Rose View Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Pennsylvania.
- Location
- 1201 Rural Avenue, Williamsport, Pennsylvania 17701
- CMS Provider Number
- 395767
- Inspections on file
- 25
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Rose View Rehab And Care Center during CMS and state inspections, most recent first.
Two residents did not receive required immunizations as per CDC guidelines: one resident consented to but did not receive the current season's influenza vaccine, and another had no record of receiving a pneumococcal conjugate vaccine despite prior administration of Pneumovax 23. These deficiencies were confirmed through record review and staff interviews.
Over a 21-day period, the facility did not meet the required minimum nurse aide-to-resident ratios for day, evening, and overnight shifts, as confirmed by staffing records and the Administrator. The deficiency was identified through a review of census and staffing data, showing consistent understaffing compared to regulatory requirements.
The facility did not provide the required minimum number of LPNs per resident on both day and overnight shifts for the majority of days reviewed, as confirmed by staffing records and administrative interview.
A review of staffing records and an interview with the Administrator confirmed that the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day over a 21-day period, with actual hours per patient day consistently below the regulatory standard.
The facility was found to have a building construction deficiency due to missing ceiling tiles in the first floor Maintenance Storage Room, affecting one of nine smoke compartments. This was confirmed during an exit interview with the Facility Administrator.
The facility did not maintain the exit stair tower enclosure, impacting all floors. An observation revealed that the fire exit hardware on the first floor's west stair tower enclosure exit discharge door was missing an end cap. This issue was confirmed with the Facility Administrator.
The facility has a deficiency in the protection of hazardous areas, such as boiler rooms and laundries, which are not adequately enclosed with a fire barrier or automatic fire extinguishing system. The required smoke-resisting partitions and doors are not installed, posing a risk to safety.
The facility failed to maintain smoke-tight doors in hazardous areas and ensure proper latching of corridor doors, affecting smoke compartments. Observations revealed that the Soiled Utility Room door was not smoke-tight, and the Dietary door failed to close and latch due to door drag. These deficiencies were confirmed during an exit interview with the Facility Administrator.
The facility failed to ensure accurate MDS assessments for two residents. One resident was incorrectly documented as having pneumonia after it was resolved, and another was inaccurately recorded as discharged to a hospital instead of home. These errors were confirmed by the facility's administration.
A facility failed to administer bowel protocol medications for a resident experiencing constipation, as documented in their clinical records. Despite physician orders for a sequential administration of Milk of Magnesia, Bisacodyl Suppository, and Fleet's Enema, there was no documentation of these medications being given or refused on several occasions. The DON confirmed the failure to provide the highest practicable care in this instance.
A resident did not receive new glasses recommended by an eye care group, despite a previous appointment. The resident's broken eyeglasses were observed, and the Nursing Home Administrator confirmed the glasses were never delivered.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying specific triggers that could lead to re-traumatization. The care plan included general interventions but lacked details on managing PTSD triggers. The Nursing Home Administrator admitted that the facility did not inquire about the resident's triggers until prompted by a surveyor.
The facility's main kitchen was found to have unsanitary conditions, including missing grout and debris buildup around the dish machine area, and broken tiles with dirt accumulation in the kitchen entrance. These issues were observed during a survey with the dietary manager, raising sanitation concerns in the food preparation area.
A facility failed to administer a pneumococcal vaccine to a resident despite having consent from the responsible party. The resident's immunization history lacked evidence of the vaccine, and the Nursing Home Administrator confirmed the absence of documentation offering the immunization after consent was obtained.
A facility failed to document the disposition of a resident's personal belongings after discharge. A resident was admitted and later discharged home, but the personal belongings inventory form was not signed by the resident or responsible party, and there was no documentation indicating what happened to the belongings.
A facility failed to document the disposition of medications for a resident who expired, including Atorvastatin, Insulin Glargine, and Metformin HCL, among others. This deficiency was identified through a closed clinical record review and staff interview, revealing a lack of documentation in the resident's clinical record upon discharge.
The facility failed to meet required nurse aide-to-resident ratios across multiple shifts, with significant understaffing noted during day, evening, and overnight shifts. Additionally, there was no evidence of the disposition of a resident's medications upon their death, indicating procedural lapses in medication management.
The facility failed to meet the required LPN staffing levels, with deficiencies noted during the day, evening, and overnight shifts. The review revealed multiple instances of understaffing, with the number of LPNs consistently below the required levels, potentially affecting resident care.
