Sarah Reed Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Erie, Pennsylvania.
- Location
- 227 West 22nd Street, Erie, Pennsylvania 16502
- CMS Provider Number
- 395206
- Inspections on file
- 19
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Sarah Reed Senior Living during CMS and state inspections, most recent first.
A resident with a history of stroke, heart failure, and kidney failure was not weighed according to physician orders, which required daily weights during the first ten days of each month. Facility records showed no documentation of weights since admission, and the DON confirmed this omission.
The facility did not maintain proper electrical system protection in the ground floor laundry room. Electrical outlets were found within six feet of washing machines without GFCI receptacles, as confirmed by the maintenance supervisor.
The facility did not maintain building construction standards in the accounting office storage room, where two ceiling tiles were missing. This issue could potentially allow smoke passage and delay sprinkler activation. The maintenance supervisor confirmed the tiles were missing during the survey.
A facility failed to provide written summaries of baseline care plans and order summaries to three residents or their representatives within 48 hours of admission, as required by policy. The residents, with various medical conditions including heart failure, dementia, and hypertension, did not receive documentation of their care plans, medications, and treatments. The Nursing Home Administrator confirmed the absence of these documents in the clinical records.
A facility failed to ensure a resident with limited ROM received physician-ordered treatment to prevent further decline. The resident, diagnosed with dementia and osteoarthritis, had a physician's order for a left palm protector to be worn at all times except during hygiene. Observations revealed the resident was not wearing the protector, and staff confirmed it should have been worn daily. Clinical records lacked evidence of intolerance, indicating a deficiency in care.
The facility failed to document the required 14-day stop dates or provide clinical rationales for the continued use of PRN Lorazepam for two residents. One resident with heart failure and anxiety and another with dementia and anxiety had orders for Lorazepam that did not comply with the facility's policy, as confirmed by the Nursing Home Administrator.
A facility failed to manage medications properly, as evidenced by expired Humalog insulin and improperly labeled Lantus insulin in a medication cart. The Humalog insulin exceeded the 28-day discard period, and the Lantus insulin lacked an open date, preventing staff from determining its expiration. A nurse confirmed these oversights during an interview.
The facility did not adhere to food safety standards, as observed in the kitchen's walk-in cooler and dry storage area. Expired items, including pasta salad, pureed ham, molasses, and baking soda, were found and confirmed by the Dietary Manager to be past their use-by dates, contrary to facility policy.
The facility failed to store food in accordance with safety standards in the walk-in freezer. During a kitchen tour, several food items were found on the floor, contrary to the facility's policy. The Food Service Director confirmed the improper storage.
The facility failed to complete discharge summaries for three residents, missing essential elements such as a recapitulation of the stay, final summary of status, and cause of death. The DON confirmed these deficiencies during interviews.
The facility failed to ensure that the pharmacist provided separate, written reports of irregularities identified during the medication regimen review for a resident with multiple diagnoses, including left-sided paralysis post-stroke and dementia. The clinical record lacked evidence that findings were communicated to the DON and medical director, as required by facility policy.
The facility failed to provide a clinical rationale and duration for the continued use of PRN psychotropic medication beyond 14 days for two residents. Orders for Lorazepam and Haloperidol lacked the required stop date or clinical rationale, and one resident was not evaluated by the attending physician for the continuation of an anti-psychotic medication.
Failure to Obtain Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain weights for a resident according to physician's orders. Facility policy required all residents to be weighed by the 10th of each month, and a physician's order specified that the resident was to be weighed every day shift from the 1st to the 10th of each month. Review of the clinical record showed that, since admission, there was no documentation that the resident had been weighed as ordered. The Director of Nursing confirmed during an interview that the resident had not been weighed since admission. The resident had diagnoses including stroke, heart failure, and kidney failure.
Electrical System Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain electrical system protection in wet locations, specifically on the ground floor laundry room. During an observation, it was noted that electrical outlets were located within six feet of the washing machines and were not equipped with ground fault circuit interrupter (GFCI) receptacles. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the receptacle deficiencies.
Plan Of Correction
1. All three identified outlets in the ground floor laundry room will be replaced with the proper GFCI outlets. 2. All other outlets in the ground floor laundry room will be audited to ensure no other outlets need to be changed to GFCI's, if within 6 feet of a sink. 3. Outlets will be monitored and reported at the next quarterly QAPI meeting/Safety meeting by Director of Maintenance.
Deficiency in Building Construction Maintenance
Penalty
Summary
The facility failed to maintain the building construction standards as required, specifically in the ground floor accounting office storage room. During an observation, it was noted that two ceiling tiles were missing, which could potentially allow the passage of smoke and delay the activation of the sprinkler system. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged that the ceiling tiles were missing at the time of the survey.
