Saint Anne Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 685 Angela Drive, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395539
- Inspections on file
- 30
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Saint Anne Home during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, who required staff assistance for daily care, was transported in a wheelchair without leg rests in violation of the facility’s wheelchair transport policy requiring footrests during transport. A nurse aide pushed the resident in the wheelchair without leg rests, the resident leaned forward, fell out of the wheelchair, and sustained abrasions and a bruise to the forehead and eyebrow. The administrator later confirmed that leg rests should have been in place during the transport, demonstrating noncompliance with established resident care and nursing service policies.
Three residents with varying cognitive and physical needs had care plans that did not include their specific bed placement preferences, such as having the bed against the wall, despite these preferences being observed and confirmed by the DON. This omission was identified through MDS assessments, room observations, and staff interviews.
The facility did not ensure that food was served at safe and appetizing temperatures, with two residents reporting that meals were not warm and tasted poor. A test tray revealed that hot foods were served below the required temperature, and the main entrée lacked seasoning, which was confirmed by the Chef Manager.
An LPN misappropriated controlled pain medications by signing out doses for nine residents without administering them, as shown by discrepancies between controlled substance logs and MARs. Both cognitively impaired and intact residents with orders for opioid pain medications were affected, with no documentation or resident reports confirming receipt of the medications. The facility's investigation confirmed a pattern of diversion by the LPN.
The facility did not consistently update care plans to reflect changes in resident status or physician orders, such as discontinuation of transmission-based precautions, new medication orders, changes in oxygen therapy, and transfer assistance requirements. These discrepancies were confirmed through record reviews and staff interviews, resulting in care plans that did not accurately represent the current needs of several residents.
A resident with an indwelling urinary catheter and obstructive uropathy did not have urinary output measured and recorded as required by their care plan on multiple shifts and dates. Review of clinical records and staff interviews confirmed the absence of documentation for these periods.
The facility did not ensure proper cleaning of the kitchen area, as evidenced by a build-up of black residue on the wall behind the dishwasher and dust on the dishwasher vents, and failed to consistently document dishwasher wash and rinse temperatures as required by policy. The Dietary Manager confirmed these lapses in cleaning and record-keeping.
The facility did not accurately complete MDS assessments for three residents, including failures to document administration of anticonvulsants, antibiotics, antiplatelet medications, and IV access, as well as incorrect coding of cognitive status that led to a required BIMS interview not being conducted. These errors were confirmed by review of clinical records and staff interviews.
A resident with orders for Tramadol did not have documented evidence of receiving several signed-out doses of the controlled medication, as required by facility policy. The MAR and clinical record lacked documentation for these administrations, which was confirmed by the facility's QA nurse.
Two medication administration errors were observed, resulting in an error rate above five percent. One involved an LPN crushing Metoprolol ER tablets for a resident, contrary to manufacturer instructions, and another involved an LPN applying Voltaren gel without measuring the prescribed dose. Both errors were confirmed by the staff involved and the facility's quality assurance nurse.
Surveyors found that multi-dose insulin containers were not labeled with the date opened and an expired Aplisol testing solution was not discarded as required. An LPN and the QAPI RN confirmed these lapses, which were identified through policy review, manufacturer instructions, observation, and staff interviews.
The QAPI committee failed to correct recurring deficiencies, including breaches of resident health information confidentiality, inaccurate MDS assessments, improper care plan timing, inadequate urinary output monitoring, medication errors above 5%, improper medication storage, and serving unpalatable food at incorrect temperatures. Despite audit and review processes, these issues persisted across multiple surveys.
Surveyors observed that the reach-in refrigerator in the Main Kitchen had a loose and hanging rubber gasket at the bottom of the door, making it difficult to close. The Chef Manager confirmed the issue and stated it should have been repaired.
A nurse failed to administer medication according to a resident's stated preference and clinical record, giving all pills at once instead of one at a time. This led to the resident experiencing coughing, watery eyes, and emotional distress, with the nurse refusing to assess the resident after the incident. The event resulted in a change to the resident's diet and a referral to speech therapy.
The facility failed to ensure hot liquids were served at safe temperatures, resulting in burns to two residents. The policy required temperatures not to exceed 155°F, but this was not followed, leading to incidents where residents were served beverages at higher temperatures. Interviews confirmed lapses in policy adherence, placing residents at risk of injury.
The facility failed to serve food at appetizing temperatures, as residents reported cold meals on certain days. Observations confirmed that food items were not maintained at required temperatures, with onion rings at 92°F, soup at 132.8°F, and milk at 55.5°F, contrary to the facility's policy.
The NHA and DON failed to manage the facility effectively, leading to a deficiency related to serving hot liquids at inappropriate temperatures, jeopardizing the health and safety of two residents. The deficiency was cited under federal and state regulations, highlighting the failure to maintain an environment free of accident hazards.
A resident with Alzheimer's and osteoporosis was improperly transferred by an agency nurse aide without using the required mechanical lift, resulting in a fracture. The incident was not reported immediately, violating the facility's abuse and neglect policies.
A resident with Alzheimer's and osteoporosis fell due to improper transfer by a nurse aide who was unaware of the need for a mechanical lift. The fall was not reported immediately, leading to a delay in medical assessment and treatment for a fracture.
The facility failed to update care plans for several residents, leading to discrepancies in medication management, fall prevention, dietary needs, and wound care. These oversights were confirmed by the DON and Corporate Compliance Officer.
The facility failed to adhere to physician's orders for several residents, including not reporting a bruise for a resident on Eliquis, administering midodrine against blood pressure parameters, and missing documentation for pulse oximetry and intake/output measurements. These deficiencies were confirmed by the DON.
A facility failed to maintain a medication error rate below five percent, with eight errors occurring during a medication pass. An LPN did not prepare Klonopin for a resident and held all medications due to perceived excessive gastric residual without a physician's order. The medications were later wasted, and the Director of Nursing confirmed the error, initiating a report.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. The resident, who was cognitively intact but needed extensive assistance, had no documented evaluation or physician's order for self-administration. An LPN left the resident with a medication cup without observing the medication intake, which was confirmed by the DON.
The facility failed to inform and assist residents with advance directives, affecting three residents with cognitive impairments and various diagnoses. An interview with the Social Service Director revealed the absence of an official process to address advance directives, leading to the deficiency.
A facility failed to provide a resident with the required notice following the end of their Medicare coverage. Although the resident signed a SNF Beneficiary Protection Notification Review form, there was no documented evidence of receiving a SNF Beneficiary Protection Notification form or an ABN. The Social Worker confirmed the oversight in issuing ABN notices.
