Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Schuylkill Center during CMS and state inspections, most recent first.
Improper Food Storage in Dietary Department: Surveyors observed brown lettuce on salads prepared for lunch, yogurt cups past expiration dates, and an open cup of vanilla ice cream in the walk-in freezer. The CDM confirmed the items were improperly stored.
Unsafe and Unclean Environmental Conditions on Multiple Units: The facility failed to maintain a safe, clean, and comfortable environment on Homestead and C Units. Surveyors observed peeling wallpaper, windows that were open and could not be closed, missing and broken hardware, dirty bathroom baseboards, stained and damaged floor tiles, food debris in microwaves, stained ceiling tiles, rust spots, cracked light covers, and a shower gurney mattress with peeling and cracks.
Failure to Send Transfer Notices to Ombudsman: The facility did not provide copies of written transfer notices to the Office of the State LTC Ombudsman for 12 residents who were transferred to the hospital after changes in condition. Record review showed no documentation that the notices were sent, and the DOSS confirmed the notices were not sent.
A resident with Parkinson's disease, heart disease, a stroke history, and severe cognitive impairment was dependent on staff for eating assistance. During lunch, a nurse aide was observed hand-feeding the resident while standing over her in the dining room, and the Administrator confirmed staff were expected to sit with residents when feeding them.
Call bells were left out of reach for residents with significant cognitive and mobility impairments. A resident with hemiplegia and severe cognitive impairment, a resident with Parkinson's disease and dementia, and a resident with Alzheimer's disease and a fractured femur all had care plans directing staff to assist with toileting, hygiene, and mobility and to encourage call bell use, but observations showed the call bell cords beneath the beds and inaccessible. The DON confirmed the call bells should have been accessible.
A resident with Alzheimer's disease, dementia, and severe protein-calorie malnutrition had a care plan for a restorative nursing program for eating, with staff to cue her to use utensils. During meal observations, she was seen using her fingers to eat instead of utensils, and staff did not redirect or cue her. The DON confirmed staff were to assist the resident with eating.
A resident with dementia, anxiety, and extensive ADL needs was found with greasy ointment on his face and clothing after using a roommate’s moisturizing ointment. He then removed another tube from his bedside drawer, and both the moisturizing ointment and an antifungal cream were later still accessible in the drawer despite his severe cognitive impairment. An RN confirmed the products should not have been accessible.
A resident with PTSD, quadriplegia, and no cognitive impairment required substantial staff assistance with ADLs, but the care plan did not include individualized interventions to address trauma history or identify and minimize triggers to prevent re-traumatization. The DON confirmed the resident did not have an individualized person-centered care plan for trauma-informed care.
An infection prevention deficiency was cited after an LPN failed to follow hand hygiene and PPE requirements during wound care for a resident with a right heel arterial ulcer, and the DON confirmed the lapse. In a separate event, a resident with dementia and toileting assistance needs was observed with feces on his leg and placed soiled underwear on a clean linen cart, where staff later used linens from the same cart for care while the soiled underwear remained on it.
The facility failed to offer influenza vaccines in accordance with policy for two residents whose records were reviewed. The policy required the vaccine to be offered during flu season, with education provided and documentation of whether the resident received or declined the vaccine. Record review showed no documented evidence that the vaccine was offered to two residents, and the DON confirmed the missing documentation.
Failure to Offer Updated COVID-19 Vaccines to Residents: The facility failed to offer the updated COVID-19 vaccine to three residents whose records were reviewed. The policy required resident education on the benefits, risks, and side effects before offering the vaccine, with documentation of education and whether the resident accepted or declined. Records showed the residents had last been offered a COVID-19 vaccine in 2024, and there was no documentation that the updated vaccine was offered. RN and DON interviews confirmed the lack of documentation.
Surveyors observed extensive unsanitary conditions in the kitchen, including black substances on ceiling tiles and floors, rusted shelves, unmanaged condensation, leaking pipes, contaminated food storage areas, and dirty equipment. The ventilation system failed to control moisture for over a month, and no temporary measures were taken to address these issues.
