Dish Machine in Main Kitchen
Penalty
Summary
The facility failed to ensure that the dish machine in the Main Kitchen was in proper working order. Observations revealed that all residents received their meals in Styrofoam containers and cups, and the drainage sink of the dishwasher contained standing water. Staff interviews confirmed that the dishwasher had been inoperable since the morning of July 5, and dietary employees had been washing dishes by hand over the weekend. The Dietary Manager was not aware of the issue until July 7, at which point staff were directed to use disposable containers. It was also confirmed that the sink portion of the dish machine was not draining and a loose, non-operational piece was found under the sink. The Nursing Home Administrator was initially unaware of the ongoing issue, despite the dish machine having been recently repaired, and later confirmed the failure to maintain the dish machine in proper working order.
Failure to Fully Investigate Resident Injuries and Possible Neglect
Penalty
Summary
The facility failed to fully investigate injuries sustained by three residents, as required by its policy on abuse, neglect, and injuries of unknown origin. For one resident with severe cognitive impairment and a history of falls, documentation showed the resident fell from a wheelchair after abruptly slamming his feet down and grabbing a hallway railing, resulting in a forehead injury. Although staff documented the incident and assessed the injury, the investigation did not address all aspects of the event as required by policy. Another resident, with diagnoses including debility and a history of falls, slid out of a wheelchair while being assisted by a CNA. The incident was attributed to a towel on the wheelchair seat, but the facility did not have a current physician's order for the resident's transfer status, and the investigation into the incident was incomplete. Documentation indicated that the resident was not assessed for chair/bed-to-chair transfers due to medical or safety concerns, and there was a lack of follow-up on transfer orders. A third resident, also with severe cognitive impairment, was found to have a skin tear on the right arm with no documentation of when or how the injury occurred. The facility was unable to provide a complete investigation into the injury of unknown origin, offering only an incident report without details on the circumstances, staff involved, or employee statements. The Director of Nursing confirmed that the facility did not fully investigate these injuries, resulting in a failure to respond appropriately to possible neglect and injuries of unknown origin.
Failure to Provide Timely ADL Assistance to Multiple Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three out of five residents reviewed. One resident with a history of diabetes, muscle wasting, and bilateral leg amputations, and a BIMS score of 00, reported that aides did not help her and that she required a mechanical lift for transfers. She stated she often waited 1-2 hours for assistance, including after episodes of incontinence. Another resident with diabetes, peripheral vascular disease, and an above-the-knee amputation, and a BIMS score of 12, reported that call lights were not answered in a timely manner and that she had to wait 2-3 hours in a soiled brief before receiving incontinence care. A third resident, diagnosed with COPD, osteomyelitis, and muscle weakness, and a BIMS score of 14, stated that there were never enough staff and that she was left in soiled clothing for five hours despite repeatedly asking for help. The Director of Nursing confirmed that the facility failed to provide adequate ADL assistance to these residents.
Failure to Provide Adequate Supervision and Prevent Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents, as evidenced by a review of facility policies, clinical records, and staff interviews. For one resident with severe cognitive impairment, atrial fibrillation, and dementia, the care plan required the use of leg rests and other safety features when being transported in a wheelchair. However, staff did not utilize the leg rests while pushing the resident, resulting in the resident abruptly slamming his feet down, grabbing the wall railing, and falling forward to the floor, sustaining a small injury to the forehead. The root cause was identified as poor safety awareness related to dementia and the failure of staff to use the required leg rests during transport. Another resident, who had diagnoses including debility, syncope, and a history of falls, was not properly assessed for transfer needs. The resident's baseline care plan did not specify the requirement for a mechanical lift for transfers, despite a physician's order indicating its necessity. After the order was discontinued, no further orders clarified the resident's transfer status. Subsequently, a CNA attempted to assist the resident into a wheelchair without a mechanical lift, and the resident slid out of the wheelchair onto the floor, with a towel in the seat contributing to the slide. The root cause was identified as the failure of staff to use a mechanical lift as required. Interviews with facility leadership confirmed that in both cases, staff did not follow established protocols and care plans designed to prevent falls. The incidents were attributed to staff not utilizing required safety equipment and not adhering to transfer procedures, resulting in falls and minor injuries to the residents involved.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative of a change in condition for one of four residents reviewed. According to the facility's policy, the physician, resident, and family or responsible party are to be notified when an accident or incident involving a resident occurs. In this case, a resident with diagnoses of atrial fibrillation and dementia, and documented severe cognitive impairment, experienced a fall from his wheelchair. The incident report and clinical notes confirmed that the resident sustained a small injury to his forehead as a result of the fall. Despite the policy requirements, the resident's representative was not notified of the incident at the time it occurred. Documentation showed that the resident's wife only became aware of the fall after noticing a bruise on the resident's face during a visit to the facility, and was formally notified of the incident two days after it happened. The Nursing Home Administrator confirmed during an interview that the facility did not notify the resident representative of the change in condition as required.
