Rouse Warren County Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Youngsville, Pennsylvania.
- Location
- 701 Rouse Avenue, Youngsville, Pennsylvania 16371
- CMS Provider Number
- 395609
- Inspections on file
- 20
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Rouse Warren County Home during CMS and state inspections, most recent first.
Three residents with respiratory or cardiac conditions were found with improperly maintained respiratory care equipment, including overdue or undated oxygen tubing, dirty concentrator filters, and a nebulizer mask left in a room after the order was discontinued. Staff interviews confirmed that required cleaning and labeling protocols were not followed.
Surveyors identified improper storage of food containers in the main kitchen, where metal steam table trays were stacked while wet, and found multiple unlabeled food items in unit pantry refrigerators. Staff confirmed that food items lacked required resident names and dates, and that wet stacking of trays occurred, contrary to facility policy.
A medication cart was found to contain an open NovoLog FlexPen that had been in use beyond the 28-day limit specified by both facility policy and manufacturer guidelines. An LPN confirmed during observation that the insulin pen was expired and should have been discarded.
The facility did not maintain a clean and sanitary environment on two units, as required by policy. Grievances and direct observations revealed unclean resident rooms and common areas, with visible debris, spills, and unemptied trash. Multiple staff expressed concerns about housekeeping, and the administrator confirmed the unsanitary conditions.
The facility did not meet the required NA staffing ratios during a day shift, with only 11.50 NAs available for 125 residents, falling short of the mandated 12.50 NAs. This was confirmed by the Nursing Home Administrator.
The facility failed to provide written notice of its bed-hold policy to residents or their representatives upon transfer to a hospital. This deficiency was identified for three residents, who were transferred without receiving the required notice, as confirmed by the Nursing Home Administrator.
The facility failed to ensure accurate MDS assessments for three residents. One resident was incorrectly documented as having a tracheostomy, while two others were wrongly marked with a psychotic disorder. These errors were confirmed by the RN Assessment Coordinator.
A facility did not provide a written summary of the baseline care plan and order summary to a resident with dementia, hypertension, and hypothyroidism within 48 hours of admission, as required by their policy. The RNAC was supposed to review and deliver the care plan, but the clinical record lacked evidence of this action, confirmed by the DON.
A facility failed to reconcile pre-discharge medications with post-discharge medications in a resident's discharge summary. The facility's policy requires listing discharge medications, including name, dose, directions, and quantity, but this was not done for a resident with dementia, high blood pressure, depression, anxiety, and weakness. Nursing documentation also lacked details on medications sent home. The DON confirmed the absence of required documentation.
The facility did not ensure medications were dated when opened and discarded in a timely manner. During an observation, two opened vials of Tubersol in the central medication storage room were found without an open date, preventing staff from determining the discard date. An LPN confirmed the absence of open dates on the vials.
The facility failed to maintain accurate clinical records for two residents. One resident's record incorrectly included a PTSD diagnosis without confirmation from a licensed practitioner, while another resident's record contained pre-admission information for a different potential resident. These discrepancies were confirmed by the DON and Director of Social Services, violating Pennsylvania Code regulations.
Failure to Maintain and Clean Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain respiratory care equipment in accordance with its own policy and physician orders for three residents. Facility policy required that humidifier bottles, oxygen tubing, and concentrator filters be changed or cleaned every two weeks and labeled with the date of change. For one resident with a discontinued nebulizer order, a nebulizer machine and mask remained in the room, with the mask found on the floor, which was confirmed by the Director of Nursing as inappropriate. Another resident receiving supplemental oxygen had a tubing bag and humidifier bottle that were not changed as required, undated oxygen tubing, and an external concentrator filter covered with a significant amount of white fluffy substance. An LPN confirmed these items were overdue for maintenance and cleaning. A third resident, also on supplemental oxygen, was observed to have an external concentrator filter covered with a copious amount of white fluffy substance, and an LPN confirmed the filter needed cleaning. All three residents had significant respiratory or cardiac diagnoses, including respiratory failure, heart failure, COPD, and emphysema. The observations and staff interviews confirmed that the facility did not follow its own protocols for respiratory equipment maintenance, labeling, and cleanliness, as required by physician orders and facility policy.
