Riverstreet Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilkes-barre, Pennsylvania.
- Location
- 440 North River Street, Wilkes-barre, Pennsylvania 18702
- CMS Provider Number
- 395691
- Inspections on file
- 32
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Riverstreet Manor during CMS and state inspections, most recent first.
A resident with chronic pain syndrome filed a grievance after not receiving prescribed oxycodone upon admission. The grievance was not resolved within the facility's required five-day timeframe, and there was no documentation of timely evaluation, corrective action, or communication of a resolution before the resident was discharged. Interviews confirmed that no further action was taken to address the grievance.
A resident was administered multiple discontinued medications, including methimazole, simvastatin, and lisinopril, after staff used an outdated medication list during admission medication reconciliation. This error led to the resident receiving conflicting therapies and experiencing elevated potassium levels, as the facility did not follow its own policy for resolving medication discrepancies.
A resident with severe cognitive impairment and physical limitations was not provided the required two-person assistance for bed mobility, as outlined in their care plan. A nurse aide performed incontinence care alone, during which the resident fell from bed, striking their head and sustaining multiple injuries including subdural hematomas and a nasal fracture. Facility investigation confirmed the aide was aware of the two-person requirement but did not follow it, resulting in substantiated neglect and actual harm.
Surveyors found that both resident shower areas and the outdoor smoking area were not maintained in a clean and sanitary condition. Observations included inappropriate storage of items in bathing areas, buildup of residue and debris on surfaces, stained and soiled equipment, and extensive cigarette litter and soiled furniture in the smoking area. The Nursing Home Administrator confirmed that all areas are expected to be kept clean and sanitary.
Surveyors found that the facility did not follow its own smoking policy, as the policy was not properly posted, required safety equipment was missing in the smoking area, and several residents with chronic respiratory conditions were observed smoking unsupervised with personal smoking materials kept in their rooms. Staff confirmed that these practices did not align with the facility's written procedures.
Surveyors observed that food delivery carts on four hallways were not maintained in a clean and sanitary condition, with dried food, liquid residue, debris, and broken shelving found on the carts during meal service. These findings were reviewed with the Nursing Home Administrator.
Two residents with chronic pain conditions received as-needed narcotic pain medications without staff attempting or documenting required non-pharmacological interventions beforehand, as specified by physician orders and facility policy. In one case, pain medication was also given despite a pain score of zero, contrary to the order parameters. The facility was unable to provide documentation supporting the use of non-pharmacological interventions prior to medication administration.
Multiple residents reported that snacks were not routinely offered in the evenings, despite facility policy requiring snacks to be provided according to individual care plans and upon request. Residents described that they had to go to the nurses' station to receive snacks, as staff did not have time to deliver them, and some expressed dissatisfaction with the limited quantity provided. The NHA was aware of the issue but could not explain the inconsistency in snack provision.
A resident with chronic kidney disease and a sacral wound requiring enhanced barrier precautions did not receive proper infection control measures when staff used hospital gowns instead of designated reusable gowns. Staff were not adequately educated on correct PPE selection, and the facility lacked a system for laundering and maintaining reusable gowns, resulting in ineffective implementation of enhanced barrier precautions.
Two residents dependent on staff for ADLs did not consistently receive scheduled showers or timely incontinence care. One resident with Parkinson's Disease missed multiple scheduled showers without documented medical reasons, while another resident with paralytic syndrome and hydrocephalus experienced prolonged periods in soiled briefs and inconsistent incontinence checks, despite care plans requiring regular assistance. Documentation and staff interviews confirmed these lapses in care and record-keeping.
A nurse failed to follow professional standards and facility policy during medication administration, including not performing hand hygiene, not using gloves, using bare hands to handle medications, and preparing medications for multiple residents at once with inadequate labeling. The nurse also left a narcotic medication unattended and the medication cart unlocked, resulting in multiple breaches of infection control and medication safety protocols.
A resident with multiple chronic conditions experienced prolonged constipation and related complications after nursing staff failed to administer a physician-ordered bowel protocol. Despite clear orders for a stepwise regimen to address constipation, staff did not provide the prescribed interventions or document their effectiveness, and the DON confirmed the lapse.
A resident with a colostomy, end-stage renal failure, and dependence on dialysis did not receive appropriate colostomy care as required by facility policy and physician orders. The care plan lacked details on colostomy management, and the resident reported not having an appliance or bag in place for weeks, with the colostomy draining into an adult brief during transport to dialysis. Staff interviews referenced refusals of care, but no such refusals were documented.
A resident with PTSD, along with other significant diagnoses, did not have an individualized care plan that identified their trauma triggers or outlined specific interventions to minimize re-traumatization. The facility was unable to demonstrate that trauma-informed, culturally competent care was provided in accordance with professional standards.
A resident with polyneuropathy and CHF missed eight doses of Pregabalin after the physician failed to sign a new medication order in a timely manner. Despite repeated contacts by staff, the physician did not provide the required signature, resulting in a delay until a unit manager obtained the signed order in person. This led to interruptions in the resident's prescribed treatment.
A resident with multiple chronic conditions experienced untreated hemorrhoids and rectal bleeding after a physician ordered topical hydrocortisone cream, which was not administered as prescribed due to pharmacy delivery delays and lack of stock. The DON confirmed the medication was unavailable, resulting in unmet pharmaceutical needs.
Nursing staff did not label multi-dose insulin pens with the date of opening and continued to use one insulin pen past the manufacturer-recommended discard date. This was confirmed through observation and staff interviews, and was not in accordance with facility policy or professional standards.
The facility failed to maintain the electrical system on the first floor. An unsecured outlet receptacle in a resident's room exposed wiring, creating a safety hazard. This issue was confirmed during an exit interview with the facility's administration.
The facility failed to provide timely assistance to residents, impacting their quality of life. A resident with moderate cognitive impairment and another cognitively intact resident reported long wait times for assistance. Concerns about staffing and call bell response times were raised in Resident Council meetings, with residents experiencing delays ranging from 30 minutes to several hours. The NHA and DON acknowledged the issue but could not explain the delays.