A facility failed to maintain the confidentiality of a resident's health information during medication administration. An LPN left a computer screen displaying personal health information visible to the hallway while assisting a resident, violating the facility's privacy policy. Both the LPN and the DON confirmed the breach of protocol.
A resident's grievance about food temperatures was not properly addressed, as evidenced by observations of meal service where food was served on an open cart, resulting in cool temperatures. The Dietary Director acknowledged the need for more insulated carts to maintain proper food temperatures.
A cognitively impaired resident, known to be afraid of showers, was inappropriately handled by a nurse aide who picked her up and carried her down the hallway despite her cries of pain. The incident, witnessed by an LPN and the resident's daughter-in-law, highlighted a failure to adhere to the facility's abuse policy, resulting in the resident's distress and potential harm.
A resident's medication was misappropriated when an agency LPN failed to perform a narcotic count, leading to the discovery of tampered medication packaging. The facility's investigation confirmed the misappropriation, and the incident was reported to the PA State Board of Nursing.
The facility failed to notify the Ombudsman in writing about the reasons for hospital transfers for five residents, as required by policy. These residents were transferred for various medical reasons, including agitation, falls, and pressure ulcers. Interviews confirmed the lack of notifications.
A facility failed to develop a comprehensive care plan for a resident with dementia and depression, who was receiving antipsychotic medications. Despite facility policy requiring care plans to address specific needs, the resident's care plan lacked documentation for their antipsychotic medication needs. This deficiency was confirmed by the DON during an interview.
A cognitively impaired resident requiring maximum assistance was transported in a broda chair without leg/footrests, contrary to the facility's policy. A nursing assistant, aware of the requirement, pushed the resident without the necessary footrests. The DON confirmed that all staff should adhere to this policy.
A facility failed to follow physician's orders for monitoring the urinary output of a cognitively impaired resident with an indwelling catheter. Despite a policy requiring output monitoring for residents with Foley catheters, records showed no documentation of monitoring across multiple months. The DON confirmed the lack of documentation, highlighting a deficiency in adhering to care protocols.
The facility failed to follow fluid restrictions for a resident with kidney failure and did not obtain weekly weights for another resident with significant weight loss and pressure ulcers, as per physician's orders. Documentation was lacking for both deficiencies, confirmed by the DON.
A facility failed to document the checking of a feeding tube's placement for a resident, as required by the care plan and facility policy. The resident, who was cognitively impaired and required assistance, had a feeding tube, but there was no evidence in the clinical record that the tube's placement was being checked. The DON confirmed the lack of documentation.
A facility failed to ensure a resident requiring dialysis had an active physician's order, obtain orders for fistula care, and maintain communication with the dialysis center. The resident, who required assistance for daily care and had kidney failure, lacked an emergency kit in his room. Staff interviews confirmed the absence of necessary documentation and awareness of emergency protocols.
The facility did not complete annual performance evaluations for two nurse aides as required. Evaluations were due months prior, but no documentation was available to confirm their completion. This was confirmed by the DON, indicating a lapse in compliance with state regulations on staff development and management.
A facility failed to provide appropriate treatment for a resident with dementia-related behaviors by not implementing an individualized care plan. The resident, diagnosed with dementia, depression, and anxiety, exhibited aggressive behaviors, including physical altercations with staff and other residents. Despite having a care plan, staff did not follow interventions, and no new behavioral strategies were developed after an incident, as confirmed by the DON.
The facility failed to secure medications properly and label them according to policy. An LPN left a medication cart unlocked and unattended, and an opened vial of Lispro Insulin was not labeled with the date it was opened. Additionally, a narcotic storage box in the refrigerator was found unlocked due to a broken key, leaving Lorazepam unsecured.
A resident experienced ongoing pain and discomfort due to ill-fitting dentures and was not provided with necessary dental services, despite the facility's policy requiring annual assessments. The resident's complaints were not followed up with a dental consultation, leading to continued issues.
A facility failed to serve food at palatable temperatures, as observed during a meal trayline inspection. A resident had previously raised concerns about meal temperatures, and although the Dietary Director educated staff on proper temperature maintenance, food was still served cool or warm when it should have been hot or cold. The Chef Manager confirmed the deficiency.
The facility failed to obtain necessary documentation from the contracted hospice provider for two residents receiving hospice services. One resident, with Alzheimer's, heart failure, and Parkinson's, lacked updated nursing notes, while another resident with cerebral atherosclerosis had no hospice RN and nurse aide progress notes. The DON confirmed the absence of required documentation.
The QAPI committee failed to address recurring deficiencies, including unresolved grievances, inaccurate MDS assessments, and issues with care plans, quality of care, accident hazards, nutrition, hydration, and hospice care. Despite previous corrective plans, the facility remained non-compliant in these areas.
A facility failed to follow infection control guidelines by not implementing Enhanced Barrier Precautions (EBP) for a resident with a history of CRE. During a transfer, a nurse aide wore gloves but not a gown, contrary to policy. The resident's care plan required EBP due to her condition, and the DON confirmed the need for both gown and gloves.
The facility did not ensure that two nurse aides completed the required annual 12 hours of in-service education. A review of their education files showed no documentation of completion, which was confirmed by the DON.
The facility failed to accurately complete MDS assessments for three residents. One resident's hospice care was not documented, another's antipsychotic medication and urinary catheter use were inaccurately recorded, and a third resident's oxygen therapy was not noted. These discrepancies were confirmed by the Corporate Compliance Officer.
Failure to Use Wheelchair Footrests During Transport Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to follow its wheelchair transport policy requiring the use of footrests during transport, resulting in a resident fall and injuries. The written policy dated January 8, 2026, specified that footrests must be used when staff, family, volunteers, and healthcare partners transport residents in wheelchairs, Broda chairs, or other chairs with attachable footrests to prevent accidents and injuries. Resident 1’s annual MDS assessment dated February 13, 2026, documented that the resident was cognitively impaired, required staff assistance for daily care needs, and had dementia among other diagnoses. On December 20, 2025, at approximately 10:40 p.m., Nurse Aide 1 was pushing Resident 1 in a wheelchair without leg rests in place when the resident leaned forward and fell to the floor. The incident investigation and witness statement from Nurse Aide 1 confirmed that the resident did not have leg rests on the wheelchair at the time of transport and that the resident leaned forward and fell out of the wheelchair. As a result of the fall, Resident 1 sustained a 1.5 by 1.5-centimeter abrasion to the left side of the forehead, a 0.5 by 0.5-centimeter abrasion to the left eyebrow, and a 3 by 3-centimeter bruise to the left side of the forehead. In an interview, the Nursing Home Administrator confirmed that leg rests should have been in place when transporting this resident, indicating noncompliance with the facility’s resident care policies and nursing services requirements under 28 Pa. Code 211.10(c)(d) and 211.12(d)(5).