Meals were not served at the scheduled times on two nursing units, with residents waiting in the dining rooms well past the planned lunch hour. Staff and resident interviews confirmed that late meal service was a recurring issue, and observations showed that lunch service began nearly an hour after the scheduled time on both units.
A resident with respiratory failure and a feeding tube experienced a significant decline, including low oxygen saturation, increased oxygen needs, choking, and fever. Despite these changes, staff did not notify the physician or have the resident assessed until the following day, contrary to facility policy and nursing standards.
Staff did not follow physician orders for insulin administration timing for two residents with diabetes, administering short-acting insulin well before meals were served. Additionally, staff failed to notify a physician when a resident's blood glucose readings exceeded 400 mg/dL, as required by orders. The DON confirmed these lapses in care.
A resident with a history of COPD, stroke, and one-sided weakness, who required total assistance for toileting and hygiene, experienced a fall when staff failed to follow protocol requiring two staff members during use of a sit to stand lift. During incontinent care, only one staff member remained in the room, resulting in the resident sliding out of the lift and falling. The DON confirmed that established safety procedures were not followed.
A resident with hemiparesis and unsteadiness, requiring two-person assistance and a mechanical lift for transfers and toileting, activated the call bell for bathroom help. Despite notifying staff, assistance was not provided for 39 minutes, resulting in a failure to accommodate the resident's needs in a timely manner.
Staff failed to follow physician orders for two residents, including not notifying a physician when a resident's blood glucose exceeded 400 mg/dL and not administering clonidine when another resident's blood pressure was above ordered thresholds. The DON confirmed these lapses in care.
A review of staffing schedules showed that the facility did not meet the required minimum nurse aide-to-resident ratios on multiple day, evening, and night shifts during a 21-day period, resulting in noncompliance with mandated staffing requirements.
A review of nursing schedules revealed that the facility did not meet required LPN-to-resident staffing ratios on multiple occasions, including day, evening, and night shifts. The deficiency was identified through examination of time schedules over a three-week period.
A review of nursing schedules showed that, on multiple days, the facility did not provide the required minimum of 3.2 direct care hours per resident in a 24-hour period. On 12 out of 21 days reviewed, the total direct care hours per resident were below the mandated level, indicating insufficient nursing staff coverage during those times.
Schuylkill Center did not provide an updated all-hazards risk assessment as required, with both the Administrator and Maintenance Director confirming the absence of this documentation during survey review.
The facility did not maintain required documentation for semi-annual fire alarm system inspections and failed to provide evidence that deficiencies with supervisory and tamper flow switches were resolved, as confirmed by facility leadership.
The facility did not maintain required documentation for quarterly inspections of its wet and dry sprinkler systems, failed to correct previously identified issues with sprinkler head orientation, and did not resolve alarm deficiencies related to Supervisory and Tamper Flow Switches. Additionally, several sprinkler heads in the laundry area were found covered with debris, with all findings confirmed by facility leadership.
A door to the Service Hall Food Storage Room was found dragging on the floor and failed to self-close and latch, compromising the smoke resistance required for hazardous area enclosures. This issue was confirmed by facility leadership during the survey.
Surveyors found that the facility's life safety drawings were missing required details such as room capacities, door swings, and fire/smoke wall boundaries. The facility also lacked documentation of annual carbon monoxide alarm testing, confirmation that alarms could be heard by staff, and verification of evacuation and alarm protocols, as required by state law.
Surveyors found that the facility did not have documentation of required owner's quick checks for the kitchen's fixed chemical fire suppression system and could not provide records of semi-annual cleaning for the kitchen exhaust ductwork. These deficiencies were confirmed by the Administrator and Maintenance Director.
Surveyors identified multiple failures in food storage and sanitation, including undated and improperly stored food items, presence of insects in food preparation areas, and a dietary employee serving food with uncovered facial hair and without changing gloves or performing hand hygiene between tasks. These actions were not in accordance with facility policy or food safety standards.