Improper Food Storage and Labeling in Kitchen and Unit Pantries
Penalty
Summary
The facility failed to ensure proper storage and handling of food in accordance with professional standards and its own policies. Observations in the main kitchen revealed that metal steam table trays were stacked while still wet, with clear liquid and moist food particles found between the trays. Staff interviews confirmed that trays were not allowed to air dry as required by policy, and that wet stacking had occurred on multiple occasions. The Dietary Manager and a Dietary Aide both acknowledged the improper practice and the need for the trays to be rewashed and dried properly. Additionally, inspections of pantry refrigerators on two nursing units found multiple food items that were not labeled with resident names or dates, as required by facility policy. Items included unknown foods wrapped in foil, salads, sandwiches, and containers with unidentifiable contents, all lacking proper labeling. Staff interviews confirmed that these items were not compliant with labeling requirements. The DON confirmed that there is a designated refrigerator for family-brought food, and that unit pantry refrigerators are intended only for dietary staff use during mealtimes.
Failure to Discard Expired Insulin on Medication Cart
Penalty
Summary
The facility failed to appropriately discard an outdated medication on one of three medication carts reviewed. According to facility policy, RNs and LPNs are required to check expiration dates and dispose of expired medications, with insulin specifically to be discarded 28 days after opening, regardless of the manufacturer’s expiration date. During an observation of the Unit 700 medication cart, an open NovoLog FlexPen was found with an open date that exceeded the 28-day limit. At the time of observation, an LPN confirmed that the insulin pen was beyond the allowed usage period and should have been discarded. This finding was based on review of facility policy, manufacturer guidelines, and staff interview.
Failure to Maintain Clean and Sanitary Environment on Multiple Units
Penalty
Summary
The facility failed to maintain a clean and sanitary environment on two of seven units observed, specifically the 100 and 200 units. Facility policies required daily room cleaning and room completes, including pulling and replacing garbage bags, sweeping, and mopping floors. However, review of grievances revealed concerns about the cleanliness of a resident room and bathroom on the 200 unit. Observations showed thick dry spots from spilled liquid, debris, straw wrappers, napkins, fuzzy dust, food crumbs, and unemptied trash in a resident room and the 200-unit break/storage area. Staff interviews across all units indicated widespread concerns about housekeeping, particularly on the 100, 200, and 300 units. The Nursing Home Administrator confirmed the dirty conditions during a tour.
Nurse Aide Staffing Ratio Not Met
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios during the day shift on December 7, 2024. Specifically, the regulation mandates a minimum of one NA per 10 residents during the day. On the day in question, the facility had a census of 125 residents, necessitating 12.50 NAs, but only 11.50 NAs were on duty. This staffing shortage was confirmed by the Nursing Home Administrator during an interview on December 17, 2024.
Plan Of Correction
It is the policy of the Rouse Home to provide adequate staffing to meet the needs of all residents. Following the new staffing requirements issued July 1, 2024, the Rouse Home has implemented numerous new measures to assure that we are doing all that we can to meet the new nurse staffing requirements. Staffing is reviewed by the Nursing Home Administrator and Director of Nursing, and or designee daily. If the staffing schedule does not meet the ratio minimums, we put incentives out to all of the nursing staff via On-shift message, personal phone calls, and text messages, and incentives are offered for staff to pick up these shifts. Additionally, we have made changes to our time and attendance policy in efforts to minimize staff calling off their scheduled shift. In 2024, we held a total of two NA classes which has helped to increase the overall number of CNAs employed at the Rouse Home. We have significantly increased our recruitment efforts as well in 2024. Efforts include job postings on Indeed, Rouse website, Facebook, radio ads in various counties, and welcome walk-in interviews at any time. Our HR team attends job fairs and other local events to advertise open positions. We also market available opportunities at our local high schools as well as colleges and universities in Warren County and the surrounding areas. We market sign-on bonuses for new hires and also offer our current staff recruitment bonuses for referring anyone to the open nursing positions, and increased our 2nd and 3rd shift differentials as part of our recruitment and retention efforts. Going forward, the projected monthly schedule will be reviewed with the roll out of the schedule to identify any shifts that do not meet ratio. Once we identify these shifts, we will begin to proactively recruit to fill the open shift. Administrator, DON, Nurse Scheduler will audit daily staffing including CNA ratios, along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly QAPI meetings.