Failure to Individualize Care Plans for Bed Placement Preferences
Penalty
Summary
The facility failed to develop individualized care plans for three residents, as required by regulation. Clinical record reviews, observations, and interviews revealed that the care plans for these residents did not address specific needs and preferences related to bed placement. For one resident with confusion, a hip fracture, and dementia, the care plan did not mention that the bed was positioned against the wall, despite this being observed in the resident's room. Another resident, who was alert with some confusion and had dementia, also had a care plan that omitted her preference to keep her bed against the wall. A third resident, who was alert and oriented with a diagnosis of schizoaffective disorder, similarly had a care plan that did not include her preference for bed placement. These omissions were confirmed during an interview with the Director of Nursing, who acknowledged that the care plans should have included information about the residents' beds being against the wall. The lack of individualized care planning for these residents was identified through comprehensive and quarterly MDS assessments, as well as direct observation and staff interviews.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to serve food that was palatable and maintained at proper temperatures, as required by its dietary policy. Review of the policy indicated that food should be prepared to retain flavor, appearance, and nutrients, and held at safe temperatures—hot foods at 140°F or above and cold foods at 40°F or below. Interviews with two residents revealed complaints about food not being warm, poor taste, and inconsistent temperatures. Observation of a test tray during a lunch meal showed that oven roasted potatoes and brussel sprouts were served at 104.1°F and 106.2°F, respectively, which are below the required hot holding temperature. Additionally, the chicken was found to be bland and unseasoned. The Chef Manager confirmed the low temperatures and lack of seasoning in the food.
Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of controlled medications for nine residents, as evidenced by discrepancies between the controlled substance dispense logs and the medication administration records (MARs). The facility's policy strictly prohibits the misappropriation of resident property, including medications, but an audit revealed that an LPN signed out doses of Norco and Oxycodone for multiple residents without documentation that the medications were administered. In several cases, the residents' MARs and clinical records contained no evidence that the signed-out doses were given, and interviews with alert residents confirmed they did not receive the medications at the documented times. The residents affected included both cognitively impaired and cognitively intact individuals, many of whom had orders for as-needed or routine opioid pain medications due to frequent or constant pain. The controlled drug records showed that doses were removed from the blister cards and signed out for administration, but there was no corresponding documentation in the MARs or clinical records to indicate that the medications were actually provided to the residents. For residents who were not alert and oriented, records indicated they did not routinely request as-needed pain medications, further supporting the finding that the medications were not administered as documented. The facility's investigation identified a pattern of misappropriation by the LPN, who removed and signed out narcotics for the affected residents without administering them. This was confirmed through record reviews, resident interviews, and the facility's own investigation, which concluded that the LPN had diverted the medications for personal use or other unauthorized purposes. The deficiency was cited under state regulations related to the responsibility of license, management, and nursing services.
Failure to Update Care Plans Following Changes in Resident Status and Physician Orders
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect the current care needs of five residents. According to the facility's policy, care plans must be evaluated at least every 90 days, annually, and whenever there is a significant change in a resident's condition, including after hospital stays or incidents. However, clinical record reviews and staff interviews revealed that care plans were not consistently updated following changes in physician orders or resident status. For example, one resident was initially placed on transmission-based precautions for VRE of the urine, but after the precautions were discontinued by physician order, the care plan was not revised to reflect this change. Similarly, another resident was placed on droplet precautions for influenza, but the care plan was not updated after the precautions were discontinued. In another case, a resident was prescribed an antipsychotic medication, but the care plan did not include this new medication. Additionally, a resident receiving oxygen therapy had a care plan that did not match the current physician orders regarding oxygen flow rate and target oxygen saturation. Finally, a resident's care plan continued to indicate a two-person assist for transfers, despite a physician order changing the requirement to a one-person assist. These deficiencies were confirmed through interviews with the Quality Assurance and Performance Improvement Registered Nurse, who acknowledged that the care plans had not been revised to reflect the most current orders or resident needs. The lack of timely updates to care plans resulted in discrepancies between the care being provided and the documented care plans for these residents.
Failure to Document Urinary Output for Catheterized Resident
Penalty
Summary
The facility failed to ensure that urinary output was measured and recorded as care planned for a resident with an indwelling urinary catheter. The resident, who had obstructive uropathy and required a catheter, had a care plan directing staff to accurately measure and document urinary output every shift. Clinical record review showed multiple instances across various shifts and dates where there was no documented evidence that the resident's urinary output was obtained. This lack of documentation was confirmed by the Quality Assurance and Performance Improvement Registered Nurse during an interview.
Failure to Maintain Sanitary Conditions and Incomplete Dishwasher Temperature Monitoring
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen by not adhering to its own cleaning and monitoring policies. Observations revealed a significant build-up of a black, removable substance on the lower wall behind the dishwasher and a thick accumulation of dust and debris on the dishwasher exhaust vents, indicating that required cleaning was not performed as specified in the facility's policy. Additionally, review of the dishwasher temperature log showed that staff did not consistently record the required wash and rinse temperatures before each meal, with multiple dates missing entries and staff initials. The Dietary Manager confirmed that both the cleaning and temperature logging procedures were not followed as required.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident, the quarterly MDS assessment did not indicate the administration of anticonvulsant medication, despite physician's orders and the Medication Administration Record (MAR) confirming that the resident received Divalproex during the seven-day look-back period. This discrepancy was confirmed by the Quality Assurance and Performance Improvement Registered Nurse. Another resident's significant change in status MDS assessment was inaccurately coded regarding cognitive status. Although the resident was sometimes understood, the assessment was marked as if the resident was rarely/never understood, resulting in the Brief Interview for Mental Status (BIMS) not being attempted, contrary to manual instructions. Additionally, a third resident's significant change MDS assessment failed to indicate the administration of antibiotics, antiplatelet medications, and the presence of IV access, despite physician's orders and the MAR confirming these treatments occurred during the assessment period. These inaccuracies were confirmed through staff interviews.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident. According to facility policy, staff are required to initial the Medication Administration Record (MAR) after administering each medication. For a resident who was cognitively intact and required assistance with daily care, physician orders specified the administration of 50 mg of Tramadol every six hours for pain. Review of the resident's MAR for a specific month showed that several doses of Tramadol were signed out for administration on multiple dates. However, there was no documented evidence in the MAR or clinical record that these doses were actually administered to the resident on those dates. This lack of documentation was confirmed by the Quality Assurance and Performance Improvement Registered Nurse during an interview. The deficiency was cited under the relevant state pharmacy and nursing services regulations.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as required. During medication administration observations, two errors were identified out of 35 opportunities, resulting in an error rate of 5.71 percent. One error involved a nurse crushing Metoprolol Extended Release (ER) tablets for a resident, despite manufacturer instructions and physician orders specifying that the ER tablets should not be crushed, as this could alter the medication's effectiveness and safety. The nurse confirmed the error during an interview, as did the Quality Assurance and Performance Improvement Registered Nurse. A second error was observed when a nurse administered Voltaren 1 percent gel to a resident without measuring the prescribed two-gram dose as directed by the manufacturer and physician orders. Instead, the nurse applied the gel by squeezing it onto her gloved hand and then onto the resident's toes, without using the dosing card to ensure the correct amount. The nurse acknowledged during an interview that she routinely applied the gel in this manner and did not measure the dose. The Quality Assurance and Performance Improvement Registered Nurse also confirmed that the gel should have been measured according to the manufacturer's instructions.