Staff failed to monitor and serve hot beverages at a safe temperature, with coffee being served as high as 181°F and not retested before reaching residents. A resident with cognitive and physical impairments, who required supervision during meals, was left unsupervised and sustained a significant abdominal burn after spilling hot coffee. Staff interviews confirmed that beverage temperatures were not routinely checked, and residents reported that coffee was often too hot to drink.
Surveyors observed that the facility did not maintain a medication error rate below 5%, with four errors out of 26 opportunities. Errors included an LPN failing to instruct a resident to rinse after inhaler use, not cleaning insulin pen tops before use, and another LPN crushing an extended-release acetaminophen tablet before administration, all contrary to orders and manufacturer instructions.
The facility did not deliver meals at scheduled times on three nursing units, with several residents reporting frequent delays that affected their routines and activities. Observations confirmed that meal deliveries were late by up to 49 minutes, and a resident was seen without a meal tray during the delay. The DON confirmed that meal service should have followed the established schedule.
Surveyors observed that trash and refuse, including used gloves, plastic debris, condiment packets, a waffle, animal droppings, and soiled briefs with cloths, were not properly disposed of and were found on the ground and sticking out from under a dumpster.
The facility did not post up-to-date nurse staffing information, as the information displayed in the lobby was outdated and confirmed to be incorrect by the Nursing Home Administrator.
The facility did not meet the required NA to resident ratios over a 21-day period, with deficiencies noted across day, evening, and night shifts. The day shift was understaffed on seven days, the evening shift on eleven days, and the night shift on two days, as revealed by a review of nursing schedules.
The facility did not meet the required LPN to resident ratios on several occasions. Specifically, the day shift ratio of one LPN per 25 residents was not met on four days, and the evening shift ratio of one LPN per 30 residents was not met on three days, as identified in a review of nursing schedules over a 21-day period.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on 16 out of 21 days. Nursing schedules showed care hours per resident ranging from 2.52 to 3.16, below the regulatory standard.
A resident with cognitive impairment and mobility dependence, who was at risk for pressure sores, was left on a bedpan for several hours without timely assistance. This resulted in the development of a stage 1 pressure sore matching the bedpan's shape, after a staff member failed to follow the care plan for regular repositioning.
The facility did not meet the required NA to resident ratios for 19 out of 21 days reviewed. The deficiency involved failing to maintain the minimum NA to resident ratio during day, evening, and night shifts on multiple days. This was confirmed by the DON.
The facility did not meet the required LPN to resident ratios over a 21-day period, failing to provide adequate staffing during day, evening, and night shifts on multiple occasions. The Director of Nursing confirmed the deficiency.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for 20 out of 21 days reviewed. The nursing schedules showed consistent shortfalls, with the lowest being 2.08 hours per resident. The DON confirmed the deficiency.
The facility failed to provide scheduled showers for five residents who required assistance with ADLs. Despite being scheduled for showers on specific days, there was no documentation of showers being provided, and residents confirmed they had not refused them. The facility's Administrator and DON acknowledged the oversight.
The facility did not provide scheduled showers to two residents, impacting their right to a dignified existence. One resident with anxiety and insomnia missed two out of eight scheduled showers, while another with hemiplegia and diabetes missed five out of nine. Both required staff assistance and preferred showers twice a week.
The facility failed to follow physician's orders for two residents with hypertension and atrial fibrillation. Medications were administered despite specific parameters to withhold them based on systolic blood pressure and heart rate. The DON confirmed the lack of documentation for withholding medications when required.
The facility failed to maintain sanitary conditions in the kitchen, with several food items improperly labeled or stored beyond recommended usage periods. Observations included undated or outdated items in refrigerators, ice buildup on food in the freezer, and missing floor tiles in the kitchen area.
The facility did not follow the pre-approved menus on the C Unit, as identified through observations, documentation, and a test tray audit. Residents had consistently complained about small portion sizes from December 2023 to April 2024. On a specific day, the menu required three ounces of glazed pork and four ounces of vegetables, but only two ounces of pork and three ounces of vegetables were served. The Dietary Manager confirmed the error.