Failure to Implement Physician-Ordered MRI Scan
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician-ordered follow-up MRI scan for a resident with a history of glioblastoma removal and traumatic brain injury. The resident, who exhibited behavioral changes and required constant monitoring, was admitted to the memory care unit and had recently returned from the hospital with an order for an MRI. Documentation showed that the MRI was scheduled, the need for an escort was noted, and the necessary pre-procedure medication (Ativan) was ordered. The resident's wife provided the relevant paperwork to an LPN, and the appointment was entered into the facility's appointment book. However, the scheduled MRI appointment was subsequently crossed out in the appointment book without explanation, and the procedure was not completed as ordered. Interviews with staff revealed that the appointment was canceled by the previous DON, but no reason was documented. The nursing home administrator confirmed that the facility did not follow through with the physician's order for the MRI scan for this resident.
Failure to Notify Physicians of Blood Sugar Irregularities
Penalty
Summary
The facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, resulting in immediate jeopardy for 14 of 22 residents. The facility's diabetic protocol and hypoglycemia policy required staff to notify physicians of significant blood glucose level changes and to assess residents for signs of hypoglycemia. However, the facility did not have procedures in place for managing hyperglycemia, which contributed to the deficiency. Several residents with diabetes had blood sugar levels that were either too high or too low, but there was no documentation of physician notification or follow-up actions. For instance, one resident had a blood sugar level of 509, but the LPN did not receive a response from the Registered Nurse Supervisor or the provider, and no additional interventions were completed. Another resident was admitted to the hospital with a diagnosis of hypoglycemia after experiencing a fall and a change in mental status, but there was no record of a blood sugar check at the time of the incident. The facility's failure to document and follow up on out-of-range blood sugar levels was consistent across multiple residents. In several cases, blood sugar results were documented as high, but there was no note showing notification or follow-up. Interviews with staff revealed that while they were aware of the procedures for managing out-of-range blood sugars, there were lapses in documentation and communication with the physician, leading to the deficiency.
Plan Of Correction
Resident R 150 was assessed for s/s hyperglycemia by the Assistant Director of Nursing (ADON) and none were noted. The blood sugar of 509 was reported to the physician by the RN supervisor and there were no new orders. Residents R 150, R195, R8, R6, R 57, R56, R79, R32, R44, R65, R22, R38, R39, and R59's blood sugars from the previous 24 hours (1/8/2025-1/9/2025) was completed to ensure no blood sugars out of range did not have physician notification. Residents R 150, R195, R8, R6, R 57, R56, R79, R32, R44, R65, R22, R38, R39, and R59's care plans were reviewed to ensure care plans reflected diabetes and had approaches for hypo and hyperglycemia management on 1/8/2025 by the Registered Nurse Assessment Coordinator (RNAC)/designee. Current residents and new admissions and readmissions with diabetes have the potential to be affected. Blood sugars of current residents with diabetes were reviewed on 1/8/2025 by the ADON to determine if any blood sugars were out of range and none were noted. Current residents with diabetes had their care plans reviewed by the RNAC/designee to ensure care plans reflected diabetes and had approaches for hypo and hyperglycemia management. A review of current residents with diabetes who require sliding scales will be conducted by the DON/designee to ensure sliding scales have physician ordered parameters appropriate to the resident. To prevent recurrence, licensed nursing staff was educated by the Director of Nursing/ designee on the Diabetic Protocol, the Hypoglycemia policy, and the Change of Condition policy to include notification of physician of blood sugars out of range. Newly hired licensed nursing staff will receive the education in orientation by the Director of Nursing/designee. Licensed nursing staff will receive directed in servicing on F 684 by Affinity Health Services on 1/27/2025. To monitor and maintain compliance, the DON/ designee has reviewed blood sugars daily x 1 week and will continue to review blood sugars daily x 1 more week, then 3x a week for 2 weeks, then weekly x 2 weeks to ensure physician notification is made for out of range blood sugars. To monitor and maintain compliance, new admissions/readmissions have been reviewed by the DON/designee 5x a week for 1 week and will continue 5x a week for 1 more week, then 3x a week for 2 weeks then weekly x 2 weeks to ensure care plans implemented for diabetes management. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.
Removal Plan
- Resident R150 was assessed by the Assistant Director of Nursing. Resident had no signs or symptoms of hyperglycemia.
- RNS Employee E2 spoke with the physician and reported the blood sugar of 509. The physician did not give any further orders.
- Education was initiated with facility RNs and LPNs on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition, and notifications to the physician of blood sugars out of range.
- Residents R150, R195, R8, R6, R57, R56, R79, R32, R44, R65, R22, R38, R39, and R59's blood sugars were reviewed to ensure none were out of range without physician notification.