Failure to Label Insulin and Discard Expired Testing Solution
Penalty
Summary
Surveyors identified that the facility failed to properly label multi-dose containers of insulin with the date they were opened on one of four medication carts reviewed. Specifically, a multidose vial of Lantus insulin for one resident and a prefilled pen of Insulin glargine for another resident were found opened and not labeled with the date of opening. Interviews with an LPN and the Quality Assurance and Performance Improvement RN confirmed that these insulin containers should have been labeled with the date they were opened, in accordance with facility policy and manufacturer instructions. Additionally, the facility failed to discard an expired bottle of Aplisol testing solution in one of four medication room refrigerators reviewed. The Aplisol multidose vial was observed to have been opened 34 days prior, exceeding the manufacturer's recommended 30-day use period. The LPN confirmed that the vial should have been discarded. These findings were based on review of facility policies, manufacturer directions, clinical records, direct observation, and staff interviews.
Repeated QAPI Failures Lead to Ongoing Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effective. Despite developing plans of correction for previously cited deficiencies, the facility continued to have repeated issues identified in multiple surveys. These deficiencies included failure to provide confidentiality of residents' personal health information, inaccurate Minimum Data Set (MDS) assessments, improper care plan timing and revision, inadequate monitoring of urinary output, failure to maintain a medication error rate below 5 percent, improper labeling and storage of medications, and not serving palatable food at appropriate temperatures. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but the same deficiencies were repeatedly cited in subsequent surveys, indicating that the committee's actions were ineffective. The report specifically notes that for each cited deficiency, the facility's plan of correction involved conducting audits and reporting the results to the QAPI committee. However, the current survey found that these measures did not result in sustained compliance, as the same issues persisted across multiple survey periods. The deficiencies were cited under specific federal tags (F583, F641, F657, F690, F759, F761, F804) and referenced state regulations, but there is no mention of individual residents' medical histories or conditions in the report.
Failure to Maintain Kitchen Refrigerator in Safe Working Condition
Penalty
Summary
The facility failed to maintain the reach-in refrigerator in the Main Kitchen in proper working condition. During an observation, the rubber gasket at the bottom of the refrigerator door was found to be loose and hanging down, which prevented the door from closing easily. The Chef Manager confirmed that the gasket was loose and acknowledged that it should have been repaired. No information about residents or their medical conditions was provided in relation to this deficiency.
Failure to Follow Resident Medication Administration Preferences Resulting in Distress
Penalty
Summary
A deficiency occurred when a nurse failed to follow a resident's stated preference and clinical record instructions for medication administration. The resident, who was cognitively intact and diagnosed with Parkinson's Disease, informed the nurse that he takes his pills one at a time on a spoon. Despite this, the nurse placed all of the resident's pills in his mouth at once, leading to a coughing episode, watery eyes, and a runny nose. The nurse did not remain with the resident to assess his condition and dismissed concerns raised by a nurse aide, refusing to check on the resident after the incident. The resident continued to experience distress until another staff member intervened and a registered nurse assessed him. The incident resulted in a downgrade of the resident's diet and a referral to speech therapy. Interviews confirmed that the nurse's actions caused both physical and emotional distress to the resident and that the nurse failed to report the incident or seek appropriate assessment for the resident after the adverse event.
Failure to Monitor Hot Liquid Temperatures Leads to Resident Burns
Penalty
Summary
The facility failed to ensure that the environment was free of accident hazards by not adhering to its policy on serving hot liquids at safe temperatures. Specifically, the facility did not check the temperature of hot liquids before serving them to residents, which resulted in burns to two residents. The policy required that hot liquids should not exceed 155 degrees Fahrenheit when served, but this was not consistently followed, leading to incidents where residents were served beverages at higher temperatures. Resident 2, who was cognitively impaired and required assistance with daily care needs, spilled hot coffee on herself, resulting in redness on her left upper thigh. The coffee temperature was later found to be 149 degrees Fahrenheit, but there was no documented evidence that the temperature was checked before serving. Similarly, Resident 5, who also required assistance with daily activities, suffered burns after spilling hot tea on herself. The tea was found to be at 185.1 degrees Fahrenheit, and again, there was no documentation of the temperature being checked prior to serving. Interviews with facility staff, including the Assistant Nursing Home Administrator and the Dietary Manager, confirmed that there were lapses in following the policy for checking and documenting the temperature of hot liquids. The Dietary Manager noted that the coffee machine used was not the facility's and that no temperature logs were being completed. These oversights placed residents at risk of serious injury, as evidenced by the burns sustained by Residents 2 and 5.
Removal Plan
- The facility will review all daily temperature logs for the current dinner meal being served to ensure the temperature falls within current policy guidelines with all staff currently working.
- The facility will educate all Dining Service staff that the requirement of taking temperatures of hot beverages in the serving container prior to serving these beverages to the residents must be done prior to every meal and documented on the Daily Temperature Log.
- If the temperature of a hot beverage falls outside the range of 145 degrees Fahrenheit to 155 degrees Fahrenheit, do not serve the beverage until it cools down and is in these parameters.
- Daily monitoring of Daily Temperature Logs will be done by the Director of Dining Services or designee.
- The Director of Dining Services or designee will audit for any allegations of abuse or neglect emphasizing to all employees zero tolerance.
- Audits will include assessing whether the unit report sheets are up to date and that staff are utilizing these quick reference guides prior to initiating care.
- All findings will be reported to the Quality Assurance Performance Improvement Committee.
- If deficient practices are identified, additional corrective action will be taken.
