Scenery Hills Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indiana, Pennsylvania.
- Location
- 680 Lions Health Camp Rd, Indiana, Pennsylvania 15701
- CMS Provider Number
- 395313
- Inspections on file
- 24
- Latest survey
- April 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Scenery Hills Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with PTSD, depression, and anxiety did not have their specific trauma triggers identified or addressed by staff, despite facility policy requiring trauma-informed care. The DON confirmed that no measures were in place to prevent or minimize re-traumatization for this resident.
A multi-dose vial of Tubersol Tuberculin injection used for TB skin testing was found in the medication room without an opening date, contrary to manufacturer instructions requiring disposal 30 days after opening. The DON confirmed the vial was not dated as required, resulting in noncompliance with pharmacy and nursing service regulations.
The facility failed to store food under sanitary conditions, as standing water was found in the basement dry storage area, affecting the emergency food supply and other items. A broken downspout was identified as the cause of the water intrusion, exacerbated by recent rain and snow. The presence of a sewer smell was also noted.
The facility failed to pay essential service bills on time, leading to service disruptions that jeopardized resident safety. Outstanding balances were owed to various providers, including Citizens Ambulance and REA, resulting in termination notices and halted services. Interviews confirmed these issues, and the facility had to change suppliers due to nonpayment.
The facility failed to conduct safety assessments for air mattress use for three residents with pressure ulcers and other conditions. Despite facility policy, there was no documented evidence of safety assessments before placing air mattresses on their beds. The DON confirmed the lack of specific assessments for these residents.
The facility did not comply with food safety standards by failing to discard pizza sauce in a timely manner and not maintaining the dishwasher's wash cycle temperature at the required 120 degrees Fahrenheit. The Dietary Manager acknowledged the oversight regarding the sauce, and the Nursing Home Administrator confirmed the dishwasher's temperature requirement.
The facility did not verify the Nurse Aide Registry for a newly hired nurse aide, as required by their abuse policy. The verification, which should have been completed upon hire, was delayed until several weeks after the nurse aide's start date. This oversight was confirmed by the HR Director.
The facility failed to document the administration of controlled medications for three residents, as required by its policies. Doses of oxycodone and hydrocodone-acetaminophen were signed out but not recorded as administered in the residents' clinical records, including the MARs and nursing notes. This discrepancy was confirmed by the DON.
The facility failed to securely store medications, as an LPN left a medication cart unattended with medications on top, and a resident's medications were left at the bedside instead of being returned to the cart. The DON confirmed these actions were against policy.
The facility failed to maintain complete and accurate clinical records for three residents. A resident's oxycodone administration was inconsistently documented, another resident's oxygen use was not recorded on two occasions, and a third resident's Morphine Sulfate administration was not properly documented. The DON confirmed these documentation errors.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies related to accident hazards, controlled medication accountability, and medical record documentation. Despite previous plans of correction involving audits and QAPI review, the same issues were identified again, indicating ineffective quality assurance processes.
A facility failed to notify a resident's representative in writing about the reasons for multiple hospitalizations. Despite the resident being transferred to the hospital several times, there was no documented evidence of written notification. Interviews with facility staff confirmed that only verbal notifications were made, violating regulatory requirements.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD), along with depression and anxiety, was properly assessed and received trauma-informed care. The resident was cognitively intact and required staff assistance for daily care needs. Although the facility's policy required culturally competent and trauma-informed approaches that minimize triggers for trauma survivors, there was no documented evidence that the facility identified the resident's specific triggers or implemented measures to prevent or minimize re-traumatization. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that specific triggers for the resident had not been identified or addressed.
Failure to Label Multi-Dose Tuberculin Vial per Manufacturer Instructions
Penalty
Summary
Surveyors found that a multi-dose vial of Tubersol Tuberculin injection, used for Mantoux TB skin testing, was present in the medication room without a date indicating when it was opened. Manufacturer's instructions specify that such vials should be discarded 30 days after opening, making it necessary to label them with the date of first use. The Director of Nursing confirmed that the vial was not dated as required. This failure to properly label the multi-dose vial constitutes noncompliance with accepted professional principles and state regulations regarding pharmacy and nursing services. No information was provided about specific residents or their medical conditions in relation to this deficiency.
Food Storage and Preparation Deficiency Due to Water Intrusion
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, as evidenced by observations in the basement dry storage area. On December 4, 2024, standing water was found covering a 12-foot by 12-foot area, with a stream extending to a floor drain next to several metal shelves containing the emergency food supply and other items. These items included cans of chicken and dumplings, pureed beef stew, cans of chicken puree, cans of tomato soup, cans of ravioli, boxes of thick and easy Hormel dairy beverage, four cases of bottled water, and cases of plastic spoons and forks. Additionally, there was a noticeable sewer smell in the basement area, and a dehumidifier was in use by the floor drain. Interviews with the Dietary Manager and the Nursing Home Administrator, along with the Maintenance Director, confirmed the presence of standing water and the sewer odor. The Dietary Manager was unsure of the water's cause but noted a crawl space behind the wall. The Maintenance Director, upon re-examination, determined that a broken downspout was causing the excess water in the basement, which had increased significantly since it was last cleaned up. The recent rain and snow were cited as contributing factors to the increased groundwater in the basement.