- An ad hoc QAPI committee meeting was held, and the medical director was made aware of the findings.
- The RN assessment coordinator is reviewing the care plans for residents R150, R195, R8, R6, R57, R56, R79, R32, R44, R65, R22, R38, R39, and R59 to ensure the care plan reflects diabetes and there are approaches for diabetic emergency management.
- Current residents with diabetes were reviewed by the ADON to determine if blood sugars were out of range and none were noted out of range.
- Current residents with diabetes are being reviewed by the RN assessment coordinator to ensure the care plan reflects diabetes and there are approaches for diabetic emergency management.
- Root cause analysis completed by the center QAPI committee and determined failure to follow the Resident Change in Condition policy led to the allegation.
- To prevent recurrence, the Director of Nursing initiated education with facility RNs and LPNs including agency staff on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition and notification of the physician of blood sugars out of range. RNs and LPNs that were not on duty received education via phone and will receive in person education on their next scheduled shift.
- Newly hired RNs and LPNs will be educated on the Resident Change of Condition policy, the Diabetic Protocol, and the Hypoglycemia policy in orientation by the Director of Nursing/ designee.
- To monitor and maintain compliance, the Director of Nursing/ designee will review blood sugars to determine if any blood sugars were out of range and notifications made. If notification not documented, the physician will be contacted at the time of discovery and notified, and new orders implemented as needed.
- To monitor and maintain compliance, new admissions/ readmissions with diabetes will be reviewed by the DON/ designee to ensure a care plan is implemented for diabetes including approaches for diabetic emergency management.
- Results of the audits will be forwarded to the center QAPI committee for review and recommendations.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed within the required time frame for six out of 24 residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following a resident's admission. However, several residents had their MDS assessments completed beyond this timeframe, with some not completed at all by the time of the survey. Specifically, Resident R67, R147, R148, R153, R248, and R249 were affected, with completion dates ranging from January 5, 2025, to January 13, 2025, or not completed at all by January 13, 2025. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), Employee E9, who acknowledged the failure to complete the assessments timely.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under state and federal laws. A comprehensive Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required next annual MDS assessment or admission MDS assessment for the in-house residents. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting comprehensive assessments by the Regional Clinical Reimbursement Specialist or a designee. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents' annual and admission MDS assessments to ensure compliance with F636 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for three of eight residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD). However, for Resident R44, the ARD was 12/5/24, and the MDS was completed on 1/7/25. For Resident R52, the ARD was 12/18/24, and the MDS was not completed as of 1/13/25. Similarly, Resident R76 had an ARD of 12/5/24, with the MDS completed on 1/7/25. During an interview, the Registered Nurse Assessment Coordinator (RNAC) confirmed the facility's failure to complete the MDS assessments within the required timeframe for these residents.
Plan Of Correction
A quarterly Minimum Data Set (MDS) assessment was completed for all residents who were identified. The completion dates for the assessments cannot be modified. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required next quarterly MDS assessment for the in-house residents. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting quarterly assessments by the Regional Clinical Reimbursement Specialist or a designee. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents' quarterly MDS assessments to ensure compliance with F638 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Failure to Update Care Plans for Hospice and Oxygen Therapy
Penalty
Summary
The facility failed to update the care plans for two residents, which did not accurately reflect their current medical needs. Resident R5, who was diagnosed with Alzheimer's disease, anemia, and chronic kidney disease, began receiving hospice services as indicated by a physician order dated 6/11/24. However, the care plan for Resident R5, reviewed on 1/9/25, did not include any goals or interventions related to the hospice care services that the resident was receiving. Similarly, Resident R195, diagnosed with chronic obstructive pulmonary disease, respiratory failure with hypoxia, and lung cancer, was ordered to receive continuous oxygen therapy as per a physician order dated 12/22/24. An observation on 1/8/25 confirmed that Resident R195 was using a nasal cannula for oxygen therapy, yet the care plan reviewed on the same day failed to include any goals or interventions related to the oxygen therapy. The Director of Nursing confirmed the oversight in updating the care plans for these residents.
Plan Of Correction
Resident 5's care plan will be reviewed by the DON/ designee and updated to reflect goals and interventions related to hospice services. Resident 195's care plan will be reviewed by the DON/ designee and updated to reflect goals and interventions related to oxygen therapy. Current residents who receive hospice services and/or require oxygen therapy have the potential to be affected. A comprehensive audit will be conducted by the DON/ designee to ensure hospice services and/or oxygen therapy is reflected in the care plan. Corrections will be made as needed. To prevent recurrence, the IDT will be educated on the Comprehensive Care Plan policy by the NHA/ designee. To maintain and monitor compliance, residents with new orders for hospice services or oxygen therapy will be audited by the DON/ designee to ensure care plans have been revised weekly x 4 weeks and monthly x 2 months. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.