The facility did not meet the required 3.2 hours of direct resident care per patient day for 20 out of 21 days reviewed. Nursing care hours ranged from 2.81 to 3.19 hours PPD, falling short of the regulatory requirement. This was confirmed through staffing hour reviews and an administrator interview.
A resident ingested medications intended for another resident after an LPN left them unattended on a bedside table. The resident, who was independent in his wheelchair, experienced hypotension and an altered mental state, requiring emergency medical intervention. This incident highlights a significant medication administration error.
Failure to Ensure Influenza and Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure proper administration of influenza and pneumococcal immunizations for two residents as required by CDC guidelines and federal regulations. For one resident, clinical record review showed that although she had provided informed consent for the influenza vaccine for the current season, there was no evidence in her medical record that she received the vaccine. Staff documented that she was not eligible for the vaccine because she had received it previously, but the record only showed administration for the prior season, not the current one. Interviews with the Nursing Home Administrator confirmed the absence of documentation or evidence that the resident received the influenza vaccine for the current season, despite being eligible and having consented. For another resident, review of immunization records revealed that she had received two doses of the pneumococcal polysaccharide vaccine (Pneumovax 23) prior to admission, but there was no evidence that she had ever received a pneumococcal conjugate vaccine (PCV), as recommended by the CDC for adults of her age group. This finding was confirmed by interviews with the Nursing Home Administrator and the Director of Nursing. The lack of documentation and administration of the recommended vaccines for both residents constituted a failure to comply with immunization requirements.
Failure to Meet Minimum Nurse Aide Staffing Ratios Across All Shifts
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing ratios for all three shifts over a 21-day review period. Specifically, during the day shift, the number of nurse aides consistently fell below the mandated ratio of one nurse aide per ten residents on all 21 days reviewed. The evening shift also did not meet the required ratio of one nurse aide per eleven residents on 16 out of 21 days. Similarly, the overnight shift failed to provide at least one nurse aide per fifteen residents on 20 out of 21 days. These findings were based on a review of staffing records, which detailed the census and number of nurse aides present for each shift and day within the review period. An interview with the Administrator confirmed the accuracy of the staffing data and the facility's failure to meet the minimum nurse aide requirements as outlined by regulation. The report does not mention any specific residents or their medical conditions, nor does it describe any direct patient outcomes related to the staffing deficiencies. The deficiency is solely based on the facility's inability to provide the required number of nurse aides per shift according to the resident census.
Plan Of Correction
P 5520 Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. P5520 1. Findings of nurse aide nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure nurse aide coverage. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. Facility offers bonuses to current staff in attempt to schedule more staff per shift. 3. Scheduling manager will be educated on the requirements there must be a minimum of one nurse aide per 10 residents during day shift and a minimum of one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. 4. Director of Nursing or Designee will conduct random audits to verify that nurse aide day shift, evening shift ratios and overnight shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) as mandated by regulation. Specifically, during the day shift, the facility did not provide at least one LPN per 25 residents for 14 out of the 21 days reviewed. The documented LPN staffing levels on these days were consistently below the required ratio based on the daily census, with several days showing a shortfall in the number of LPNs scheduled compared to what was required. Additionally, on the overnight shift, the facility did not meet the minimum requirement of one LPN per 40 residents for 20 out of the 21 days reviewed. The staffing records indicated that the number of LPNs present was frequently less than the required amount, with some nights having only one LPN when more were needed according to the resident census. These findings were confirmed during an interview with the Administrator, who acknowledged the discrepancies in LPN staffing levels during the specified review period.
Plan Of Correction
P5530 1. Findings of LPN nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one Licensed Practical Nurse per 25 residents during the day shift and a minimum of one LPN per 40 residents during the night shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure LPN coverage. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. The facility offers bonuses to current staff in an effort to schedule more staff per shift. 3. Scheduling manager will be educated on the requirements of one Licensed Practical Nurse per 25 residents during the day shift and a minimum of one LPN per 40 residents during the night shift. 4. Director of Nursing or Designee will conduct random audits to verify that LPN day shift and night shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day, as mandated effective July 1, 2024. A review of nursing staff care hours for the period from July 11, 2025, through July 31, 2025, showed that on each of the 21 days reviewed, the facility did not meet this minimum standard. The reported hours per patient day (PPD) ranged from 2.41 to 3.05, consistently falling short of the regulatory requirement. This deficiency was confirmed through both a review of staffing records and an interview with the Administrator, who acknowledged the findings. The report does not mention any specific residents or their medical conditions, nor does it provide details about the impact on individual patients. The deficiency is solely based on the facility's failure to meet the mandated nursing care hours across the entire facility during the specified period.