Plan Of Correction
1. The two ceiling tiles in the ground floor accounting office were immediately replaced at time of discovery on 12/17/2024. 2. All other ground floor storage rooms will be audited to ensure no other ceiling tiles are missing. 3. Education to be completed with maintenance team on the importance of ceiling tile placement. 4. Ceiling tiles will be monitored and reported at the next quarterly QAPI/Safety meeting by the Director of Maintenance.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to three residents or their representatives within 48 hours of admission, as required by their policy. The policy, dated 2/15/24, mandates that a copy of the baseline care plan be given at the new admission care plan meeting, typically held within 48 hours of admission. This includes a summary of the resident's medications, dietary instructions, and any services and treatments to be administered. However, the clinical records for three residents lacked evidence of this documentation. Resident R8, admitted with diagnoses including heart failure, atrial fibrillation, and anxiety, did not receive the required documentation. Similarly, Resident R15, with dementia, osteoarthritis, and hypothyroidism, and Resident R60, with hypertension, hypothyroidism, and congestive heart failure, also did not receive the necessary written summaries. The Nursing Home Administrator confirmed the absence of these documents in the clinical records during an interview, indicating a failure to comply with the facility's care plan policy.
Plan Of Correction
1) Baseline Care Plan to be provided to R60, R15, and R8 with completion of Admission Care Plan assessment in PointClick Care. 2) Admission Care Plan assessment created in PointClick Care for nursing staff to complete at time of admission with proof that baseline care plan was provided. 3) Provide training to LPN's/RNs on new assessment and importance of completing the required documentation. 4) The Director of Nursing/designee will audit all new admissions/recent admissions for completion of assessment; 1x weekly for 3 weeks then 1x monthly x2. 5) Results of the audits to be reviewed at quarterly QAPI meeting.
Failure to Provide Physician-Ordered Range of Motion Treatment
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the physician-ordered treatment and services necessary to prevent further decline in range of motion. Specifically, Resident R15, who was diagnosed with dementia, osteoarthritis, and hypothyroidism, had a physician's order for a left palm protector to be worn at all times except during hygiene activities. However, multiple observations over several days revealed that the resident was not wearing the palm protector as prescribed. The clinical records lacked documentation indicating that the resident was unable to tolerate the palm protector, and staff interviews confirmed that the resident should have been wearing it daily according to the physician's orders. Despite education provided to staff upon the resident's discharge from occupational therapy, the facility did not ensure compliance with the prescribed use of the palm protector, leading to a deficiency in the care provided to Resident R15.
Plan Of Correction
1) R15 to be assessed by therapy to ensure that the resident is receiving the appropriate interventions and therapies. R15 physician order to be changed to specify correct adaptive equipment. 2) Complete facility wide assessment to identify other residents with palm protectors to ensure proper documentation/orders. 3) Provide training to LPNs/CNAS on the importance of palm protectors and documentation of refusals. 4) Restorative Nurse/designee will audit all residents with adaptive equipment with hand contractures for appropriate use and documentation; 1x weekly for 3 weeks then 1x monthly x2. 5) Results of the audits to be reviewed at quarterly QAPI meeting.
Failure to Document Required Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of PRN psychotropic medications, specifically Lorazepam, for two residents. The policy mandates that orders for psychotropic drugs are limited to 14 days unless a clinical rationale for continued use is documented. For Resident R8, who has diagnoses including heart failure, atrial fibrillation, and anxiety, a physician's order dated 11/12/24 prescribed Lorazepam 0.25 ml by mouth every 2 hours as needed for anxiety. This order did not include the required stop date within 14 days or a documented clinical rationale for its continuation beyond this period. Similarly, Resident R15, diagnosed with dementia, osteoarthritis, and hypothyroidism, had a physician's order dated 11/15/24 for Lorazepam 0.25 mg by mouth every 12 hours as needed for anxiety. This order also lacked the necessary 14-day stop date or a clinical rationale for continued use beyond 14 days. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging the absence of the required documentation for both residents.
Plan Of Correction
1) R15 and R8 stop dates to be added to Lorazepam. 2) All PRN psychotropic medications will be audited to ensure there is a stop date in place or documentation with rationale to continue the medication. 3) The nurses will be trained by the Director of Nursing/designee on ensuring there is a stop date in place for all PRN psychotropic medications unless there is documentation with rationale to continue the medication. 4) The Director of Nursing/designee will audit all new orders to ensure there are stop dates for all residents on PRN psychotropic medications and rationale to support continued use; 1x weekly for 3 weeks then 1x monthly x2. 5) Results of the audits to be reviewed at quarterly QAPI meeting.