Failure to Maintain Appetizing Food Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures, as evidenced by observations and staff interviews. The facility's policy on taste and temperature control requires that hot foods be held at temperatures of 140 degrees Fahrenheit or above, and cold foods at 40 degrees Fahrenheit or below. However, during a Resident Council meeting, residents from the Villa [NAME] Unit reported that their food was often cold on Thursdays and Fridays when the usual dietary aide was absent. This complaint was substantiated by observations made on November 21, 2024, when food items were not maintained at the required temperatures. During the observation, it was noted that the dietary worker placed prepared food items into the steam table and later removed cold beverages from the refrigerator, placing them on the counter without ice. The meals were prepared for residents in the dining room first, followed by those who eat in their rooms. By the time the last resident was served, the temperature of the onion rings was 92 degrees Fahrenheit, the Italian Wedding soup was 132.8 degrees Fahrenheit, and the white milk was 55.5 degrees Fahrenheit. These temperatures were confirmed to be unpalatable by the Chef Manager, indicating a failure to adhere to the facility's policy on maintaining appropriate food temperatures.
Failure to Ensure Safe Serving of Hot Liquids
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to manage the facility effectively, resulting in a deficiency related to the serving of hot liquids at inappropriate temperatures. This failure jeopardized the health and safety of two residents, identified as Resident R2 and Resident R5, during the survey. The job descriptions for both the NHA and DON emphasize their responsibility to direct the functions of the Nursing Department and ensure compliance with professional standards and regulations. However, the survey findings indicate that they did not fulfill these essential duties, leading to an environment that was not free of accident hazards. The deficiency was cited under the Code of Federal Regulatory Groups for Long-Term Care, specifically 483.25(b)(1)(2) Free of Accident Hazards/Supervision/Devices (F689). Additionally, the report references state regulations, including 28 Pa. Code 201.14(a) Responsibility of Licensee, 28 Pa. Code 201.18(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(5) Nursing Services. These citations highlight the failure of the NHA and DON to ensure that the facility operated in compliance with state regulations and codes, particularly concerning the safe serving of hot liquids to residents.
Resident Injury Due to Improper Transfer
Penalty
Summary
The facility failed to ensure that residents were free from abuse and neglect, as evidenced by an incident involving a resident who was transferred incorrectly, resulting in a fracture. The resident, who was cognitively impaired and required assistance with transfers due to Alzheimer's disease and osteoporosis, was supposed to be transferred using a mechanical lift. However, an agency nurse aide attempted to transfer the resident without the lift, leading to the resident falling and sustaining a minimally impacted supracondylar fracture of the distal left femur. The incident occurred when the agency nurse aide, unaware of the resident's care plan requirements, attempted to help the resident stand and pivot without the necessary equipment. The resident fumbled to the floor during this process. Another nurse aide entered the room and assisted in lifting the resident into a wheelchair without reporting the incident to the licensed practical nurse or registered nurse on duty. The resident was later assessed and found to have a swollen left leg and was in severe pain, leading to the discovery of the fracture. The facility's investigation revealed that the agency nurse aide had received abuse and neglect training earlier in the year but failed to follow the care plan for the resident. The incident was not reported immediately, and the failure to notify the appropriate nursing staff was verified. The facility's policies clearly stated that residents must not be subjected to abuse or neglect by anyone, and the actions of the nurse aides were in direct violation of these policies.
Failure to Report Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that staff immediately reported a fall with injury involving a resident who was cognitively impaired and required assistance with care needs. The resident, who had Alzheimer's disease and osteoporosis, was dependent on a mechanical lift for transfers. On August 5, 2024, Nurse Aide 1 discovered the resident on the floor in her room with Nurse Aide 2 present. Despite the incident, neither nurse aide reported the fall to the licensed practical nurse or registered nurse on duty. The resident was assessed the following day, complaining of severe pain in her left leg, which was swollen. An x-ray revealed a minimally impacted supracondylar fracture of the distal left femur, and the resident was subsequently sent to the hospital. Investigation documents revealed that Nurse Aide 2 had attempted to transfer the resident without the required mechanical lift, leading to the fall. Nurse Aide 2 claimed she was unaware of the resident's need for a mechanical lift and did not see the hoyer sling in the room. The incident was reported to the Area Agency on Aging after the fact, and it was confirmed that the licensed practical nurse assigned to the resident was not informed of the fall. The failure to follow the resident's care plan for transfers and the delay in reporting the incident were verified. Nurse Aide 2 had previously received abuse and neglect training, yet the incident was not reported promptly, resulting in a deficiency finding against the facility.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect the specific care needs of several residents. For Resident 3, the care plan did not include the need for antianxiety and antipsychotic medications, despite physician orders for Olanzapine and Lorazepam. The Director of Nursing confirmed that the care plan should have been revised to include these medications. Similarly, Resident 7's care plan was not updated to address the need for a reacher to aid in fall prevention, nor did it include the resident's need for re-education on using the reacher after a fall incident. Resident 26's care plan failed to reflect the use of plastic utensils, which were necessary for the resident's safety as part of a feeding program. The Director of Nursing acknowledged that the care plan should have been updated to include this information. For Resident 30, the care plan did not reflect the current physician's order for feeding tube flushes, which had been changed from 175 ml to 250 ml of water every four hours. This discrepancy was confirmed by the Director of Nursing. Additional deficiencies were noted for Resident 64, whose care plan was not revised to reflect the discontinuation of a urinary catheter. Resident 66's care plan did not reflect the current anticoagulant medication, Eliquis, and instead contained outdated information about Xarelto. Lastly, Resident 73's care plan was not updated to reflect current treatment orders for pressure ulcers and did not indicate that certain wounds had resolved. The Corporate Compliance Officer confirmed these oversights in the care plans.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to follow physician's orders for four residents, leading to deficiencies in care. For one resident, who was cognitively impaired and on Eliquis, a bruise was observed but not reported to the physician as required. Another resident, who was cognitively intact and had atrial fibrillation, received midodrine despite blood pressure readings that should have prompted the medication to be held according to physician's orders. Additionally, a resident with hypoxia did not have pulse oximetry readings documented for several days, contrary to the physician's orders for every shift monitoring. Lastly, a resident with chronic kidney disease did not have intake and output measurements documented for multiple days, as was ordered by the physician. These failures were confirmed through interviews with the Director of Nursing.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by observations during a medication administration session. During this session, eight medication errors were made out of 28 opportunities, resulting in an error rate of 28.57 percent. The errors involved a resident with multiple medical conditions, including a seizure disorder and profound mental retardation with agitation, who was prescribed several medications to be administered via a gastric tube. However, the Licensed Practical Nurse (LPN) responsible for administering these medications did not prepare one of the prescribed medications, Klonopin, and subsequently held all medications due to perceived excessive gastric residual without a physician's order to do so. The LPN, upon checking the gastric residual, found approximately 60 ml and decided not to administer the prepared medications, contacting her supervisor instead. Despite not having an order to hold the medications based on residual amount, the LPN and a Registered Nurse Supervisor later wasted the prepared medications. Interviews with the nursing staff and the Director of Nursing confirmed that the medications should have been administered, as the residual content was not over 100 ml. This incident was documented in the Medication Administration Record, and a medication error report was initiated by the Director of Nursing.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine if a resident was safe to self-administer medications, as required by their policy. The policy stated that a physician's order was necessary for a resident to self-administer medications, and the nurse must remain with the resident until the medication is taken. However, for one resident, there was no documented evidence of an evaluation or a physician's order for self-administration of medications. The resident was cognitively intact but required extensive assistance from staff, and had multiple medications prescribed, including Colace, Eliquis, Renvela, Benadryl, and aspirin. During an observation of medication administration, the resident was found lying in bed with a medication cup containing their morning doses, and the LPN was not present in the room. The LPN confirmed that she left the room after administering the medication and did not observe the resident taking it. The Director of Nursing also confirmed that no assessment was completed to determine the resident's capability to self-administer medications and that the LPN should not have left the medications with the resident.