The facility failed to involve residents and their representatives in the development and revision of comprehensive care plans, as required by policy. This deficiency was identified for several residents, who reported not being invited to participate in care planning meetings. Facility staff confirmed that care planning conferences were not occurring quarterly, and there was no documented evidence of resident participation.
The facility failed to maintain sanitary practices for food storage and service, increasing the risk of food-borne illness. In two resident pantries, microwaves were soiled, dustpans were dirty, and ice machines had mold-like substances on condensation hoses. These deficiencies were confirmed by the nursing home administrator.
A resident with a history of cerebral infarction and right side hemiparesis was moved to a new room without receiving the required written notice explaining the reason for the change. Although the resident verbally agreed to the move, there was no documentation of written notice provided to the resident or their representative, as confirmed by interviews with the resident and the social services director.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy between the resident's stated wishes and the POLST form. The resident, who was cognitively intact and had a history of cerebral infarction, expressed a desire not to receive CPR, contrary to the unsigned POLST form indicating otherwise. The facility did not provide evidence of periodic review of the resident's advance directive, and the DON confirmed the form did not reflect the resident's wishes.
A resident, requiring two staff for transfers, fell and sustained a minor injury when only one staff member was present. The facility failed to conduct a timely and thorough investigation to rule out neglect and did not ensure care-planned interventions were in place, leading to a deficiency.
A facility failed to follow physician orders for a resident's therapeutic device, specifically a neck positioning pillow, which was not used as prescribed. The resident, with significant medical conditions, was observed multiple times without the pillow, and staff confirmed the oversight. The facility could not provide documentation to show compliance with the orders.
A facility failed to follow physician orders for a resident's midline catheter management, resulting in unreported changes in catheter length. The resident, with a history of being a hard stick and pulling out IVs, required a new midline catheter. Additionally, the facility did not maintain an emergency kit at the bedside as ordered, confirmed by staff interviews and observations.
A resident with dementia and a fractured femur experienced pain without relief due to the facility's failure to implement pain management interventions. Despite the resident's reported pain during therapy sessions and multiple occasions, there was no documented evidence of pharmacological or non-pharmacological interventions being offered. The DON confirmed the facility's responsibility for pain management but could not provide evidence of interventions being provided.
A resident with major depressive disorder expressed a desire to die, but the facility failed to update the care plan or provide therapeutic social services. Despite emotional support from a nurse and physician notification, no follow-up or documentation of social services was conducted.
A resident in an LTC facility did not receive the correct dosage of Oxycodone as per physician orders, and the administration of the medication was not accurately recorded. The facility's staff failed to follow procedures for verifying medication dosage and administration, leading to discrepancies in the Controlled Drug Administration Record and the Medication Administration Record. This was confirmed by the DON and the Nursing Home Administrator.
A resident with dementia was prescribed Seroquel, an antipsychotic, without documented clinical necessity. Despite no signs of anxiety or disruptive behaviors, the medication was administered, and the DON confirmed the lack of documentation supporting its use.
A resident with multiple diagnoses, including cancer and heart disease, had a physician order for CPR in case of cardiac arrest. Despite this, when the resident was found unresponsive with no pulse, the facility staff failed to perform CPR as required by the advance directive. This deficiency was confirmed by the DON and Nursing Home Administrator.
The facility failed to maintain a safe environment on Station 2, where hallways were obstructed by large reclining/wheelchairs and high back chairs, impeding access to handrails needed for resident mobility. The Nursing Home Administrator acknowledged the need for clean and orderly resident care areas.
The facility failed to properly store and label medications on Station 1. Observations revealed a basin with 16 medication cards awaiting return to the pharmacy without proper documentation. An unlocked drawer contained unlabeled vials and medications prescribed for specific residents, not stored properly. An LPN confirmed the improper storage, citing delivery delays and theft concerns. The Nursing Home Administrator and DON acknowledged the issue.
An LPN, functioning as a unit secretary, documented treatments for three residents as completed before the scheduled shift time and without being scheduled to work as an LPN. This included premature documentation of safety alarm checks and dressing applications. The facility's staffing schedule did not support the LPN's involvement in nursing duties on that day, leading to inaccurate and incomplete medical records.
The facility did not post daily nurse staffing information as required. During an observation, the posted nursing hours were not visible, and a registered nurse supervisor was unaware of the requirement. The Assistant Director of Nursing confirmed the failure to comply with the relevant codes.
The facility failed to respond timely to residents' requests for assistance, as evidenced by six residents reporting extended wait times for staff help, leading to situations where residents soiled themselves. These delays occurred daily and across all shifts, particularly during the evening and night shifts.
The facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for two residents. One resident was observed with unsanitary oxygen equipment, and another resident was not consistently monitored for oxygen use and saturation levels. Staff were aware of the issues but did not ensure proper procedures were followed.
The facility failed to provide food that accommodates resident preferences, as observed in 26 meal trays and reported by nine residents. Complaints included a lack of variety, hard rice, tough meat, burnt eggs, and missing condiments like butter. Interviews and observations confirmed these issues, and the Nursing Home Administrator acknowledged the failure to consider individual food preferences.
Failure to Promptly Resolve Resident Grievance Regarding Pain Medication
Penalty
Summary
The facility failed to make prompt and adequate efforts to resolve a resident grievance in accordance with its own grievance policy. The policy required that grievances be resolved within five working days and that routine follow-up on outstanding concerns be completed through daily meetings. A resident, admitted with diagnoses including frequent falls and chronic pain syndrome, filed a grievance stating that prescribed oxycodone was not administered upon admission. The grievance was assigned to the DON and Unit Manager for follow-up, but documentation showed that the medication was not given until the following day, and the resident did not receive timely evaluation or resolution of the grievance. Further review revealed that social services met with the resident three days after the grievance was filed, but the grievance was closed with the notation that the resident was discharged prior to resolution. The resident remained in the facility for eight days after filing the grievance, exceeding the policy's five-day resolution timeframe. There was no documented evidence of attempts to resolve the grievance within the required timeframe, nor was there documentation of corrective action, findings, or communication of a resolution to the resident prior to discharge. Interviews with the NHA confirmed that no further action was taken to resolve the grievance.