Expired and Improperly Labeled Insulin Found in Medication Cart
Penalty
Summary
The facility failed to ensure proper medication management as evidenced by the presence of expired and improperly labeled insulin in one of the medication carts. During a review of the facility's policy on medication storage, it was noted that medications and biologicals should be stored safely and securely, following the manufacturer's recommendations. Specifically, insulin vials are to be stored in the refrigerator until opened, then dated and placed in the medication cart. However, during an observation of the [NAME] medication cart, a Humalog insulin vial was found with an opened date that exceeded the 28-day discard period recommended by the manufacturer. Additionally, a Lantus insulin vial was found without an open date, making it impossible to determine its discard date. During an interview, Registered Nurse Employee E2 confirmed the oversight, acknowledging that the Humalog insulin was expired and should have been discarded, and that the Lantus insulin lacked an open date, preventing staff from determining its expiration. This deficiency was identified during a survey, which included a review of facility policy, manufacturer's recommendations, observations, and staff interviews. The failure to adhere to proper medication labeling and storage protocols resulted in a violation of the facility's policy and state regulations regarding pharmacy and nursing services.
Plan Of Correction
1) 12/09/2024: Expired and undated insulin discarded from medication cart at the time of discovery. 2) All other medication carts were audited for expired/undated insulin the day the expired insulin was discovered. 3) FT/PT LPN's and RN's to be educated on proper med storage. 4) Medication carts will be audited on each unit for expired meds 1x weekly for 3 weeks then 1x monthly x2 by Director of Nursing. 5) Results of the audits to be reviewed at quarterly QAPI meeting.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage in accordance with food safety standards in one of two walk-in coolers and the dry storage area in the kitchen. During an inspection, it was observed that an open, partially used container of pasta salad was stored in the cooler with a use-by date that had passed. Additionally, the dry storage area contained eight cans of pureed ham with an expiration date of March 2024, an open gallon jug of molasses with a use-by date of October 2023, and two tubs of baking soda with an expiration date of May 2024. The Dietary Manager confirmed during an interview that these items were beyond their use-by or expiration dates and should have been discarded according to the facility's policy. The policies reviewed indicated that products past their use-by dates should be disposed of properly, and unconsumed food should be discarded in line with manufacturing guidelines and food labels.
Improper Food Storage in Walk-In Freezer
Penalty
Summary
The facility failed to ensure that food was stored in accordance with standards for food safety and sanitation in the walk-in freezer located in the main kitchen. During an initial kitchen tour, several food items were observed on the floor of the walk-in freezer. The facility policy, dated 2/6/2024, clearly indicated that all food items should be placed on shelves and not on the floor of the refrigerator or freezer. This observation was confirmed by an interview with the Food Service Director, who acknowledged that the food items should not be on the floor in the walk-in freezer.
Incomplete Discharge Summaries for Three Residents
Penalty
Summary
The facility failed to ensure that a discharge summary, which included a recapitulation of the resident's stay and the resident's discharge status, physician's final diagnosis and prognosis or cause of death, was completed for three closed clinical records. The facility's policies required an interdisciplinary discharge summary to be completed for all discharges, including a short summary of the resident's stay, final summary of resident status, disposition of medications, and physician's discharge prognosis, diagnosis, and cause of death. However, the clinical records for Residents CR94, CR95, and CR96 lacked these required elements. Resident CR94's record did not include a discharge summary with a recapitulation of the resident's stay and a final summary of the resident's status. Resident CR96's record was missing the physician's discharge summary, including the cause of death. Resident CR95's record lacked a recapitulation of the stay and the reason for discharge. The Director of Nursing confirmed these deficiencies during interviews, acknowledging the incomplete documentation in the residents' closed clinical records.
Failure to Document Pharmacist's Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the contracted pharmacist provided separate, written reports of irregularities identified during the medication regimen review (MRR) for one of five residents reviewed for unnecessary medications. The facility policy required that findings and recommendations from the MRR be communicated to the Director of Nursing (DON) or designee and the medical director, and documented in the resident's chart. However, for Resident R49, who had diagnoses including left-sided paralysis post-stroke, Type 2 Diabetes, heart failure, irregular heartbeat, and dementia, the clinical record lacked evidence that the pharmacist's findings and recommendations were communicated and documented as required. The DON confirmed the absence of such documentation during an interview.
Failure to Provide Clinical Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to provide a clinical rationale and duration for the continued use of PRN psychotropic medication beyond 14 days for two residents. Resident R34 had a physician's order for Lorazepam 0.5 mg every 24 hours PRN for anxiety, which lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Similarly, Resident R50 had a physician's order for Lorazepam 0.5 mg every four hours PRN for anxiety and Haloperidol 0.5 mg every four hours PRN for agitation, both of which lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Additionally, there was no evidence that Resident R50 was evaluated by the attending physician or prescribing practitioner for the continuation of the anti-psychotic medication Haloperidol. During an interview, the Nursing Home Administrator and Employee E1 confirmed that the orders for both residents lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. They also confirmed that Resident R50 was not evaluated by the attending physician or prescribing practitioner for the continuation of the anti-psychotic medication. This failure to comply with the facility's policy on psychotropic medications and regulatory requirements led to the identified deficiencies.
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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