Failure to Document and Notify Hypo/Hyperglycemic Events
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to address previously cited deficiencies, specifically concerning the documentation and notification of hypo/hyperglycemic events. The review of the facility's policy and plan of correction from a previous survey indicated that the facility had developed a plan to ensure compliance with nursing home regulations. However, the current survey identified repeated deficiencies related to the documentation of blood sugar levels and timely notification to the medical director. Multiple residents were affected by the facility's failure to document and notify medical personnel of blood sugar levels outside of ordered parameters. For instance, one resident was sent to the hospital for a change in condition without a blood sugar reading being obtained as per protocol. Another resident had a blood sugar result of 59, but the note was placed 48 hours later. Several other residents had high blood sugar results with no documentation or notification to the medical director, indicating a systemic issue in following the established protocol. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to maintain an effective Quality Assurance Committee to address these concerns. The deficiencies have the potential to affect 26 of the 84 residents, highlighting a significant lapse in the facility's management and oversight of critical health indicators.
Plan Of Correction
The NHA/DON will conduct a root cause analysis for F 684 from the 1.13.25 survey. Those results will present to the facility QAPI for review and will provide guidance to the plan of correction. To prevent recurrence, the NHA/designee will implement a plan of correction including correction of the practice for residents identified in the citation F 684, identification and correction as needed of other residents who have the potential to be affected, system correction including education on the diabetic protocol, the hypoglycemia policy, and the change in condition policy including hyperglycemia is a change of condition to the licensed nurses. Ongoing monitoring of blood sugar results and care plans for diabetic residents to maintain compliance will be conducted by the DON/designee. The facility's QAPI members will be educated on the QAPI policy by the NHA/designee. Weekly reviews with the QAPI team of the plan of correction audits for the citations from the 1.13.25 survey x 5 weeks and monthly for 2 months and recommendations will be made as needed if noncompliance identified.
Failure to Develop Baseline Care Plans for Diabetic Residents
Penalty
Summary
The facility failed to develop baseline care plans that included diabetes care and necessary interventions for four residents diagnosed with diabetes mellitus. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission to address their immediate needs. However, the review of clinical records revealed that the baseline care plans for Residents R22, R32, R150, and R195 did not include diabetes care, despite their diagnosis. This omission was confirmed during an interview with the Director of Nursing and Assistant Director of Nursing. Resident R22 was admitted with a diagnosis of diabetes mellitus, but their baseline care plan, completed on January 11, 2025, did not address diabetes care. Similarly, Resident R32's care plan, completed on November 9, 2024, and Resident R150's care plan, completed on November 30, 2024, also lacked diabetes care planning. Resident R195 was not care planned within 48 hours of admission, and their care plan, completed on September 2, 2024, did not include diabetes care. These findings indicate a failure to provide effective and person-centered care for residents with diabetes, as required by the facility's policy and state regulations.
Plan Of Correction
Residents 22, 32, 44, 150, and 195 have been in the center greater than 48 hours. Their care plans were reviewed and care plans updated to reflect diabetes by the RNAC/designee. New admissions and readmissions have the potential to be affected. A review of residents admitted from 1/13/2025-1/17/2025 was conducted by the DON/designee to ensure baseline care plans included diabetes diagnosis. Corrections will be made as needed. To prevent recurrence, licensed nursing staff will be educated on the Interim Baseline Care Plan policy by the DON/designee. To monitor and maintain compliance, new admission and readmissions with diabetes will be audited by the DON/designee weekly x 4 weeks and monthly x 2 months to ensure baseline care plans include diabetes as appropriate. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for five out of fourteen residents, as required by the Resident Assessment Instrument (RAI) User's Manual and the facility's own Comprehensive Care Planning Policy. The RAI User's Manual mandates that for each triggered Care Area, a decision must be made within seven days regarding whether a new care plan, revision, or continuation is necessary. However, for residents R22, R32, R44, R150, and R195, the Section V Care Area Assessment (CAA) Summary, Question V0200, was not completed, indicating a lack of proper assessment and care planning. Each of these residents had significant medical conditions, including diabetes mellitus, chronic kidney disease, end-stage renal disease, heart failure, dementia, and lung cancer. Despite these diagnoses, their care plans dated January 9, 2025, did not include goals and interventions related to diabetes mellitus, a critical aspect of their care needs. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to develop and implement comprehensive care plans to meet the residents' needs, as required by 28 Pa. Code 211.11(d).