Failure to Complete Accurate Medication Reconciliation Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not completing an accurate medication reconciliation upon admission. Despite having an updated medication list from the referring facility dated November 3, 2025, staff used an outdated list from May 22, 2024, during the reconciliation process. This resulted in the resident being prescribed and administered multiple medications that had previously been discontinued, including methimazole, simvastatin, and lisinopril. The resident had a medical history that included hypertension, hypothyroidism, and other chronic conditions. Upon admission, the resident was placed on methimazole for hyperthyroidism and lisinopril for hypertension, despite the current medication list indicating treatment with levothyroxine for hypothyroidism and losartan for blood pressure control. The referring facility's documentation confirmed that methimazole, simvastatin, and lisinopril had been discontinued due to an episode of hyperkalemia. Following the administration of these discontinued medications, the resident experienced another episode of hyperkalemia, as evidenced by elevated potassium levels in laboratory results. The facility's failure to follow its own medication reconciliation policy, which required resolving discrepancies and using the most current medication information, directly led to the resident receiving inappropriate medications and experiencing a significant medication error.
Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for bed mobility, was not provided care according to their established plan. The resident's care plan and facility policy required two staff members to assist with bed mobility due to the resident's physical limitations, including hemiplegia and a history of falls. Despite this, a nurse aide provided incontinence care alone, rolling the resident onto their side without assistance. During the care episode, the nurse aide turned away to retrieve a clean brief while maintaining only one hand on the resident. The resident continued to roll toward the edge of the bed, and the aide was unable to prevent the resident from falling. The resident fell from the bed, striking their head on an oxygen concentrator and sustaining a laceration, multiple subdural hematomas, and a closed nasal fracture. The incident was witnessed by another staff member who responded to the aide's call for help and found the resident on the floor with facial bleeding. Facility documentation and staff interviews confirmed that the nurse aide was aware of the requirement for two-person assistance but failed to follow the resident's care plan. The facility's internal investigation substantiated neglect due to the failure to provide care as planned, resulting in actual physical harm to the resident. The resident required hospital evaluation and treatment for the injuries sustained during the incident.
Failure to Maintain Clean and Sanitary Resident and Smoking Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment in both resident shower areas and the outdoor smoking area. In the Area 145 shower/bathroom, multiple items were inappropriately stored within resident bathing areas, including shower chair buckets, a mechanical lift sling, sneakers, and an open plastic bag of briefs inside the bathtub. The bathtub's waterspout had a thick layer of dried white residue, and the first shower stall's floor perimeter was coated with a black, sticky substance and visible soil. The stainless-steel soap dispenser was streaked and discolored, and the ceiling vent and air conditioning/heating unit were layered with lint and dust. The second shower stall's shower bed had a white powdery film and dried residue. In Area 158, similar black, sticky buildup was found on the floor perimeter, a large rust stain was visible beneath the handrails, and the ceiling vent had significant lint accumulation. The shower chair was stained, the wheelchair scale had visible buildup and liquid residue, and the mechanical lift showed dried deposits and staining. The bathtub contained wheelchair leg rests, and the floors had visible debris and adhesive-like residue. The outdoor smoking area near the laundry entrance was also found to be unclean, with extensive cigarette litter, ashes, and cigarette butts scattered across the concrete. The patio furniture, including three white plastic chairs and a table, was coated with black residue and cigarette debris. Four fabric chairs were worn, soiled, and had several burn holes. During an interview, the Nursing Home Administrator acknowledged that all facility areas are expected to be maintained in a clean and sanitary condition at all times.
Failure to Implement Smoking Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to implement its established smoking policy to ensure resident safety. Surveyors observed that the smoking policy was not posted in a conspicuous and legible manner in any resident area or common space, contrary to facility requirements. Additionally, the designated smoking area lacked required safety equipment, and residents were found to possess and use smoking materials independently, without staff supervision, and without adherence to the policy's storage and supervision requirements. Multiple residents, all identified as independent smokers with diagnoses such as COPD, emphysema, hypertension, and chronic respiratory failure, were observed smoking in the designated area without staff present. These residents had access to their own cigarettes and lighters, which they kept in their rooms or on their person, despite care plans and facility policy requiring these materials to be secured at the reception desk. Some residents also knew the door code to the smoking area and accessed it independently, further bypassing the intended supervision and control measures. Interviews with the DON and NHA confirmed that the facility's actual practices did not align with the written smoking policy. Smoking materials were not consistently secured by staff, and the smoking policy was only posted outside the smoking-area exit door, not in other required locations. The facility's failure to follow its own policy was evident in both staff and resident interviews, as well as direct observations by surveyors.
Unsanitary Food Delivery Carts Observed During Meal Service
Penalty
Summary
The facility failed to maintain food delivery equipment in a clean and sanitary condition, as observed during meal service on four separate hallways (Pine, Oak, Willow, and Spruce). Surveyors found that the stainless-steel food delivery carts in each hallway had significant accumulations of dried food, liquid residue, paper debris, and visible dirt on both exterior and interior surfaces. In one instance, a metal shelving unit inside a cart was broken, with detached metal brackets resting inside the cart. These conditions were directly observed by surveyors at various times during meal service. According to established standards by the USDA and FDA, all equipment and utensils used in food storage, preparation, and delivery must be kept clean and in good repair, requiring a two-step process of cleaning and sanitizing. The observations made indicate that these procedures were not followed, resulting in unsanitary conditions of the food delivery carts. The findings were reviewed with the Nursing Home Administrator during an interview on the same day.