Plan Of Correction
P5640 1. Findings of nursing staff care hours cannot be retroactively corrected. 2. Facility will provide a minimum of 3.2 hours nursing care hours per patient day. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. Facility offers bonuses to current staff in an effort to get more staff scheduled per shift. 3. Scheduling manager will be educated on the requirement of providing a minimum of 3.2 nursing care hours per patient per day. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure adequate coverage. 4. Director of Nursing or Designee will conduct random audits to verify that facility is providing a minimum of 3.2 nursing care hours per patient per day weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Building Construction Deficiency: Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain building construction requirements, as evidenced by an observation on December 30, 2024. During the inspection, it was noted that the ceiling tiles were missing in two locations within the first floor Maintenance Storage Room. This deficiency affected one of the nine smoke compartments in the facility. The issue was confirmed during an exit interview with the Facility Administrator on the same day.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. 1. Both ceiling tiles were replaced with a rated ceiling tile. 2. Other ceiling tiles will be checked to ensure they are in place. 3. Maintenance will be re-educated on ensuring that ceiling tiles are in place. 4. Maintenance Director/ designee will conduct random audits to verify that ceiling tiles are in place weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.
Stair Tower Enclosure Deficiency
Penalty
Summary
The facility failed to maintain the exit stair tower enclosure, affecting all three floors. During an observation on December 30, 2024, at 10:40 a.m., it was noted that the fire exit hardware on the first floor's west stair tower enclosure exit discharge door was missing an end cap. This deficiency was confirmed during an exit interview with the Facility Administrator later that morning.
Plan Of Correction
1. Missing end cap on the first floor west stair tower door was replaced. 2. Other stair tower door enclosures will be checked for missing end caps. 3. Maintenance will be re-educated on ensuring that door enclosures have end caps installed. 4. Maintenance Director/ designee will conduct random audits to verify that exit hardware end caps are in place weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.
Deficiency in Hazardous Area Enclosure
Penalty
Summary
The report identifies a deficiency in the protection of hazardous areas within the facility. Specifically, hazardous areas such as boiler and fuel-fired heater rooms, laundries larger than 100 square feet, repair, maintenance, and paint shops, soiled linen rooms exceeding 64 gallons, trash collection rooms exceeding 64 gallons, combustible storage rooms or spaces over 50 square feet, and laboratories classified as severe hazard are not adequately enclosed. These areas are required to be protected by a fire barrier with a 1-hour fire resistance rating or an automatic fire extinguishing system. However, the report indicates that the separation of these areas is not achieved as there is no automatic sprinkler system in place, and the necessary smoke-resisting partitions and doors are not installed as per the standards outlined in sections 8.4 and 19.3.5.9. This lack of compliance with fire safety regulations poses a significant risk to the safety of the facility's occupants.
Plan Of Correction
1. Soiled utility room door will be adjusted for smoke-tight gap. 2. Soiled utility room door gaps will be checked for smoke-tight gap. 3. Maintenance will be re-educated on ensuring that all doors are smoke-tight. 4. Maintenance Director/designee will conduct random audits to verify that doors are smoke-tight weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.
Deficiencies in Door Maintenance Affecting Smoke Compartments
Penalty
Summary
The facility was found to have deficiencies in maintaining hazardous area enclosures and corridor openings, affecting smoke compartments. On December 30, 2024, an observation revealed that the door to the Soiled Utility Room on the second floor was not smoke-tight, which is a requirement for hazardous area enclosures. This deficiency was confirmed during an exit interview with the Facility Administrator. Additionally, another deficiency was noted on the same day when the first-floor Dietary door failed to close and latch properly due to door drag. This issue was also confirmed during the exit interview with the Facility Administrator. Both deficiencies indicate a failure to comply with the requirements for doors protecting corridor openings, which are essential for resisting the passage of smoke and ensuring safety in the event of a fire.