Plan Of Correction
Residents 22, 32, 44, 150, and 195's care plans were reviewed and care plans were updated to reflect diabetes by the RNAC/ designee. Current residents with diabetes have the potential to be affected. A comprehensive audit of current residents with diabetes was completed by the RNAC/ designee to ensure diabetes is reflected in the care plan. Corrections were made as needed. To prevent recurrence, the IDT will be educated on the Comprehensive Care Plan policy by the NHA/ designee. To maintain and monitor compliance, the DON/ designee will audit 5 residents with a diabetes diagnosis weekly x 4 weeks and monthly x 2 months to ensure diabetes is reflected in the care plan. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.
Failure to Implement Comprehensive Water Management Program for Legionella Control
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program specifically for water management to monitor and control the potential development and spread of Legionella bacteria. This deficiency was identified through a review of the facility's policy, documentation, and staff interviews. The facility's Legionella Assessment and Prevention Program, dated January 13, 2025, indicated the use of water management practices to reduce the risk of Legionella growth. However, the facility did not implement these practices effectively for ten out of twelve months, from April 2024 through January 2025. The facility's water management information lacked specific testing protocols, acceptable ranges for control measures, and a description of the water system using a flow diagram. The facility also failed to maintain a log for Point of Use Disinfectant to measure and record chlorine concentration levels in the water, which are critical for controlling Legionella. During an interview, the Nursing Home Administrator confirmed the absence of a Maintenance Director and acknowledged the facility's failure to maintain a comprehensive water management program. This deficiency was in violation of the Department of Health and Human Services, CMS memo requirements, and ASHRAE guidance, which emphasize the need for a water management plan to prevent Legionella outbreaks in healthcare facilities.
Plan Of Correction
Annual Legionella testing was completed in the facility on March 25, 2024, and no legionella species were detected. To prevent recurrence, the NHA will be educated on the Legionella Assessment and Prevention Program by the RVPO/designee. To prevent recurrence, the NHA will assign persons responsible to complete the required Legionella assessment. A text and flow diagram will be formulated to describe the facility's water system. A risk assessment with control methods including physical controls, temperature management, and disinfection level control if a cooling tower or evaporative condenser is present, visual inspection/environmental testing for pathogens, and corrective actions will be completed by the assigned persons. After the assessment is completed, the assessment team will develop a plan for any areas identified that require a plan. To maintain and monitor compliance, annual legionella testing will be conducted in March 2025. Additional risk assessment will be completed if new equipment meeting assessment criteria has been placed or replaced, local authorities and/or utility providers announce a boil water order, there is loss of service, or there is a service main break immediately adjacent to the center.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for one of four residents. Specifically, the deficiency was identified for Resident R83, whose discharge tracking records were not completed and transmitted as required. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated October 2023, mandates that discharge tracking records must be completed and transmitted within 14 days of the Event Date. Upon review of Resident R83's records, it was found that the discharge date was recorded as 11/25/24, but there was no Discharge MDS completed. This oversight was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), Employee E9, who acknowledged the failure to ensure timely transmission of MDS assessments for Resident R83. This lapse in protocol highlights a specific instance where the facility did not adhere to the required timelines for data submission, as outlined by CMS guidelines.
Plan Of Correction
The completion dates for the discharge assessments cannot be modified. The facility's Registered Nurse Assessment Coordinator, or a designee, will audit the assessment reference dates of the required discharge MDS assessment for residents who have discharged in the last 30 days. She will ensure that the Interdisciplinary Team staff involved in the assessment process are provided with the audit information to assure compliance with subsequent completion dates. The members of the Interdisciplinary Team involved in the assessment process will be re-trained on the requirements and procedures for conducting discharge assessments by the Regional Clinical Reimbursement Specialist or a designee. The Regional Clinical Reimbursement Specialist, or a designee, will conduct audits of residents who have discharged to ensure compliance with F640 requirements related to completion timing twice weekly times two, weekly times two and monthly times two. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.
Emergency Lighting Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper documentation for emergency lighting tests, which is a requirement under NFPA 101. During a document review and interview conducted on December 30, 2024, it was found that the facility did not have records of the annual 90-minute test and the monthly 30-second testing for the emergency lights. This deficiency affects the entire facility, as confirmed by the Facility Administrator and Maintenance Director during the interview.
Plan Of Correction
The Maintenance Director/Maintenance staff will be educated on the NFPA regulation requiring emergency lighting to being tested monthly for 30 seconds and 90 minutes and annually for 90 minutes. NHA/Designee will audit the emergency lighting monthly testing monthly x 2 months. The Maintenance Director/Maintenance staff will be educated on the NFPA regulation requiring emergency lighting to being tested monthly for 30 seconds and 90 minutes and annually for 90 minutes. NHA/Designee will audit the emergency lighting monthly testing monthly x 2 months.