Failure to Implement Individualized Pain Management and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to develop and implement individualized pain management programs consistent with professional standards of practice for two residents. Clinical record reviews showed that both residents, who had diagnoses including Parkinson's Disease, chronic pain, and osteoarthritis, had physician orders for as-needed narcotic pain medications that required non-pharmacological interventions to be attempted prior to administration. However, medication administration records revealed that staff administered these pain medications multiple times without first attempting or documenting any non-pharmacological interventions, as required by the physician orders and facility policy. Additionally, there was an instance where pain medication was administered to a resident despite a pain score of zero, which was outside the parameters of the physician's order. Interviews with the Director of Nursing confirmed that the facility could not provide documentation supporting the use of non-pharmacological interventions prior to medication administration for the residents in question. These findings indicate a failure to follow both facility policy and physician orders regarding pain management.
Failure to Consistently Provide Snacks According to Resident Preferences
Penalty
Summary
The facility failed to consistently provide snacks to residents in accordance with their needs, preferences, and requests, as required by facility policy. A review of the facility's snack policy indicated that snacks and beverages should be provided as identified in residents' care plans, with bedtime snacks available for all residents and additional snacks upon request. However, during a group interview, all seven residents present reported that snacks were not routinely offered in the evenings, and they expressed a desire to receive evening or bedtime snacks. Some residents noted that, previously, kitchen staff would offer snacks in the evening, but currently, the snack cart is delivered to the nurses' station, and nursing aides are responsible for distribution. Residents reported that aides often do not have time to deliver snacks, requiring residents to go to the nurses' station if they want a snack. Additionally, one resident expressed dissatisfaction with the limited quantity of snacks provided, stating that only one small snack was allowed, which was sometimes insufficient. The Nursing Home Administrator was interviewed and could not explain why residents were not consistently offered snacks as desired, though acknowledged awareness of the issue and affirmed that residents should be provided a snack at bedtime. These findings were reviewed with the Nursing Home Administrator, confirming that the facility was not adhering to its own policy regarding the provision of snacks and beverages to residents.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement enhanced barrier infection control procedures and ensure the proper use of personal protective equipment (PPE) for one resident with chronic kidney disease and peripheral vascular disease, who had a sacral wound requiring enhanced barrier precautions. Despite a physician's order for these precautions, staff were observed using hospital gowns instead of the designated reusable gowns intended for this purpose. The facility policy required the use of specific gowns and gloves during high-contact care activities, but this was not followed during care provided after the resident experienced a fall. Further investigation revealed that staff had not received adequate education regarding the correct selection and use of PPE, specifically the designated color of gowns for enhanced barrier precautions. The Director of Nursing confirmed that reusable gowns were to be used, and that the use of hospital gowns was not appropriate. Additionally, the facility lacked a system for laundering, maintaining, and storing the reusable gowns as required by CDC recommendations. These failures resulted in the ineffective implementation of enhanced barrier precautions for the resident.
Failure to Provide Consistent ADL and Incontinence Care
Penalty
Summary
The facility failed to consistently provide necessary care and services to residents dependent on staff for activities of daily living (ADLs), specifically in the areas of personal hygiene and incontinence care. One resident with Parkinson's Disease and muscle weakness, who was cognitively intact and required substantial assistance for bathing, reported that scheduled showers were frequently missed, sometimes for up to three weeks. Documentation confirmed multiple instances where showers were not provided or not documented as completed, with no supporting evidence of a medical reason for omission. The facility's records and staff interviews corroborated these inconsistencies, and the Nursing Home Administrator was unable to explain the lapses in care or documentation. Another resident with paralytic syndrome, hydrocephalus, and muscle weakness, who was always incontinent of urine and bowel, was care planned to receive regular toileting assistance and incontinence checks. However, the resident reported extended periods in soiled briefs, including an incident where requests for a change after dinner were not addressed until the following morning. Review of electronic care records showed gaps and inconsistencies in documentation of incontinence care, with missing entries and lack of evidence that the resident's individualized needs were met as outlined in the care plan. The Director of Nursing confirmed that the resident should have been on a two-hour check and change program, but the facility could not provide documentation to support that this was consistently implemented. These findings were based on clinical record reviews, resident and staff interviews, and facility documentation, demonstrating that the facility did not ensure residents dependent on staff for ADLs consistently received the necessary care and services to maintain personal hygiene and dignity.
Failure to Follow Medication Administration and Infection Control Standards
Penalty
Summary
Licensed nursing staff failed to adhere to professional standards and facility policy during medication administration for four residents. Observations revealed that the nurse did not perform hand hygiene between residents, wore elongated acrylic nails, and did not use gloves while preparing medications. The nurse used bare hands and nails during medication preparation, dropped pills onto the medication cart and then placed them into a medication cup without proper sanitation, and prepared medications for two residents in the same room simultaneously, labeling the cups only with bed numbers. This led to a situation where the wrong medication cup was handed to a resident, who questioned the contents, prompting the nurse to exchange the cups without verifying the resident's identity or medication details. Additionally, the nurse left a cup containing a narcotic medication unattended on top of the medication cart and left the cart unlocked while leaving the area on two occasions, contrary to facility policy. These actions were confirmed by the Director of Nursing as not meeting the facility's expectations for medication administration and infection control, as outlined in both state regulations and facility policy.
Failure to Follow Physician-Ordered Bowel Protocol
Penalty
Summary
Facility staff failed to follow physician orders for a prescribed bowel protocol for a resident with a history of congestive heart failure, chronic obstructive pulmonary disease, and Type 2 diabetes. The physician's orders specified a stepwise bowel regimen involving Milk of Magnesia, Dulcolax suppository, and Fleet Enema, to be administered if the resident did not have a bowel movement within specified timeframes, with documentation of effectiveness and notification of the physician if the protocol was ineffective. Despite these orders, the resident went four consecutive days without a bowel movement, and there was no documented evidence that the prescribed bowel protocol was administered during this period. The resident reported frequent constipation and described a recent episode of significant straining that resulted in hemorrhoids and rectal bleeding. Review of the Medication Administration Record confirmed that nursing staff did not implement the bowel protocol as ordered. The Director of Nursing acknowledged that staff failed to carry out the physician's orders. Additionally, the facility was unable to provide a written policy regarding bowel elimination management.