Plan Of Correction
The water on the floor in the storage basement was immediately cleaned and a ventilator fan placed in the area to keep it dry. The cause was determined to be a detached drain spout along the outside wall at that point; it was immediately repaired. The other outside roof drain spouts were checked to ensure they were all in good working order and none were found to be out of order. While the entire sewer drainage system was recently rebuilt, this was not seen as a possible cause; nonetheless, a Sewer Drain contracting company was brought in with a line camera which was used to scope both drain pipes and no issues were found from the farthest point on both lines up to and including the initial drainage tank in the on-site sewage treatment plant. To ensure any rainwater or melting snow accumulation would not run down the wall to possibly penetrate the basement walls, dirt and mulch was added at the base of the exterior wall to provide drainage away from the building for any water that is not handled by the down spouts. As a preventative measure, Scenery Hill contracted with the sewage contractors for jet spray line cleaning for both the North and South halls' sewage pipes on a bi-annual basis. The roof down spouts will be added to the monthly maintenance checklist so these are reviewed monthly. The Maintenance team will be educated on the new monthly checklist requirements by the Nursing Home Administrator. They will also be educated on the new sewer cleanout contract requirements. The Maintenance Director or designee will audit the dietary storage floor for water daily for one week and weekly for three weeks. The Maintenance Director or designee will also audit the down spouts daily for a week and weekly for three weeks to ensure proper function and drainage. The results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for adherence or further action. The plan of correction date of compliance will be January 7, 2025.
Failure to Pay Essential Service Bills Jeopardizes Resident Safety
Penalty
Summary
The facility failed to pay bills in a timely manner for services essential to the residents' health and safety, as evidenced by a review of the facility's accounts payable ledger and interviews with administrative staff. The outstanding balances included significant amounts owed to various service providers such as Citizens Ambulance, REA for electric service, Suburban Propane, US Foods, Liberty Healthcare, Medvan Transport, RCP O2, Twin Med, Supply Line, Penn Highlands Dubois, Hugill Sanitation, and ICMSA. These unpaid bills resulted in termination notices and service disruptions, which could jeopardize the residents' well-being. An email communication revealed that the facility had fallen behind in payments to Citizen's Ambulance Service, leading to a halt in non-emergent transportation services until the payment was settled. Additionally, a billing statement from REA indicated a significant arrears balance, and a termination notice from the Indiana County Municipal Authority highlighted an overdue water bill. Interviews with the Nursing Home Administrator and Business Office Manager confirmed the existence of these outstanding balances and the receipt of termination notices due to nonpayment. The facility had to change medical suppliers and transportation services when services were terminated for nonpayment.
Plan Of Correction
The facility cannot retroactively correct. The residents' health and safety were / are not jeopardized due to this practice. The disposition of the listed invoices are: - Citizens Ambulance - invoice to be paid December 30. - REA Energy - $3872.83 was due within the past week and was paid in full. - Suburban Propane - Was paid on 12/4 and delivery received on 12/6. - US Foods - This vendor has always been on autopay and has never been late. - Liberty Healthcare - This is a consulting firm that ended service in August of 2022. They were assigned to review the buyout and not clinically related. - MedVan - Up to date, invoice payment made. - RCP 02 - paid up and regular deliveries every Friday prior to survey and since. - Twin Med - Invoice paid December 2. - Supply Line - invoice paid under payment agreement. - Penn Highlands Dubois - We don't know what this is for as they are not a vendor. - Hugill Sanitation - no service break, invoices up to date. - ICMSA - Invoice paid 12/3/24 with no break in service at any time. The accounts payable ledger was reviewed for any other outstanding invoices with shut-off notices and none were found. REA Energy, the provider that initiated this survey, was put on the auto-pay list so their invoices will be automatically paid upon receipt. The Nursing Home Administrator (NHA) or designee will educate the Operator (person responsible for approving payment to vendors) on timely bill payment for invoices incurred in the operation of the facility that for services without which the residents' health and safety would be jeopardized. The NHA or designee will audit the monthly payment arrangement to ensure payments are made to the vendor per the arrangement plan. These audits will be performed monthly for three months, and the results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for adherence or further action. The plan of correction date of compliance will be January 7, 2025.
Failure to Conduct Safety Assessments for Air Mattress Use
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards by not completing safety assessments for the use of air mattresses for three residents. The facility's policy stated that air mattresses were reserved for residents with pressure ulcers, yet there was no documented evidence of safety assessments being conducted for these residents before the air mattresses were placed on their beds. This oversight was identified for three residents who were cognitively intact and had various medical conditions, including pressure ulcers and a history of stroke. Resident 20 had a Stage III pressure ulcer and was observed with an air mattress in place without a prior safety assessment. Similarly, Resident 44, who had multiple pressure ulcers and venous and arterial ulcers, was also observed using an air mattress without a documented safety assessment. Resident 47, who had a stroke and limited range of motion, was using an air mattress with bolsters, again without a safety assessment. The Director of Nursing confirmed that no specific assessments were completed to ensure the safety of air mattress use for these residents.