The facility failed to provide dignified dining assistance to two residents, one with Alzheimer's and another with arthritis and vision problems. Both residents were observed eating with their hands without staff intervention, despite care plans indicating the need for assistance. This failure violated residents' rights to dignity and appropriate nursing services.
The facility did not develop comprehensive care plans for two residents. A resident with cognitive impairment and hearing loss lacked interventions for communication issues in their care plan. Another resident with dementia and chronic kidney disease had no interventions for urinary incontinence. The DON confirmed these omissions, violating nursing service regulations.
The facility failed to provide food at appetizing temperatures on the C Unit. Residents reported cold lunches and tough pork, with a pattern of complaints noted from previous months. A test tray audit confirmed that food was served at inadequate temperatures, and observations of residents eating lunch corroborated these findings.
Two residents with specific medical conditions requiring adaptive eating equipment were not provided with the necessary Kennedy cups as per their care plans. Despite recommendations from the dietitian, observations showed that the residents were served drinks in regular cups without lids or straws, which was confirmed by the DON.
Improper Food Storage in Dietary Department
Penalty
Summary
The facility failed to ensure food was stored under sanitary conditions in the dietary department. During a kitchen tour, surveyors observed a tray of ten side salads and two chef's salads with brown lettuce prepared for lunch service in the walk-in refrigerator. On the second shelf of the walk-in refrigerator, there was a tray of food prepared for the residents' lunch meal with four individual four-ounce yogurt cups that had an expiration date of May 9, 2026, along with two cases of four-ounce yogurt cups with expiration dates of May 9 and May 15, 2026. In the walk-in freezer, one cup of vanilla ice cream was observed with the lid not sealed and the product open to the air. The Certified Dietary Manager confirmed that the items observed were improperly stored.
Unsafe and Unclean Environmental Conditions on Multiple Units
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment on two of four nursing units, Homestead and C Units. Observations on May 17, 2026 and May 20, 2026 identified multiple environmental issues in resident rooms, including peeling wallpaper behind a bed, a peeling window ledge cover, windows that were open and could not be closed, a missing metal handle on a closet door, unpainted wall repairs with visible spackling, dirty bathroom baseboards, a tear in the painted wall adjacent to a toilet, and worn, rippled bathroom floor tiles behind a toilet. Additional observations on the Homestead unit found a ceiling tile with brown stains in the main dining room, food debris inside microwaves in the dining room and lounge, and peeling wallpaper near the central bathroom door. In the Homestead central bathroom, there was a dried brown substance on the back railing of a shower chair, chipped floor tiles, brown substance in the tile grout, a black substance on the baseboard tile near the shower entry, rust spots on a shower rod, a cracked plastic light cover, peeling wallpaper by the tub, a crack in the ceiling tile above the light near the shower gurney, and a shower gurney mattress that was peeling and had several cracks. The handle of the bathroom in one resident room was also broken.
Failure to Send Transfer Notices to Ombudsman
Penalty
Summary
The facility failed to provide copies of written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for 12 of 12 residents who were transferred out of the facility. The residents identified were Residents 1, 3, 7, 15, 19, 47, 90, 109, 137, 141, 158, and 178. Clinical record review showed each resident was transferred to the hospital after a change in condition, including multiple transfers for some residents, such as Resident 3 and Resident 47. For each of the listed residents, the record did not contain documented evidence that the facility sent a copy of the transfer notice to the Ombudsman representative. Resident 1 was transferred on January 16, 2026; Resident 3 on January 27, 2026 and February 12, 2026; Resident 7 on March 24, 2026; Resident 15 on February 6, 2026; Resident 19 on February 2, 2026; Resident 47 on February 10 and February 24, 2026; Resident 90 on April 28, 2026; Resident 109 on March 2, 2026; Resident 137 on January 29, 2026; Resident 141 on January 18, 2026; Resident 158 on February 26, 2026; and Resident 178 on March 1, 2026. In an interview on May 20, 2026, at 11:45 a.m., the Director of Social Services confirmed that the written copies of the transfer notices were not sent to the Office of the State Long-Term Care Ombudsman.