Fire Alarm System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system in compliance with NFPA 70 and NFPA 72 standards, as evidenced by a document review and interview conducted on December 30, 2024. The survey revealed two specific deficiencies: the absence of documentation verifying that a sensitivity test of smoke detectors had been performed within the previous two years, and the lack of a semiannual visual fire alarm inspection. These deficiencies were identified during a review of the facility's records at 8:40 a.m. and 8:45 a.m., respectively. An interview with the Facility Administrator and Maintenance Director at 1:30 p.m. on the same day confirmed that the facility could not provide the necessary documentation for both the semiannual fire alarm inspection and the two-year sensitivity test. This failure to maintain proper records and conduct required tests and inspections affected the entire facility, indicating a lapse in adherence to the established fire safety protocols.
Plan Of Correction
The sensitivity test of the smoke alarms is scheduled to be completed in April 2025. The semiannual visual fire alarm inspection was completed on October 31, 2024, and one is scheduled for April 2025. The Maintenance Director/Maintenance staff will be educated on the NFPA requirements of a 2-year smoke detector sensitivity test and the semiannual visual fire alarm inspection. The sensitivity test of the smoke alarms is scheduled to be completed in April 2025. The semiannual visual fire alarm inspection was completed on October 31, 2024, and one is scheduled for April 2025. The Maintenance Director/Maintenance staff will be educated on the NFPA requirements of a 2-year smoke detector sensitivity test and the semiannual visual fire alarm inspection.
Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain its automatic sprinkler system as required by NFPA 25, which led to deficiencies affecting the entire facility. During a document review on December 30, 2024, it was discovered that the facility did not have documentation for the semiannual inspection of the automatic sprinkler system. This lack of documentation was confirmed in an interview with the Facility Administrator and Director of Maintenance. The absence of these records indicates a failure to adhere to the necessary inspection and maintenance schedule for the sprinkler system. Additionally, observations made on the same day revealed physical deficiencies in the sprinkler system. Specifically, a sprinkler head behind the dryer room in the laundry was found to be covered in lint and dust, and another sprinkler head on the overhang at the main entrance was covered in dust. These observations were also confirmed in the interview with the Facility Administrator and Director of Maintenance. The accumulation of dust and lint on the sprinkler heads suggests a lack of regular cleaning and maintenance, which is essential for the proper functioning of the fire protection system.
Plan Of Correction
The NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA requirements of the semiannual automatic sprinkler system inspection. The semiannual sprinkler system was conducted on February 26, May 21, August 26, and November 18, 2024. Inspections are on file at the facility. The NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA requirements of the semiannual automatic sprinkler system inspection. The semiannual sprinkler system was conducted on February 26, May 21, August 26, and November 18, 2024. Inspections are on file at the facility.
Failure to Maintain Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain portable fire extinguishers as required by NFPA 10, Standard for Portable Fire Extinguishers. On December 30, 2024, at 9:30 a.m., an observation revealed that the facility did not perform the necessary monthly inspections of the fire extinguishers throughout the entire facility. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director later that day at 1:30 p.m.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA requirements for portable fire extinguishers inspections. NHA/Designee will audit all the facility's fire extinguishers to ensure the monthly inspections are completed. NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA requirements for portable fire extinguishers inspections. NHA/Designee will audit all the facility's fire extinguishers to ensure the monthly inspections are completed.
Failure to Conduct and Document Required Fire Drills
Penalty
Summary
The facility failed to conduct the required fire drills as mandated by NFPA 101 standards, which necessitate fire drills to be held at least quarterly on each shift. The documentation review revealed that the facility did not have records for fire drills for the first shift and second shift of the first quarter, as well as for all three shifts during the second, third, and fourth quarters of the year. This indicates that eleven out of the twelve required fire drills were not documented, affecting the entire facility. An interview with the Facility Administrator and Maintenance Director confirmed the absence of documentation for the fire drills that were supposed to be conducted over the previous twelve months. This lack of documentation suggests that the facility did not adhere to the established routine of conducting fire drills at expected and unexpected times under varying conditions, as required by the NFPA 101 standards.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff/Designee on the fire drill policy. Fire drills will be conducted monthly by the Maintenance Director/Designee at varying times to ensure that each shift has a fire drill quarterly. NHA will audit the fire drills monthly x 3 months.
Deficiency in Hazardous Area Enclosure
Penalty
Summary
The facility failed to maintain hazardous area enclosures as required by NFPA 101 standards. During an observation on December 30, 2024, at 11:45 a.m., a penetration was found in the ceiling of the Janitor's closet located in the Memory Care Unit. This deficiency was confirmed through an interview with the Facility Administrator and the Maintenance Director later that day at 1:30 p.m. The issue affected one of the eight smoke compartments in the facility, indicating a lapse in maintaining the required fire barrier protection for hazardous areas.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA requirements for hazardous area - corridors. The penetration in the ceiling of the janitor's closet in the Memory Care Unit was fixed on 1/8/25. A visual inspection of all of the facility's janitor's closets will be completed to ensure no more penetrations are present.