Food Safety and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not discarding food in a timely manner and not maintaining the appropriate washing cycle temperature for the dishwasher. During an observation in the kitchen, a plastic container of pizza sauce was found with a date indicating it should have been discarded after seven days, but it was still present nine days later. The Dietary Manager confirmed that the sauce should have been discarded. Additionally, the dishwasher's wash cycle was observed to reach only 100 degrees Fahrenheit, below the manufacturer's recommended operational temperature of 120 degrees Fahrenheit. The Dietary Manager did not express any concerns about the temperature that morning, and the Nursing Home Administrator confirmed the manufacturer's instructions regarding the required temperature.
Failure to Verify Nurse Aide Registry
Penalty
Summary
The facility failed to complete a Nurse Aide Registry verification for one of the five nurse aides reviewed upon hire. The facility's abuse policy, dated February 15, 2024, mandates that they will not employ individuals with findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property in the state Nurse Aide Registry. However, the personnel file for Nurse Aide 1, who was hired on May 10, 2024, lacked documented evidence of registry verification until May 28, 2024. This was confirmed during an interview with the Human Resources Director on May 30, 2024.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents, as evidenced by discrepancies in the documentation of medication administration. The facility's policy requires that the nurse administering the medication record specific details, including the resident's name, medication details, time, method, remaining quantity, and the nurse's signature. However, for Resident 6, a dose of oxycodone was signed out but not documented as administered in the clinical record, including the Medication Administration Record (MAR) and nursing notes. This lack of documentation was confirmed by the Director of Nursing. Similarly, for Resident 28, a dose of hydrocodone-acetaminophen was signed out but not documented as administered in the clinical record. Additionally, Resident 47 had multiple instances where doses of oxycodone were signed out but not documented as administered. These discrepancies were also confirmed by the Director of Nursing. The failure to document the administration of these controlled substances is a violation of the facility's policies and state regulations regarding pharmacy and nursing services.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by an unattended medication cart in the hallway with a medication souffle cup containing medications in applesauce. This incident occurred when a Licensed Practical Nurse (LPN) left the cart unattended due to being called to an emergency. The LPN later confirmed that the medication should not have been left on top of the cart, and the Director of Nursing (DON) corroborated that medications should not be left unattended on the cart. Additionally, the facility did not securely store medications for Resident 28, who was cognitively intact and required assistance for daily care needs. Observations revealed that Resident 28 had a brown bottle of Flonase nasal spray and a Trelegy Ellipta inhaler on her overbed table, which the nurse forgot to take back after administration. The DON confirmed that these medications should have been returned to the medication cart and secured after administration, rather than being left at the resident's bedside.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for three residents. For Resident 6, there was a discrepancy in the documentation of oxycodone administration. The controlled drug record indicated a dose was signed out on May 9, 2024, but there was no evidence in the clinical record that it was administered. Conversely, the MAR showed a dose was administered on May 10, 2024, without corresponding documentation in the controlled drug record. The Director of Nursing confirmed the documentation errors, attributing them to a night shift nurse's oversight. Resident 20's records also lacked documentation of oxygen administration on two observed occasions, despite the resident being on oxygen as per physician's orders. The Director of Nursing confirmed the absence of documentation for these dates. Similarly, for Resident 28, the MAR indicated a dose of Morphine Sulfate was administered, but the controlled drug record did not reflect this. The Director of Nursing acknowledged the inaccuracies in Resident 28's MAR documentation.
Ineffective QAPI Committee Leads to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in the current survey. These deficiencies included ensuring that the resident's environment was free of accident hazards, accountability of controlled medications, and complete and accurate clinical record documentation. The facility had previously developed plans of correction for these issues, which included quality assurance systems with audits to ensure compliance. However, the results of the current survey indicated that these plans were ineffective, as the same deficiencies were identified again. Specifically, the facility's plans of correction for deficiencies regarding accident hazards, controlled medications, and medical record documentation, cited during the survey ending on June 22, 2023, involved conducting audits and presenting the results to the QAPI committee for further monitoring. Despite these measures, the current survey revealed that the QAPI committee was ineffective in maintaining compliance with the regulations, as the same issues were cited again under F689, F755, and F842. This indicates a failure in the facility's quality assurance processes to address and rectify these recurring deficiencies.
Failure to Provide Written Notification of Hospitalization
Penalty
Summary
The facility failed to provide written notification to the resident's representative regarding the reasons for hospitalization for one of the residents reviewed. Specifically, Resident 29, who was cognitively intact and required assistance for daily care needs, was transferred to the hospital multiple times between December 2023 and May 2024. Despite these transfers, there was no documented evidence in the clinical record that the resident's representative was notified in writing about the purpose of these hospitalizations. Interviews with the Social Services Director and the Director of Nursing confirmed that the facility only provided verbal notifications and did not document written notifications to the resident's representative. This lack of documentation was acknowledged by the facility staff, indicating a failure to comply with the requirement to notify the resident's representative in writing, as mandated by the relevant regulations.
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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