Failure to Provide Colostomy Care and Services per Professional Standards
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for one resident. The facility's policy required that residents needing colostomy services receive care that prevents skin exposure to fecal matter. The resident in question had a history of peritoneal abscess, end-stage renal failure, dependence on dialysis, and a colostomy. A physician's order was in place for the colostomy appliance to be changed every three days and as needed. However, the resident's care plan did not address the specific needs related to the colostomy, such as the type and size of the appliance or collection bag required for maintenance. The resident reported not having a colostomy appliance or bag in place for weeks and stated that requests for an appliance before dialysis were not fulfilled. Instead, the resident was sent to dialysis wearing only an adult brief, allowing the colostomy to drain directly into it. Interviews with facility staff indicated that the resident frequently refused colostomy care, but there was no documentation in the clinical record to support this claim. The deficiency was identified through a review of clinical records, facility policy, and interviews with the resident and staff.
Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted with diagnoses including major depressive disorder, anxiety, malignant neoplasm of the lung, and PTSD, did not have their PTSD triggers or specific interventions identified in their current care plan as of the review date. This omission meant that the resident's needs for minimizing triggers and preventing re-traumatization were not addressed according to professional standards of practice. An interview with the Nursing Home Administrator confirmed that the facility could not demonstrate the provision of culturally competent, trauma-informed care that accounted for the resident's experiences and preferences.
Delayed Physician Signature Causes Missed Medication Doses
Penalty
Summary
The facility failed to ensure that a physician signed medication orders in a timely manner, resulting in missed doses of a prescribed medication for one resident. The resident, who was admitted with diagnoses including polyneuropathy and congestive heart failure, was prescribed Pregabalin to manage neuropathic pain. The original prescription included 45 capsules with no authorized refills. When the medication supply ran out, staff contacted the physician's office multiple times to obtain a new signed order, as required for continued therapy. Despite assurances, the physician did not come to the facility to sign the order as expected. As a result of the delay in obtaining the physician's signature, the resident missed eight scheduled doses of Pregabalin over a three-day period. The delay persisted until a unit manager personally delivered the unsigned prescription to the physician's office and obtained the necessary signature. The facility's failure to secure timely physician authorization directly led to interruptions in the resident's prescribed medication regimen.
Failure to Provide Timely Pharmacy Services for Prescribed Medication
Penalty
Summary
A resident with a history of congestive heart failure, chronic obstructive pulmonary disease, and Type 2 diabetes reported ongoing constipation and developed hemorrhoids with rectal bleeding. The resident stated that staff repeatedly indicated they would provide treatment, such as suppositories or cream, but no intervention was provided, resulting in continued discomfort and burning. Nursing documentation confirmed the presence of hemorrhoids and rectal bleeding. A physician ordered topical hydrocortisone cream (Preparation H) to be applied twice daily for the resident's hemorrhoids. However, the medication was not administered as prescribed on multiple occasions due to a delay in pharmacy delivery, as the cream was not a stock item at the facility. The DON confirmed the medication was unavailable during this period, resulting in the resident not receiving timely pharmaceutical services as required.
Failure to Label and Discard Multi-Dose Insulin Pens per Manufacturer Guidelines
Penalty
Summary
Nursing staff failed to properly label and store multi-dose insulin pens in accordance with professional standards and manufacturer instructions. During an observation of a medication cart on the Pine Hall unit, one multi-dose insulin pen of Insulin Lispro and three multi-dose insulin pens of Insulin Glargine were found to be opened and in use without being labeled with the date they were initially opened. Additionally, one Insulin Glargine pen was labeled with an opening date of April 16, 2025, but was still available for use beyond the manufacturer-recommended discard date of 28 days after opening. Interviews with a registered nurse and the Nursing Home Administrator confirmed that the insulin pens were being used without proper labeling and that one pen was used past its recommended discard date. Facility policy requires multi-use medication vials and bottles to be labeled accordingly and for nursing staff to maintain proper medication storage, including labeling. These findings were in violation of both facility policy and state regulations regarding pharmacy and nursing services.
Electrical System Deficiency in Resident Room
Penalty
Summary
The facility failed to maintain the electrical system properly in one location, specifically affecting the first floor. During an observation on January 30, 2025, at 9:45 a.m., it was noted that in Station 1, Resident Room 19, an outlet receptacle was not secured into the wall. This created a gap that exposed the wiring inside the room, near bed 19W. This deficiency was confirmed during an exit interview with the Facility Administrator and Facility Representative #1 at 10:00 a.m. on the same day.
Plan Of Correction
- The outlet receptacle in Room 19 was secured into the wall. - Outlet receptacles in the facility are being checked to ensure they are secured into the wall. - NHA/Designee will re-inservice Maintenance Staff on ensuring outlet receptacles are secured to the wall, and current staff will also be in-serviced to ensure they are reporting any issues with same immediately. - Maintenance Director/Designee will complete an audit on random outlet receptacles weekly for 4 weeks and then monthly to ensure they are secured into the wall. - Results of the audits will be discussed at the monthly Quality Assurance Performance Improvement Meeting for review and/or recommendations.