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave. This deficiency was identified for three residents during a review of facility policy, clinical records, and staff interviews. The facility's policy, dated January 6, 2024, requires the Admissions office to send out a Notice of Involuntary Discharge, Transfer, and Bed Hold letter at the time of transfer. However, documentation was lacking for Residents R30, R88, and R114, indicating that they or their representatives did not receive the required notice. Resident R30, who was admitted with chronic obstructive pulmonary disease, vascular dementia, and hypotension, was transferred to the hospital on May 31, 2024, without receiving the bed-hold policy notice. Similarly, Resident R88, with diagnoses including dementia, anxiety, hyperlipidemia, and feeding difficulties, was transferred on August 16, 2024, without the notice. Resident R114, diagnosed with dementia, difficulty walking, hyperlipidemia, and anxiety, was transferred on September 2, 2024, also without receiving the notice. The Nursing Home Administrator confirmed the absence of documentation and acknowledged that the policy should have been provided upon transfer.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of three residents. For Resident R78, the MDS inaccurately indicated that the resident had a tracheostomy, which was not supported by visual observation or the resident's confirmation. This discrepancy was noted in the quarterly MDS assessment with an Assessment Reference Date (ARD) of 6/10/24. Additionally, the MDS assessments for Residents R72 and R99 incorrectly marked psychotic disorder as an active diagnosis. Resident R72's comprehensive MDS with an ARD of 7/01/24 and Resident R99's quarterly MDS with an ARD of 7/29/24 both contained this error. The Registered Nurse Assessment Coordinator confirmed these inaccuracies during interviews conducted on 9/26/24 and 9/27/24.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to a resident and/or their representative within 48 hours of admission, as required by their policy. The policy, dated 1/06/24, mandates that the RNAC reviews the 48-hour care plan for completion and provides a copy to the resident or family in the resident's room, documenting this in the record. However, for Resident R55, who was admitted with diagnoses including dementia, hypertension, and hypothyroidism, there was no evidence in the clinical record that this requirement was fulfilled. The Director of Nursing confirmed the absence of documentation for providing the care plan and order summary to the resident or their representative upon admission.
Failure to Reconcile Discharge Medications
Penalty
Summary
The facility failed to include a reconciliation of all pre-discharge medications with the resident's post-discharge medications in the discharge summary for one of the two closed records reviewed. The facility's policy, dated 1/06/24, requires that discharge medications be listed in the Discharge Planning & Instructions assessment section, including the name of the medication, dose, directions for use, and quantity. However, the clinical record of Resident CR122, who had diagnoses including dementia, high blood pressure, depression, anxiety, and weakness, lacked evidence of medication reconciliation at the time of discharge. Additionally, nursing documentation did not provide details on the type or number of medications sent home with the resident. The Director of Nursing confirmed the absence of this documentation and acknowledged that discharge medications should have been reconciled and documented in the discharge summary.
Failure to Date and Discard Medications Properly
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner in the central medication storage room. A review of the facility's policy on Medication Administration General Guidelines, dated 1/06/24, indicated that new multi-dose bottles must be dated and initialed upon opening. Additionally, the manufacturer's guidelines for Tubersol PPD, a solution used for tuberculosis testing, require that vials in use for 30 days should be discarded. During an observation of the drug storage area, two opened vials of Tubersol were found without an open date, making it impossible for staff to determine the appropriate discard date. This was confirmed by an LPN, who acknowledged the lack of open dates on the vials.
Inaccurate Clinical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in safeguarding resident-identifiable information and maintaining medical records according to professional standards. For one resident, identified as R48, the clinical record included a diagnosis of Post Traumatic Stress Disorder (PTSD) that was added on a specific date. However, subsequent psychiatric consult notes did not provide evidence of this diagnosis being confirmed by a licensed practitioner. This discrepancy was acknowledged by the Director of Nursing during an interview. Another resident, identified as R116, had their clinical record erroneously contain pre-admission information from a referring agency intended for another potential resident. This error was confirmed by the Director of Social Services during an interview. The facility's failure to accurately maintain these clinical records was in violation of specific Pennsylvania Code regulations related to nursing services and medical records.
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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