Failure to Inform and Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed of their rights to develop advance directives and were not provided with the opportunity or assistance to formulate one. This deficiency was identified for three residents during a review of clinical records and staff interviews. Resident 3, who was cognitively impaired and diagnosed with dementia, had no evidence in their clinical record indicating that they or their representative were informed about advance directives. Similarly, Resident 7, who was cognitively impaired with diagnoses including hemiplegia and stroke, also lacked documentation of being informed or assisted with advance directives. Resident 55, with cognitive impairment and a diagnosis of dementia, was found in the same situation. An interview with the Social Service Director confirmed that there was no official process in place to address advance directives with residents or their representatives upon admission or during their stay. The Social Service Director acknowledged that if residents did not have an advance directive, they were not offered assistance in formulating one. This lack of a formal process contributed to the facility's failure to uphold residents' rights to request, refuse, or discontinue treatment, and to formulate an advance directive, as required by regulations.
Failure to Provide Required Medicare Coverage Notice
Penalty
Summary
The facility failed to provide the required notice to a resident or the resident's representative following the end of their Medicare coverage. Specifically, for one resident, Medicare coverage began on April 21, 2024, and ended on May 8, 2024. Although the resident signed a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form on May 6, 2024, there was no documented evidence that the resident received a SNF Beneficiary Protection Notification form or an Advanced Beneficiary Notice (ABN) as required. An interview with the Social Worker confirmed that the ABN was not completed in a timely manner, as she forgot to issue any ABN notices for any residents.
Breach of Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during medication administration. On July 25, 2024, at 8:27 a.m., a Licensed Practical Nurse (LPN) left the medication cart unattended while assisting a resident, leaving the computer screen displaying the resident's personal health information visible to the hallway. This action was in violation of the facility's privacy policy dated October 13, 2023, which mandates that residents' health information must remain private. The LPN confirmed during an interview that she should have secured the computer screen to cover the resident's personal information when leaving the medication cart. The Director of Nursing also confirmed that the computer screen should have been covered when unattended, ensuring the confidentiality of the resident's health information.
Failure to Address Dietary Grievance and Maintain Food Temperatures
Penalty
Summary
The facility failed to adequately address a grievance related to dietary complaints from a resident. The resident expressed concerns about the temperature of hot meals during a resident council meeting, suggesting that meals would be better if served from a hot meal cart. Despite this, the facility's grievance logs did not reflect any grievances related to food. A memo from the Director of Resident and Community Engagement indicated that the Dietary Director was informed of the food temperature concerns and had instructed dietary staff to ensure proper temperature checks. However, observations during a lunch meal service revealed that food was served on a metal, open cart without insulation, resulting in food temperatures that were below acceptable levels. The French fries and hamburger were notably cool to taste, with temperatures recorded at 108°F and 116°F, respectively. The Dietary Aide suggested reheating the food in a microwave if necessary. Interviews with the Dietary Director confirmed that there was only one insulated cart available, and she acknowledged the need for additional insulated carts to maintain food temperatures during transport.
Inappropriate Handling of Resident During Shower Refusal
Penalty
Summary
The facility failed to protect Resident 63 from abuse and neglect, as evidenced by an incident involving inappropriate handling by a staff member. Resident 63, who was cognitively impaired with diagnoses including dementia and Alzheimer's disease, was known to be afraid of showers and became agitated during certain times of the day. On the morning of January 29, 2024, Nurse Aide 3 and an LPN attempted to give Resident 63 a shower, which she refused. During this interaction, Nurse Aide 3 picked up Resident 63 by the waist and carried her down the hallway, despite the resident's repeated cries of 'ouch' and complaints of pain. The incident was witnessed by the resident's daughter-in-law, who is also an employee, and the LPN. Both witnesses reported that Resident 63 was visibly distressed and stated that she was hurt, rubbing her right hip after being put down. The daughter-in-law attempted to calm the resident and suggested that an evening bath might be more suitable, given the resident's usual mood patterns. Despite the resident's agitation and refusal, Nurse Aide 3 continued to insist on the shower, demonstrating a lack of sensitivity to the resident's needs and preferences. The facility's investigation revealed that Nurse Aide 3 had previously used similar methods to coax Resident 63 into the shower, believing it to be a calming technique. However, this approach was deemed inappropriate and contrary to the facility's abuse policy, which emphasizes the residents' right to be free from any form of abuse or mistreatment. The incident highlighted a failure in adhering to the policy, resulting in the resident experiencing unnecessary distress and potential harm.