Delayed Staff Response to Resident Needs
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, negatively impacting their quality of life. Resident 97, who has moderate cognitive impairment, reported waiting 20 minutes for ice water during breakfast. Similarly, Resident 159, who is cognitively intact, experienced a 20-minute wait for assistance, with staff attributing the delay to being busy. Concerns about staffing and call bell response times were consistently raised in Resident Council meetings from June to August 2024. Residents expressed dissatisfaction with the time it took for staff to respond to their needs, particularly during the evening and night shifts. During a group interview, several residents reported waiting times ranging from 30 minutes to several hours, with some residents feeling neglected and frustrated due to the lack of timely care. The Nursing Home Administrator and Director of Nursing acknowledged that all residents should be treated with dignity and respect but could not explain the delays in staff responses. The ongoing staffing issues and long wait times for care were highlighted as significant problems affecting the residents' quality of life, as documented in the clinical records and resident interviews.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and revised with the participation of residents and their representatives. This deficiency was identified for two residents out of 27 sampled and five out of seven residents during a resident council interview. The facility's policy requires that residents be informed of their right to participate in care planning and be provided advance notice of care planning conferences. However, the facility did not adhere to this policy, as evidenced by the lack of documentation showing resident participation or invitations to participate in care planning. Resident 62, who is cognitively intact with a BIMS score of 15, reported not participating in any care plan meetings and could not recall being invited to such meetings. Similarly, clinical record reviews for Residents 38, 49, 53, 79, 91, and 94 revealed no evidence of their participation or invitation to participate in the development of their person-centered care plans. During interviews, these residents confirmed they had not been invited to participate in care conference meetings. Interviews with facility staff, including the Social Services Director, Nursing Home Administrator (NHA), and Director of Nursing (DON), confirmed that care planning conferences were not occurring quarterly for each resident. The NHA and DON acknowledged the facility's responsibility to ensure resident participation in care planning but were unable to provide documented evidence of such participation for the affected residents. This lack of adherence to policy and failure to involve residents in their care planning process constitutes a deficiency in resident rights as per 28 Pa. Code 201.29(a).
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness in two resident pantries. Observations in Station 1 revealed that the interior of the microwave was soiled with dried-on food splatters, and the back interior was pitted and rust-colored. Additionally, a dustpan stored next to the counter was heavily soiled with dirt and debris. The ice machine's condensation hose was covered with a thick layer of a black mold-like substance, and it lacked an air gap, posing a risk of contamination. In Station 2, the freezer had food substance stains and debris scattered across the base, and a cabinet containing resident snacks had food debris on the shelving. The microwave was stained and discolored both inside and out. The ice machine's condensation hose was similarly covered with a black mold-like substance. These observations were confirmed by the nursing home administrator, who acknowledged that sanitary practices for food and ice storage should be maintained in the resident pantries.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident and their representative before a room change, as required by federal regulatory guidelines. The guidelines emphasize the importance of considering a resident's preferences and providing a written explanation for room changes initiated by facility staff. In this case, Resident 62, who was cognitively intact and had a medical history of cerebral infarction with right side hemiparesis, was moved from one room to another on August 28, 2024. Although the resident verbally agreed to the move, there was no documented evidence that a written notice, including the reason for the room change, was provided to the resident or their representative. Interviews conducted with Resident 62 and the social services director confirmed the lack of written notice. The resident reported being informed of the room change only a few hours before it occurred and did not receive any written explanation. The social services director acknowledged the absence of documentation regarding the provision of written notice to the resident and their responsible party. This oversight constitutes a violation of the resident's rights as outlined in the federal regulatory guidelines and state code.
Failure to Honor Resident's Advance Directives
Penalty
Summary
The facility failed to accurately identify and document a resident's wishes regarding future health care and advance directives. The clinical record review, resident interview, and staff interview revealed that the facility did not have documented evidence of the resident's advance directive, despite the resident being cognitively intact and having expressed her wishes. The resident, who was admitted with a diagnosis of cerebral infarction and right side hemiparesis, had a POLST form indicating a desire for CPR, but it was not signed by the resident or a surrogate as required. During an interview, the resident stated she did not want CPR and denied having a Living Will, contradicting the POLST form. The facility also failed to provide evidence of periodic review of the resident's advance directive to ensure her wishes were honored. The director of nursing confirmed that the POLST form was not signed by the resident and did not accurately reflect her wishes, indicating a failure to uphold the resident's rights as per the relevant Pennsylvania codes.
Failure to Investigate Resident Fall and Implement Care Plan
Penalty
Summary
The facility failed to timely and thoroughly investigate an incident involving a resident who sustained a fall with a minor injury. The resident, who was cognitively intact and required the assistance of two staff for bed mobility and transfers, was found on the floor with a small skin tear on her forehead. The incident occurred while a nurse aide was assisting the resident with a sit-to-stand lift, and only one staff member was present, contrary to the care plan that required two staff members for such transfers. The facility's investigation into the incident was inadequate. There was no documentation indicating that the facility determined whether the required two staff members were present during the transfer. Additionally, the facility did not obtain all necessary witness statements at the time of the incident, and the investigation did not thoroughly explore potential neglect or mistreatment as a cause of the fall. The facility's incident report and subsequent documentation failed to address these critical aspects, and the investigation was not conducted in a timely manner. The director of nursing later confirmed that the facility could not provide documented evidence of a full investigation to rule out potential neglect. The facility did not identify that planned interventions were not in place to ensure the resident's safety and prevent the fall. This lack of thorough investigation and failure to implement care-planned interventions contributed to the deficiency identified by the surveyors.
Failure to Follow Physician Orders for Therapeutic Device
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not following physician orders for the consistent application of a prescribed neck positioning pillow for a resident. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage, lack of coordination, and muscle disorder, was observed multiple times without the neck positioning pillow while lying in bed. This was contrary to the physician's orders, which specified the use of the pillow to maintain the neck in a neutral position. Observations on two consecutive days revealed that the resident's neck was laterally flexed towards the left shoulder without the prescribed pillow. Interviews with staff, including an LPN and the DON, confirmed the absence of the neck pillow as ordered. The facility was unable to provide documentation to show compliance with the physician's orders, indicating a failure to ensure the resident's therapeutic device was in place as required.