Plan Of Correction
1. Door will be replaced so it will close and latch properly. 2. Other doors enclosures will be checked to verify closing and latching. 3. Maintenance will be re-educated on ensuring that all door enclosures are closing and latching. 4. Maintenance Director/ designee will conduct random audits to verify that door enclosures are closing and latching weekly for 4 weeks and then monthly for 2 months thereafter. Audits results will be presented at the QAPI meeting for review and recommendations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents. Resident 102 was admitted with pneumonia, which was resolved by October 10, 2024. However, the MDS assessment dated November 15, 2024, incorrectly indicated that the resident still had pneumonia, despite no evidence in the clinical record supporting this. The error was confirmed by the Administrator. Resident 108's MDS assessment inaccurately documented a discharge to a hospital setting, while physician progress notes indicated the resident was discharged home. This discrepancy was confirmed by the Nursing Home Administrator. These inaccuracies in MDS assessments were previously cited on December 1, 2023, under the regulation S483.20(g) for the accuracy of assessments.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. F0641 1. MDS corrections were submitted for residents 102 and 108. 2. Current residents with MDS completed from January 6, 2025, through January 20, 2025, will be reviewed to determine accuracy of section I 2000. Current residents with MDS completed from January 6, 2025, through January 20, 2025, will be reviewed to determine accuracy of section A2105. 3. Education will be completed with Social Services on accuracy of section A 2105 of the MDS. Education will be provided to the RNAC on accuracy of section I 2000 of the MDS. 4. Random audits will be completed by DON or designee weekly for 4 weeks, then monthly for 2 months of residents' MDS to ensure accuracy of sections A 2105 and I 2000. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Administer Bowel Protocol Medications
Penalty
Summary
The facility failed to provide the highest practicable care for a resident regarding the administration of bowel protocol medications. A clinical record review revealed that the resident had difficulty passing stool, as noted in a medical provider's progress note. Despite physician orders for a bowel protocol that included Milk of Magnesia, Bisacodyl Suppository, and Fleet's Enema to be administered sequentially if constipation persisted, there was no documentation indicating that these medications were administered or refused by the resident on several specified dates. The Director of Nursing confirmed the findings that the facility did not initiate the bowel protocol as ordered. The lack of documentation on the medication administration record (MAR) for the specified dates indicates a failure to adhere to the prescribed bowel protocol, which was intended to address the resident's constipation issues. This oversight in medication administration and documentation led to the deficiency noted in the report.
Plan Of Correction
F0684 1. The bowel protocol medication administration cannot be retroactively implemented for resident 48. 2. Audit will be completed for current residents' bowel elimination records from January 6, 2025 - January 13, 2025 to ensure that appropriate bowel protocol interventions are being administered. 3. Education will be provided to licensed staff on ensuring that the bowel protocol is being followed. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months to ensure appropriate bowel protocol interventions are being administered. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Provide New Glasses to Resident
Penalty
Summary
The facility failed to provide proper treatment to maintain vision for a resident with vision concerns. An interview with the resident revealed that she had seen an eye doctor a long time ago and had not received her new glasses. Observation of the resident's overbed table showed a pair of broken eyeglasses with one lens missing. A review of the resident's clinical record indicated that she had an appointment with Health Drive Eye Care Group, which recommended new glasses to be delivered upon arrival. However, an interview with the Nursing Home Administrator confirmed that the resident never received the new glasses ordered several months prior.
Plan Of Correction
1. Resident 41's glasses will be delivered. 2. Current residents will be audited to ensure they have received their glasses if recommended by their optometrist. 3. Education will be completed with social services on ensuring residents receive their glasses timely. 4. Audits will be completed by the Social Services Director or designee monthly for 3 months to validate that residents with recommendations for new glasses receive them. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The clinical record review revealed that the resident was admitted on March 1, 2023, with a diagnosis of PTSD. The care plan for the resident included goals and interventions to improve mood and manage PTSD symptoms, such as administering medications, monitoring for side effects, and providing behavioral health consults as needed. However, the facility did not identify specific triggers related to the resident's PTSD that could lead to re-traumatization. An interview with the Nursing Home Administrator revealed that the facility did not inquire about the resident's PTSD triggers from his wife until after the surveyor's inquiry. The administrator confirmed that the resident's wife was unaware of specific triggers but mentioned that the resident would wake up and move to another room when experiencing PTSD-related issues. This lack of proactive identification and management of PTSD triggers in the care plan led to the deficiency, as the facility did not adequately address the potential for re-traumatization of the resident.