Medication Misappropriation Incident
Penalty
Summary
The facility failed to prevent the misappropriation of medication for one resident, identified as Resident 111. The resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of chronic pain. Physician's orders indicated that the resident was to receive Carisoprodol, a muscle relaxant, four times a day. During a routine narcotic count, it was discovered that the count for Resident 111's medication was incorrect, with one extra pill noted. Further inspection revealed that the blister pack containing the medication had been tampered with, and the pills in the opened slots did not match the remaining ones. The alleged perpetrator was an agency nurse, identified as Licensed Practical Nurse 9, who left the facility without performing the required medication count at the end of her shift. The facility attempted to contact her for a statement, but she did not respond, leading to the involvement of the local police to identify the pills. The investigation concluded that misappropriation of the resident's medication had occurred, and the incident was reported to the PA State Board of Nursing.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman in writing regarding the reasons for transfers or discharges to the hospital for five residents. The facility's policy, dated October 13, 2023, requires reporting of emergent facility discharges/transfers to the Ombudsman on a monthly basis. However, there was no documented evidence of such notifications for Residents 11, 47, 67, 73, and 108, who were transferred to the hospital for various medical reasons. Resident 11, who was cognitively impaired and receiving antipsychotic medications, was transferred to the hospital due to agitation and a potential septic condition. Resident 47, with Parkinson's disease, was sent to the hospital after a fall resulting in a hip fracture. Resident 67, who had heart failure, was transferred for evaluation. Resident 73, with a Stage 4 pressure ulcer, was sent for surgical debridement. Resident 108, who had a stroke, was transferred following a fall. Interviews with the Director of Nursing confirmed the lack of written notifications to the Ombudsman for these transfers.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed for a resident to reflect their specific care needs. The deficiency was identified during a review of facility policy, clinical records, and staff interviews. The facility's policy, dated October 13, 2023, mandates that care plans should address resident concerns and unique characteristics, including diagnosis, activity level, diet, medication, treatments, and specific therapeutic interventions. However, for one resident, identified as Resident 84, the care plan did not include the necessary details regarding the resident's need for antipsychotic medications, despite the resident being cognitively impaired and diagnosed with depression and dementia. The quarterly Minimum Data Set (MDS) assessment for Resident 84, dated June 8, 2024, indicated that the resident required assistance with care needs and was receiving antipsychotic medications. A physician's order dated April 2, 2024, prescribed 25 mg of Quetiapine twice a day for depression and behaviors. Despite these documented needs, there was no evidence in the clinical records that a care plan was created to address the resident's requirement for antipsychotic medications in conjunction with their dementia diagnosis. This oversight was confirmed during an interview with the Director of Nursing on July 25, 2024.
Failure to Use Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure a safe environment for residents by not adhering to its transportation policy, which mandates the use of footrests when transporting residents in wheelchairs. This deficiency was identified during a review of policy, clinical records, observations, and staff interviews. Specifically, a cognitively impaired resident, who required maximum assistance for all care and used a broda chair, was observed being transported without leg/footrests. The incident occurred when a nursing assistant pushed the resident from her room to the dining room without the necessary leg/footrests, despite being aware of the policy requirement. The Director of Nursing confirmed that all staff, including agency and hospice staff, should use leg/footrests when transporting residents in wheelchairs.
Failure to Monitor Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to adhere to physician's orders for monitoring the urinary output of a resident with an indwelling urinary catheter. According to the facility's policy dated October 13, 2023, output monitoring is required for residents with specific conditions, including those with a Foley catheter. The resident in question, who was cognitively impaired and required assistance for daily care, had a physician's order dated February 9, 2024, mandating intake and output monitoring every shift. However, a review of the Treatment Administration Records (TARs) for April, May, June, and July 2024 revealed a lack of documented evidence that the resident's catheter output was monitored as ordered. Specifically, there was no documentation of output monitoring on all three shifts for the entire months of April, June, and July, with only a few exceptions in May and July. The Director of Nursing confirmed the absence of documentation for the specified dates and shifts, indicating a failure to comply with the physician's orders.
Failure to Follow Fluid Restrictions and Obtain Weekly Weights
Penalty
Summary
The facility failed to ensure that fluid restrictions were being followed for a resident with kidney failure. The resident was on a 1500 cc/day fluid restriction, with specific allocations for dietary and each shift. However, there was no documented evidence in the medical record that this fluid restriction was adhered to. This was confirmed by an interview with the Director of Nursing, who acknowledged the lack of documentation. Additionally, the facility did not obtain and document weekly weights for a resident with a history of significant weight loss and pressure ulcers, as per the physician's order. The resident experienced a weight loss of 22.8 pounds over six months and had inadequate intake of meals, although she was taking all prescribed supplements. Despite the order for weekly weights to monitor her condition, the weights were not recorded on several specified dates. This deficiency was also confirmed by the Director of Nursing.
Failure to Document Feeding Tube Placement Checks
Penalty
Summary
The facility failed to ensure that a resident receiving tube feedings received appropriate treatment and services to prevent complications. The facility's policy on Enteral Feeding required that the peg tube be checked for placement before administering feedings. A quarterly Minimum Data Set (MDS) assessment for Resident 30, who was cognitively impaired and required assistance with care needs, indicated the presence of a feeding tube. The resident's care plan also specified that the feeding tube should be checked for placement. However, a review of the clinical record revealed no documented evidence that the feeding tube was being checked for placement as required by the care plan and facility policy. An interview with the Director of Nursing confirmed the absence of documentation for the feeding tube checks.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis had an active physician's order to attend dialysis, obtain physician's orders for the care and monitoring of dialysis sites, and maintain communication with the dialysis facility. The facility's policy required a physician's order to establish dialysis days, and communication forms from the dialysis clinic were to be scanned into the resident's electronic medical record. However, there was no documented evidence of a physician's order for dialysis or for the care of the resident's fistula, nor was there evidence of continued communication between the facility and the dialysis center. The resident involved was cognitively intact, required assistance for daily care needs, and had a diagnosis of kidney failure necessitating dialysis treatments. Observations revealed that the resident had a dry gauze dressing on his fistula site but lacked an emergency kit in his room. The resident reported not taking any paperwork to dialysis and only bringing back a piece of paper for the registered nurse supervisor. Interviews with staff, including an LPN and the Director of Nursing, confirmed the absence of necessary documentation and awareness of protocols for emergency situations related to the resident's dialysis care.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for two of five nurse aides reviewed. Specifically, the evaluations for Nurse Aides 11 and 12 were due between November 2023 and February 2024, but as of July 24, 2024, there was no documented evidence that these evaluations had been completed. This deficiency was confirmed during an interview with the Director of Nursing, who was unable to provide evidence of the required evaluations. The failure to conduct these evaluations is a violation of the facility's responsibility under the specified Pennsylvania Code sections related to the responsibility of the licensee, management, and staff development.