Failure to Follow Physician Orders and Maintain Emergency Supplies for Midline Catheter
Penalty
Summary
The facility failed to provide person-centered care and follow physician orders for the management of a midline catheter for a resident diagnosed with a urinary tract infection and Extended Spectrum Beta Lactamase Resistance. The resident had a midline catheter inserted in the left arm, with an initial external catheter length of 0 cm. However, subsequent measurements showed a significant change to 10 cm, but there was no documented evidence that the physician was notified of this change. Additionally, after the completion of the ordered antibiotic, the midline catheter was removed intact, but the resident was later readmitted and required a new midline catheter due to being a hard stick and pulling out IVs. The facility also failed to ensure the availability of prescribed emergency supplies for the resident's midline catheter. Despite a physician's order to maintain an emergency kit at the bedside, an observation revealed that no such kit was available in the resident's room. Interviews with nursing staff confirmed the absence of the emergency kit and the inaccuracy in the documentation of the external catheter length in the Medication Administration Record. These deficiencies highlight a lack of adherence to physician orders and inadequate preparation for emergency situations.
Failure to Implement Pain Management for Resident
Penalty
Summary
The facility failed to implement appropriate pain management interventions for a resident, identified as Resident 92, who experienced pain without relief. Resident 92 was admitted with diagnoses including dementia and aftercare following a fractured femur. The facility's policy on pain management required the identification of individuals at risk for pain and the establishment of goals for pain treatment. Despite this, there was no documented evidence that the facility provided pharmacological or non-pharmacological interventions for Resident 92's pain, even though she experienced mild pain on multiple occasions. Resident 92 was readmitted to the facility after undergoing surgical repair for a fractured femur, with instructions to manage pain using Acetaminophen. Observations and interviews revealed that Resident 92 experienced pain during physical and occupational therapy sessions, yet there was no documentation of pain management interventions being offered or administered. The resident was unable to articulate what interventions alleviated her pain, and staff failed to document any efforts to manage her pain effectively. The Director of Nursing confirmed the facility's responsibility to provide pain management but was unable to provide evidence that interventions were offered to Resident 92 from her readmission through the observed period. The lack of documented pain management interventions, despite the resident's reported pain, indicates a deficiency in the facility's adherence to its pain management policy.
Failure to Provide Therapeutic Social Services
Penalty
Summary
The facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of a resident diagnosed with major depressive disorder and intermittent explosive disorder. The resident, admitted with a care plan indicating a risk for distressed mood symptoms related to anxiety, expressed a desire to die during a nursing interaction on April 9, 2024. Despite the nurse providing emotional support and notifying the physician, the resident's care plan was not updated to include interventions addressing this expression of suicidal ideation. Furthermore, there was no documentation in the resident's clinical record indicating that therapeutic social services were provided following the resident's statement. An interview with the Social Service Director revealed that there was no follow-up or conversation with the resident regarding his expressed desire to die. The Nursing Home Administrator confirmed the absence of documented evidence of therapeutic social services being provided to the resident after the incident.
Failure to Accurately Administer and Record Controlled Medications
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting and administration of controlled medications for a resident. A review of the clinical record showed that the resident had a physician order for Oxycodone HCl 5 mg to be administered every 6 hours as needed for pain. However, the Controlled Drug Administration Record indicated that doses were signed out by nursing staff on several occasions, but the administration of the medication was not recorded on the resident's Medication Administration Record (MAR). This discrepancy was confirmed by the Director of Nursing during an interview. Additionally, the facility did not adhere to the physician's updated order for Oxycodone HCl 10 mg, as the resident continued to receive the 5 mg dose. The Nursing Home Administrator confirmed that the nursing staff failed to follow the facility's policy by not verifying the correct medication dosage and did not comply with the physician's orders for pain management. The facility's policy required medications to be administered according to prescriber orders, with checks to ensure the right resident, medication, dosage, time, and method of administration.
Lack of Clinical Justification for Antipsychotic Use
Penalty
Summary
The facility failed to ensure the presence of documented clinical necessity for the use of an antipsychotic medication for a resident diagnosed with dementia. The resident, who was moderately cognitively impaired, was prescribed Seroquel, an antipsychotic medication, for agitation without corresponding physician documentation indicating the clinical need for its initiation. The medication was prescribed after discontinuing Buspar, an anti-anxiety medication, and the resident's medication administration record showed no signs of anxiety, insomnia, or socially inappropriate behaviors from June through early September. During an interview, the Director of Nursing confirmed the absence of documented evidence supporting the clinical rationale for the antipsychotic medication. The facility is responsible for ensuring that antipsychotic drugs are not administered to residents without a documented diagnosed condition. The deficiency was identified through clinical record review and staff interviews, highlighting the facility's failure to comply with regulations regarding unnecessary medications.
Failure to Administer CPR as per Resident's Advance Directive
Penalty
Summary
The facility failed to provide emergency care consistent with a resident's advance directives, specifically failing to administer CPR to a resident who was designated as full code status. The resident, who had multiple diagnoses including cancer, diabetes, and heart disease, had a physician order indicating CPR should be performed in the event of cardiac or pulmonary arrest. However, when the resident was found unresponsive with no pulse or respirations, the facility staff did not initiate CPR as required by the physician's order and the resident's advance directive. The incident was confirmed through a review of clinical records, facility policy, and staff interviews. The resident was observed declining in a wheelchair and was transferred to bed, where he was pronounced dead by a Physician Assistant. Despite the clear directive to perform CPR, the nursing staff did not act according to the resident's wishes and the physician's order. This deficiency was acknowledged by the Director of Nursing and the Nursing Home Administrator during an interview.