Plan Of Correction
F0699 1. Resident 57 and his wife reported no triggers to his PTSD and would not discuss further. 2. Audit of current residents with diagnoses of PTSD will be audited to ensure they have specific triggers in their PTSD care plans. 3. Education will be completed with social services on identifying and care planning specific triggers for a resident with the diagnosis of PTSD. 4. Random audits will be completed weekly by the Social Services Director or designee for 4 weeks then monthly for 2 months to ensure residents with a diagnosis of PTSD have specific triggers in their PTSD care plans. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Sanitation Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain the food preparation and dishwashing area in a safe and sanitary manner in the main kitchen. During an observation with the dietary manager, it was noted that the flooring tiles surrounding the dish machine area lacked grout, leading to a buildup of liquid and food debris between the tiles. Additionally, multiple vinyl tiles in the kitchen entrance area, surrounding the ice machine and production area, were broken and cracked, accumulating dirt and debris. These conditions present sanitation concerns in a food preparation area. Furthermore, significant black buildup was observed where the tile meets the wall and the transition strip from the kitchen to the dish machine room.
Plan Of Correction
F0812 1. Grout in the dishroom around the dish machine area was cleaned and a vendor will be secured to complete the grout replacement. A vendor will be secured to fix the vinyl tiles around the ice machine and production area inside the entrance area. The threshold from the kitchen to the dish machine room was cleaned. 2. Audit will be completed of the dish room to ensure the grout is present and kitchen floor to ensure there are no cracked or broken vinyl tiles. Other thresholds in the kitchen will be checked to ensure they do not have black buildup. 3. Education will be completed with maintenance staff on maintaining the kitchen floor tiles and grout. Education will be completed with dietary staff on keeping the kitchen thresholds free of black buildup. 4. Random audits will be completed by the Dietary Manager or designee weekly for 4 weeks then monthly for 2 months to ensure the threshold from the kitchen to the dish room is free of black buildup. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal immunization, as required. Resident 5 was admitted to the facility on December 3, 2018, and a review of their immunization history showed no evidence of receiving the recommended pneumococcal vaccine. Although a Pneumococcal Immunization Informed Consent was signed by Resident 5's responsible party on November 18, 2024, granting permission for the vaccination, there was no documented evidence that the facility offered or administered the pneumococcal immunization to the resident after obtaining consent. During an interview with the Nursing Home Administrator on December 20, 2024, it was confirmed that the facility did not have documentation showing that the pneumococcal immunization was offered to Resident 5 following the consent. This deficiency was noted in the context of a previous citation for similar issues related to nursing services.
Plan Of Correction
1. Resident 5 refused to have his pneumococcal vaccine administered and it was documented. 2. Audit will be completed of current residents to ensure those residents who consented to receive the pneumococcal vaccine have received it or documented refusal. 3. Education will be provided to the Infection Preventionist on ensuring those residents who consent to the pneumococcal vaccine receive it. 4. Random audits will be completed weekly for 4 weeks then monthly for 2 months to ensure residents who have newly consented to receiving the pneumococcal vaccine are offered it. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Document Disposition of Resident's Belongings Post-Discharge
Penalty
Summary
The facility failed to meet the regulation regarding the protection of personal and property rights of residents, specifically concerning the return of personal property after discharge. This deficiency was identified through a clinical record review and staff interview, which revealed that there was no evidence documenting the disposition of a resident's personal belongings following their discharge. Resident 108 was admitted to the facility on February 8, 2024, and discharged home on November 11, 2024. However, the personal belongings inventory form for Resident 108 was not signed by the resident or their responsible party upon discharge, and there was no documentation in the closed clinical record indicating what happened to the resident's personal belongings after they left the facility.
Plan Of Correction
P1210 1. A signed belonging sheet cannot be retroactively produced for resident 108. 2. Audit will be completed of residents who have discharged from facility from January 6, 2025, to January 13, 2025, to ensure that disposition of their personal property was completed. 3. Education will be provided to licensed nursing staff on ensuring disposition of residents' personal property is completed and documented at the time of discharge. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months, on residents who have discharged from the facility to ensure disposition of their personal property is completed. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Document Medication Disposition for Deceased Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 110, who expired at the facility on November 19, 2024. A closed clinical record review revealed that there was no documented evidence regarding the disposition of several medications prescribed to Resident 110. These medications included Atorvastatin, Cyanocobalamin, Insulin Glargine, Melatonin, Metoprolol Succinate, Pantoprazole Sodium, Magnesium Oxide, Metformin HCL, and Ranolazine. The deficiency was identified based on a closed clinical record review and staff interview, which confirmed the lack of documentation in the clinical record upon the resident's discharge. The facility's failure to document the disposition of these medications is a violation of the regulation requiring control and accountability of medications awaiting final disposition, as well as proper documentation of the actual disposition of medications.