Failure to Implement Individualized Care Plan for Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with dementia-related behaviors, as evidenced by the lack of an individualized, person-centered care plan. The resident, who was cognitively impaired and diagnosed with depression, anxiety, and dementia, exhibited inappropriate behaviors such as screaming, hitting staff, and refusing care. Despite having a care plan that included monitoring behaviors and maintaining a calm environment, the facility did not implement these interventions effectively. On a specific day, the resident displayed extreme confusion and agitation, entering another resident's room multiple times and becoming physically aggressive when asked to leave. The resident threatened staff with tweezers and engaged in a physical altercation with another resident. Although the staff managed to separate the residents and calm the situation, there was no evidence that the facility had developed or implemented new behavioral interventions to prevent future incidents. The Director of Nursing confirmed that the staff did not follow the existing interventions for managing the resident's behaviors, nor did they create a new, individualized behavior plan following the incident. This oversight left other residents at risk and highlighted the facility's failure to address the resident's dementia-related behaviors adequately.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medications as per their policies. During an observation, a medication cart was found unlocked and unattended by an LPN while providing care to a resident. Both the LPN and the Director of Nursing confirmed that the cart should have been locked when not in view. Additionally, a medication cart was found to contain an opened vial of Lispro Insulin that was not labeled with the date it was opened, contrary to the facility's policy requiring such labeling. This was confirmed by both a registered nurse and the Director of Nursing. Furthermore, the facility did not properly secure narcotic medications in the medication refrigerator. A clear plastic box meant for storing narcotics was found unlocked, containing a bottle of Lorazepam oral concentrate. The LPN present confirmed that the box was not locked due to a broken key. The Director of Nursing also confirmed the unsecured state of the Lorazepam. These findings indicate a failure to adhere to the facility's policies regarding medication security and labeling.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services to a resident, as required by their dental services policy. The policy, dated October 13, 2023, mandates annual oral assessments by a licensed dentist or hygienist for all residents. However, a dental progress note from May 25, 2023, indicated that the resident refused treatment and there was no documented follow-up attempt. This lack of follow-up led to the resident experiencing significant discomfort and pain, as noted in a nursing note from December 28, 2023, where the resident complained of right-side facial pain and requested Tylenol. Further documentation from January 26, 2024, revealed that the resident had not worn her dentures due to poor fit and discomfort, yet there was no evidence of a dental consultation to address these issues. An interview with the resident on July 22, 2024, confirmed ongoing pain and the absence of dentures due to discomfort. The Corporate Compliance Officer acknowledged on July 25, 2024, that the resident had not been seen by a dentist for her complaints or for an annual assessment, as required.
Deficiency in Serving Palatable Food Temperatures
Penalty
Summary
The facility failed to serve food items at palatable temperatures, as evidenced by observations and interviews. During a resident council meeting, a resident expressed concerns about the temperature of hot meals, suggesting that meals would be more enjoyable if served from a hot meal cart. Despite no grievances being recorded in the facility logs, the issue was acknowledged by the Director of Resident and Community Engagement, who communicated with the Dietary Director to address the concern. The Dietary Director subsequently educated staff on ensuring food temperatures were properly maintained. However, during an observation of the meal trayline, it was noted that food was not served at palatable temperatures. The food was placed on an open cart without insulation, and by the time it reached the residents, items such as French fries and hamburgers were cool, while cold beverages were warm. The Dietary Aide suggested reheating food in a microwave if necessary, and the Chef Manager confirmed the food was not served at a palatable temperature. This deficiency was in violation of the relevant Pennsylvania Code sections regarding management and dietary services.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two residents receiving hospice services. For one resident, who was cognitively impaired and required extensive assistance with daily care needs, there was no documented evidence in the clinical record or the hospice provider's record that updated nursing notes from hospice were obtained. This resident had diagnoses including Alzheimer's disease, heart failure, and Parkinson's disease, and was receiving hospice services as per physician's orders. Similarly, for another resident who was cognitively impaired and required assistance for daily care needs, there was no documented evidence of the hospice's registered nurse and nurse aide progress notes in the clinical record. This resident had diagnoses including cerebral atherosclerosis and was also receiving hospice services. Interviews with the Director of Nursing confirmed the absence of necessary documentation in both cases, which should have been part of the hospice provider's clinical record.
QAPI Committee Fails to Correct Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address and correct recurring deficiencies identified in both previous and current surveys. The deficiencies included unresolved grievances, inaccuracies in Minimum Data Set (MDS) assessments, and issues with initiating and revising residents' care plans. Additionally, the facility struggled with maintaining quality of care, addressing accident hazards, ensuring proper nutrition and hydration, and providing adequate hospice care. These issues were identified in the current survey ending July 25, 2024, despite the facility having developed plans of correction in response to a previous survey ending September 14, 2023. The plans of correction from the previous survey included implementing quality assurance systems, conducting audits, and reporting audit results to the QAPI committee. However, the current survey revealed that these measures were ineffective in maintaining compliance with nursing home regulations. The repeated deficiencies indicate that the QAPI committee did not successfully implement or sustain the corrective actions necessary to improve the delivery of care and services, as evidenced by the continued non-compliance in several critical areas.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to prevent the spread of infections and cross-contamination. Specifically, the facility did not implement Enhanced Barrier Precautions (EBP) as required for a resident with a history of Carbapenem Resistant Enterobacterales (CRE) in her urine. The facility's policy, updated in April 2024, mandates the use of gloves and gowns during high-contact care activities for residents with certain conditions, including those with chronic wounds or indwelling medical devices, regardless of their MDRO status. During an observation, a nurse aide was seen preparing to transfer the resident using a mechanical lift while wearing gloves but not a gown, contrary to the facility's policy and CDC guidelines. The resident's care plan indicated that EBP was in place due to her history of CRE. The nurse aide admitted to not wearing a gown during the transfer, and the Director of Nursing confirmed that the staff should have been wearing both a gown and gloves during such activities.
Failure to Ensure Annual Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides completed the required annual education for two of the five nurse aides reviewed. According to the facility's policy on Orientation/Training/Evaluation, nurse aides are required to complete a minimum of 12 hours of in-service education annually, based on their anniversary hire date. However, a review of the employee education files for Nurse Aides 12 and 18 revealed no documented evidence that they completed the required education hours. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation for the required in-service education for these nurse aides.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as identified during a review of clinical records and staff interviews. For one resident, the care plan indicated that the resident was receiving hospice services, yet the MDS assessment incorrectly marked that the resident was not receiving such services. Another resident was prescribed and administered an antipsychotic medication, Aripiprazole, during the seven-day look-back period, but the MDS assessment failed to reflect this. Additionally, the same resident had an indwelling urinary catheter, but the MDS assessment inaccurately indicated that the resident was always continent of urine. A third resident was ordered to receive oxygen therapy to maintain a specific oxygen saturation level, but the MDS assessment incorrectly noted that the resident did not receive oxygen therapy. These discrepancies were confirmed by the Corporate Compliance Officer, indicating a failure to accurately document the residents' care needs and services received, as required by the Resident Assessment Instrument (RAI) User's Manual.
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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