Obstructed Hallways and Mobility Hazards
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards and obstacles for safe mobility on one of its resident units, specifically Station 2. During an observation, it was noted that the hallway leading to the therapy department from the main entrance had four large reclining/wheelchairs lined up against the right-hand side of the wall. Additionally, the hallway in the resident care area had multiple high back chairs placed outside of resident rooms, causing congestion. These items obstructed access to the handrails, which are intended for resident ambulation or mobility assistance, and did not create a homelike environment. The Nursing Home Administrator acknowledged that resident care areas should be maintained in a clean and orderly manner.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications on one of its nursing units, specifically Station 1. During an observation, it was found that a mauve wash basin labeled 'Return to Rx' contained 16 medication cards that needed to be returned to the pharmacy. These medications were not properly inventoried or documented for disposition, as required by the facility's policy. Additionally, medications prescribed for a resident who had been discharged remained in the medication room without a completed medication disposition form. Further observations revealed an unlocked drawer at the nurse's station containing a blue zipper pouch filled with various single-use vials of medications, none of which were labeled for any current resident. The drawer also contained medications prescribed for specific residents, but they were not stored properly. Employee 2, an LPN, confirmed the improper storage and stated that the registered nurse unit manager kept these medications on hand due to potential delivery delays and theft concerns. The Nursing Home Administrator and Director of Nursing confirmed that the medications were not stored or labeled according to policy.
Inaccurate Documentation of Resident Treatments by LPN
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, as identified during a review of clinical records, observations, and staff interviews. Specifically, the issue involved an LPN, who was also functioning as a unit secretary, documenting the completion of treatments for residents before the scheduled shift time and without being scheduled to work as an LPN on that day. For Resident 7, treatments such as checking the placement and function of safety alarms and dressings were signed out as completed before the shift began. Similarly, for Resident 11, treatments including the application of zinc oxide and checking dressings were documented as completed prematurely. Resident 14's records also showed treatments signed out before the shift, including skin prep applications and checking alarm placements. The nurse staffing schedule for the day in question did not show that the LPN was scheduled to work as an assigned nurse, raising concerns about the accuracy of the documentation. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the LPN was not scheduled to perform nursing duties on that date, and the treatments were signed out before the start of the shift. This discrepancy indicates a failure to adhere to professional standards for maintaining accurate and complete medical records, as required by the Pennsylvania Code and the American Nurses Association's principles for nursing documentation.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information. During an observation on August 11, 2024, at approximately 8:15 AM, it was noted that the facility's current posted nursing hours were not visible. An interview with a registered nurse supervisor revealed that she was unaware of what posted nursing time was. Further confirmation from the facility's Assistant Director of Nursing indicated that the facility did not post the daily nurse staffing data as mandated by 28 Pa. Code 211.12 (d)(1)(3)(5) and 28 Pa. Code 201.18 (b)(1)(3).
Failure to Respond Timely to Residents' Requests for Assistance
Penalty
Summary
The facility failed to provide care in a manner and environment that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This was evidenced by complaints from six out of 15 interviewed residents who reported extended wait times for staff assistance, including untimely responses to the nurse call bell system. The residents expressed that these delays occurred daily and across all shifts, leading to situations where residents soiled themselves while waiting for assistance. Specific instances included residents waiting up to an hour for help, with some experiencing these delays multiple times a week or month, particularly during the evening and night shifts. Interviews with the residents revealed consistent concerns about the facility's staffing levels and the impact on their quality of life. The Nursing Home Administrator confirmed the expectation that all residents be treated with dignity and respect but was unable to explain the reported delays in staff response times. The deficiency was noted under the regulations 28 Pa. Code 201.18 (e)(1) Management, 28 Pa. Code 201.29 (a) Resident rights, and 28 Pa Code 211.12 (c)(d)(5) Nursing services.
Failure to Administer Oxygen as Ordered and Maintain Sanitary Equipment
Penalty
Summary
The facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for two residents. Resident 59, who was admitted with chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen, was observed multiple times with his oxygen tubing and nasal cannula lying on the floor. Despite being aware of the situation, an LPN picked up the tubing from the floor and placed it on the resident's lap without cleaning or replacing it, leading to the resident using unsanitary equipment. The resident's care plan indicated he was noncompliant with treatment, but the facility did not ensure proper oxygen administration or infection control procedures were followed. Additionally, the facility obtained a physician order for hourly monitoring of the resident's oxygen and wound vac compliance only after the surveyor's observations and interviews with staff. The facility also failed to monitor Resident 72's compliance with oxygen use and oxygen saturation levels. Resident 72, who had multiple diagnoses including COPD and congestive heart failure, was observed without her nasal cannula on multiple occasions, despite having a physician order for continuous oxygen. The resident stated that she removed her oxygen daily and that staff were aware, but the facility did not consistently monitor her oxygen use or saturation levels. An LPN confirmed that the resident's nasal cannula was not in use and that her oxygen saturation was low when measured. The facility did not ensure that the physician's order for supplemental oxygen was consistently followed for both residents, and the oxygen equipment was not maintained in a sanitary manner.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodates resident preferences, as observed in 26 resident meal trays and reported by nine residents out of 15 interviewed. The deficiency was identified through a review of Resident Council meeting minutes, facility grievances, and resident interviews. Specific complaints included a lack of variety in meals, hard rice, tough meat, burnt scrambled eggs, and missing condiments like butter. Residents also reported that their documented food preferences were not being honored, leading to dissatisfaction with the meals provided. During interviews, several residents expressed their dissatisfaction with the food quality, stating that it was often overcooked, bland, or salty. Some residents mentioned that additional items like butter and condiments were frequently missing from their meal trays. Observations during lunch confirmed that butter was missing from all observed meal trays, despite the facility having a sufficient supply in the kitchen. The Dietary Manager acknowledged that butter packets were only provided with certain food items and that residents would need to request them specifically. The Nursing Home Administrator confirmed that the facility failed to consider individual food preferences to increase resident satisfaction with meals. The deficiency was further supported by the facility's own documentation and resident feedback, indicating a systemic issue in accommodating resident dietary preferences and ensuring the quality of food served. The facility's failure to address these concerns led to widespread dissatisfaction among residents regarding their meals.
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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