Plan Of Correction
1. A disposition of medication for resident 110 cannot be retroactively produced. 2. An audit will be completed of residents who have discharged from the facility from January 6, 2025, to January 13, 2025, to ensure that a disposition of medication is completed upon discharge. 3. Education will be provided to licensed nursing staff on ensuring a disposition of medication is completed upon resident discharge. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months on residents who have discharged from the facility to ensure disposition of medication is completed. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Staffing and Medication Management Deficiencies
Penalty
Summary
The facility was found to have deficiencies in nursing services, specifically in maintaining the required nurse aide-to-resident ratios during various shifts. The report highlights that for 15 out of 21 days reviewed, the facility did not meet the minimum requirement of one nurse aide per 10 residents during the day shift. Similarly, the evening shift was understaffed for eight out of 21 days, failing to meet the one nurse aide per 11 residents requirement. The overnight shift was also deficient, with 17 out of 21 days not meeting the one nurse aide per 15 residents standard. These findings were confirmed through a review of nursing care hours and staff interviews. Additionally, the report notes a specific incident involving Resident 110, where there was no evidence of the disposition of the resident's medications upon their death. This was confirmed during an interview with the Nursing Home Administrator. The lack of documentation regarding the handling of medications post-mortem indicates a lapse in the facility's procedures for managing resident medications, contributing to the overall deficiencies identified in the report.
Plan Of Correction
1. Findings of nurse aide nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure nurse aide coverage. 3. Scheduling manager will be educated on the requirements there must be a minimum of one nurse aide per 10 residents during day shift and a minimum of one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. 4. Director of Nursing or Designee will conduct random audits to verify that nurse aide day shift, evening shift ratios and overnight shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as mandated by the regulation effective July 1, 2023. Specifically, the facility did not maintain the minimum staffing levels of one LPN per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the overnight shift. This deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Administrator. The review covered specific periods in November and December 2024, revealing multiple instances where the number of LPNs on duty was below the required levels. During the day shift, the facility was understaffed on six occasions, with the number of LPNs ranging from 4 to 4.16, while the required number ranged from 4.32 to 4.44 based on the census. The evening shift was understaffed on one occasion, with 3.44 LPNs instead of the required 3.63. The overnight shift showed the most significant deficiency, with 14 instances of understaffing, where the number of LPNs ranged from 2 to 2.08, while the required number ranged from 2.68 to 2.80. These findings indicate a consistent failure to meet the staffing requirements, potentially impacting the quality of care provided to the residents.
Plan Of Correction
P5530 1. Findings of LPN nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one Licensed Practical Nurse per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents during the night shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure LPN coverage. 3. Scheduling manager will be educated on the requirements of one Licensed Practical Nurse per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents during the night shift. 4. Director of Nursing or Designee will conduct random audits to verify that LPN day shift, evening shift and night shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient day (PPD) for 20 out of the 21 days reviewed. Specifically, during the periods from November 10 to November 16, November 24 to November 30, and December 13 to December 19, 2024, the facility consistently fell short of the required nursing care hours. The daily PPD ranged from 2.81 to 3.19 hours, with most days not reaching the mandated 3.2 hours. This deficiency was confirmed through a review of nursing staffing hours and an interview with the Administrator on December 19, 2024.
Plan Of Correction
P5640 1. Findings of nursing staff care hours cannot be retroactively corrected. 2. Facility will provide a minimum of 3.2 hours nursing care hours per patient day. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure adequate coverage. 3. Scheduling manager will be educated on the requirement of providing a minimum of 3.2 nursing care hours per patient per day. 4. Director of Nursing or Designee will conduct random audits to verify that facility is providing a minimum of 3.2 nursing care hours per patient per day weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Resident Ingests Wrong Medications Due to LPN Error
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by an incident involving Resident 4. During a medication administration, Employee 1, a licensed practical nurse, left medications intended for Resident 3 unattended on a bedside table while Resident 3 was being assisted to the bathroom. Resident 4, who was in the same room and independent in his wheelchair, ingested the medications left for Resident 3. This error was discovered when Employee 1 returned to the room after retrieving a pain pill for Resident 4. As a result of ingesting the wrong medications, Resident 4 experienced hypotension and an altered mental state, necessitating emergency medical intervention. The resident was sent to the emergency department, where he was treated with intravenous fluids and observed for several hours. Despite initial stabilization, Resident 4 experienced another episode of hypotension, requiring further medical attention. The incident highlights a significant lapse in medication administration protocols, leading to adverse health effects for Resident 4.
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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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