Deficiencies in Kitchen Hood Maintenance and Equipment Installation
Penalty
Summary
The facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system in four instances, affecting one of eight smoke compartments. During an observation on December 30, 2024, a gas-fired oven on wheels in the main kitchen was found not to have an approved method to ensure it was returned to an approved design location after being moved for maintenance and cleaning. This was required by section 12.1.2.3 and 12.1.2.3.1 of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. The Facility Administrator and Maintenance Director confirmed that the gas-fired cooking appliance was not tethered to prevent it from being moved from the ventilation hood and gas connection. Additionally, the facility failed to maintain the kitchen hoods in three instances, affecting one of eight smoke compartments. Document review and observation revealed that the facility did not perform one of the two required semi-annual hood cleanings and one of the two required semi-annual fire suppression system inspections. Furthermore, the facility failed to document the required monthly fire suppression system visual inspections. These deficiencies were confirmed during an interview with the Facility Administrator and the Maintenance Director.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA 101 cooking facilities standard for ventilation control and fire protection. Maintenance staff will ensure the gas fired oven on wheels is tethered securely to the wall. NHA will audit the completion of the tethered oven to the wall. The hood cleaning is scheduled for February 2, 2025. The Maintenance Director/Designee will conduct monthly fire suppression system visual inspections. The NHA/Designee will audit the monthly inspections x3 monthly. The semi-annual fire suppression system inspections were performed on April 16, 2024, and October 8, 2024. The inspection reports are on file at the facility.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as observed during a survey on December 30, 2024. Specifically, three corridor doors in different smoke compartments did not latch properly, which is a requirement to resist the passage of smoke. The doors in question included the door to Patient Laundry in the 400 Hallway, the door to room 507, and the door to the Soiled Utility in the 800 hallway. The latter door's failure to latch was due to tape covering the striker plate, which impeded its proper function. These deficiencies were confirmed through an interview with the Facility Administrator and Maintenance Director on the same day. The inability of these doors to latch compromises the facility's ability to contain smoke in the event of a fire, which is a critical safety measure in long-term care settings. The report does not mention any corrective actions taken by the facility to address these issues at the time of the survey.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff NFPA requirements corridors - doors. Maintenance has repaired the Patient laundry door, room 507 and the Soiled Utility on the 800 hall. Maintenance staff will conduct a weekly audit of all corridor doors to make sure all doors latch properly.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and inspect its emergency generator system, as evidenced by the absence of documentation for several required tests and inspections. During a document review on December 30, 2024, it was found that the facility could not provide records of weekly visual inspections and battery checks for December 2024. Additionally, there was no documentation of a 4-hour load test being performed within the last three years, which is a requirement for ensuring the generator's reliability. An interview with the Facility Administrator and the Maintenance Director confirmed the lack of documentation for the emergency generator. This deficiency affects the entire facility, as the generator is a critical component of the essential electrical system, designed to provide power in emergencies. The failure to maintain proper records and conduct necessary tests indicates a lapse in the facility's adherence to NFPA standards, specifically NFPA 101, NFPA 110, and NFPA 111, which govern the maintenance and testing of essential electrical systems.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff on the weekly NFPA generator inspection requirements and the 3-year, 4-hour load testing. The 3 year, 4-hour load testing is scheduled on 1/23/2025. NHA/Designee will audit the weekly generator inspections monthly x 3 months. NHA/Designee will educate the Maintenance Director/Maintenance staff on the weekly NFPA generator inspection requirements and the 3-year, 4-hour load testing. The 3 year, 4-hour load testing is scheduled on 1/23/2025. NHA/Designee will audit the weekly generator inspections monthly x 3 months.
Deficiency in Emergency Preparedness Plan at Riverside Health and Rehab Center
Penalty
Summary
Riverside Health and Rehab Center was found to have deficiencies in its Emergency Preparedness (EP) Plan during a survey conducted on December 30, 2024. The facility failed to include updated and accurate names and contact information for residents and their physicians in the EP Plan. This deficiency was identified through an interview and documentation review conducted at 8:45 a.m. on the same day. The Facility Administrator and Maintenance Director confirmed during an interview at 1:30 p.m. that the EP Communication Plan lacked the necessary accurate contact information for residents and their physicians. This omission in the communication plan is a violation of the requirements set forth in 42 CFR 483.73, which mandates that such information be included and maintained in the facility's emergency preparedness communication plan.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Designee on the Emergency Preparedness Plan requirements regarding Names and Contact Information. The current resident roster and physicians names and contact information will be put in the EPP binder and be updated weekly by the Receptionist/Designee. NHA/Designee will audit the EPP names and contacts on weekly x 4 weeks.
Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
The facility was found to have deficiencies in its Emergency Preparedness (EP) Training Program. During a review of the facility's EP Plan, it was discovered that the facility failed to maintain documentation of staff training and testing. Specifically, the facility could not provide documentation for maintaining records of all emergency preparedness training and demonstrating staff knowledge of emergency procedures. On December 30, 2024, an interview and documentation review revealed that the facility did not have records of an annual tabletop exercise of the Emergency Preparedness program. This lack of documentation indicates that the facility did not comply with the requirement to maintain records of all emergency preparedness training activities. The deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director on the same day. They acknowledged the absence of the necessary documentation for the EP training and testing, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
Preparation and submission does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness set forth in the statement of deficiencies. The plan of correction is prepared and submitted solely because of the requirements under state and the federal laws. The NHA will be educated on the Emergency Preparedness Training Program annual tabletop exercise requirement. The facility will conduct a tabletop exercise of the Emergency Preparedness Program.
Failure to Maintain Carbon Monoxide Alarms
Penalty
Summary
The facility failed to maintain battery-operated carbon monoxide alarms in compliance with the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act. On December 30, 2024, observations revealed several deficiencies related to the carbon monoxide alarms. Specifically, the facility did not perform the required annual battery replacement for these alarms, which is a critical maintenance task to ensure their proper functioning. Additionally, the facility neglected to conduct the necessary testing and cleaning of the battery-operated carbon monoxide alarms. Furthermore, there was a lack of documentation regarding the Carbon Monoxide Evacuation and Alarm protocols, which are essential for ensuring the safety of residents and staff in the event of a carbon monoxide incident. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The Maintenance Director/Maintenance staff will be educated on the requirements of the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act. All carbon monoxide alarms will have their batteries replaced along with a log will be maintained to record the alarms' location and the date of the annual battery replacement. The facility will perform all the required testing and cleaning of the battery-operated alarms on a monthly basis. A log will be maintained at the facility. All current staff will be educated on the carbon monoxide evacuation and alarm protocols. Any new employees will be trained on the carbon monoxide evacuation and alarm protocols during their general orientation.
Staffing Deficiency on Daylight Shift
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the daylight shift on December 15, 2024. According to the staffing documents reviewed, the facility was required to provide one nurse aide per 10 residents, but on this particular day, the facility did not meet this requirement. The census for the day was 92 residents, necessitating 73.60 hours of nurse aide coverage, but only 64.00 hours were provided. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 16, 2024.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of the requirements under state and federal laws. The center recognizes the requirement of nursing assistants ratios of 1 to 10 on daylight, 1 to 11 on evening shifts and 1 to 15 on night shifts. The Director of Nursing/Designee will review documentation for the date 12/15/24 to ensure no adverse events occurred. To prevent recurrence, the scheduler and Director of Nursing will be re-educated by the administrator on the PA state requirements for nursing ratios and HPPD. The Administrator/Director of Nursing/Designee and scheduler will meet to review staffing ratios for the day as well as staffing projections through the week and weekends. The Director of Nursing is the backup for the scheduler. To monitor and maintain ongoing compliance, the Administrator/Designee will conduct weekly audits x 4 weeks to ensure nursing assistants ratios are met using the facility staffing tool. Findings of the audits will be reviewed at the facility's monthly QAPI meeting.
Failure to Investigate Allegations of Neglect and Abuse
Penalty
Summary
The facility failed to identify and investigate incidents of possible neglect and abuse for two residents. For Resident R1, the facility's Event Summary Report indicated that the resident had a fall while receiving care, rolling out of bed onto a fall mat on 2/21/24. Despite the Minimum Data Set (MDS) indicating that Resident R1 required assistance of two for bed mobility and transfers and was dependent for rolling left and right while in bed, the Director of Nursing (DON) did not complete an investigation or report the incident as neglect as required by the facility's policy. For Resident R2, a Concern Form dated 1/19/24 indicated that the resident alleged neglect, stating he had sat in his own urine for four hours on 1/18/24 and had the call bell on for two and a half hours. The form was filled out by the Social Worker, and the DON documented that she had spoken to Resident R2. However, the DON did not identify the incident as neglect and did not complete an investigation or report the incident as required. These actions are in violation of the facility's policy and state regulations.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered by the physician for one resident. Resident R3, who was admitted with diagnoses including syncope, muscle weakness, and rheumatoid arthritis, had a physician's order for Hydroxychloroquine to be administered twice daily. However, the Medication Administration Record (MAR) indicated that the medication was not given from 2/14/2024 through 2/19/2024. Progress notes revealed that the order had been sent to the pharmacy, but the medication was not available, and the Nursing Supervisor was informed of the issue. During an interview, the Assistant Director of Nursing confirmed that the facility failed to provide the medication as ordered, resulting in a significant medication error. This error was particularly critical given that the medication was for the resident's immunosuppressive disorder. The facility's policy on medication administration, last reviewed on 1/2/24, mandates that medications be administered as prescribed by the provider, which was not adhered to in this case.
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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