Feeding Assistance Provided Without Maintaining Resident Dignity
Penalty
Summary
The facility failed to provide feeding assistance in a manner that maintained dignity for one resident who had Parkinson's disease, heart disease, and a history of strokes. The resident's MDS assessment showed severe cognitive impairment and dependence on staff for help with eating, and the care plan identified a nutritional deficit risk with an intervention for staff to provide assistance with eating. During lunch observation, a nurse aide was seen hand-feeding the resident while standing over her in the dining room. In interview, the Administrator confirmed that staff were to sit with residents when feeding them.
Call Bells Left Out of Reach for Residents Needing Assistance
Penalty
Summary
The facility failed to ensure that call bells were accessible for three residents who had significant mobility and cognitive impairments and were dependent on staff for assistance. Resident 12 had diagnoses including hemiplegia and hemiparesis from prior strokes, kidney disease, and chronic pain; the MDS showed severe cognitive impairment, limited range of motion in both arms and legs, and substantial assistance needs for activities of daily living. The care plan identified the resident as at risk for falls related to reduced mobility and directed staff to assist with toileting, hygiene, and mobility as needed while encouraging use of the call bell for assistance. During observation, Resident 12's call bell cord was tangled beneath the bed and out of reach, and it remained in the same position on a later observation. Resident 14 had diagnoses including Parkinson's disease, dementia, and muscle weakness, with the MDS showing moderate cognitive impairment and a need for assistance with activities of daily living. The care plan identified fall risk related to impaired balance and included staff assistance with toileting, hygiene, and mobility, along with encouragement to use the call bell. Observation showed Resident 14's call bell cord beneath the bed and out of reach, and it remained there on a later observation. Resident 105 had diagnoses including Alzheimer's disease, kidney disease, a fractured femur, and chronic back pain; the MDS showed severe cognitive impairment, limited range of motion in both legs, and substantial assistance needs. The care plan identified fall risk related to reduced mobility and dementia and directed staff to assist with toileting, hygiene, and mobility as needed and encourage call bell use. The DON confirmed that the call bells should have been accessible to the residents.
Failure to Cue Resident to Use Utensils During Meals
Penalty
Summary
The facility failed to provide services to maintain or improve activities of daily living for Resident 153, who had diagnoses including Alzheimer's disease, dementia, and unspecified severe protein-calorie malnutrition. The care plan identified a self-care deficit and included a restorative nursing program for eating, with staff to assist by giving cues to encourage the resident to use utensils. During observation on May 18, 2026, Resident 153 was seen in the dining room at lunch using her fingers to scoop ice cream instead of using a spoon, and staff did not redirect or cue her to use utensils. On May 19, 2026, the resident was again observed eating her lunch with her fingers while a nurse aide was seated at the same table, and staff again did not redirect or cue her to use utensils. The Director of Nursing later confirmed that staff were to assist Resident 153 with eating.
Accessible Ointments Left Within Reach of Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent accident hazards for one resident with unspecified dementia, anxiety, and a need for assistance with personal care. The resident’s MDS assessment showed severe impairment in daily decision-making and a need for help with personal hygiene, and the care plan stated that he required extensive staff assistance with activities of daily living. During observation, the resident was found in the doorway of his room with a greasy substance on his face and clothes; a NA identified the substance as Remedy Essentials moisturizing ointment from the roommate’s tube, cleaned the resident, moved that tube to the closet, and left. The resident was then observed taking another tube of Remedy Essentials moisturizing ointment from his bedside table drawer. The next day, the moisturizing ointment and antifungal cream were still in the resident’s bedside table drawer and accessible to him, and an RN confirmed that the cream and ointment should not have been accessible to the resident.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to assess a resident with PTSD and develop and implement an individualized, person-centered care plan to provide trauma-informed care. Resident 14 was admitted with diagnoses including quadriplegia and PTSD related to military service and an auto accident. The MDS assessment showed the resident had no cognitive impairment, required substantial assistance from staff for ADLs, and had a diagnosis of PTSD. Review of the care plan revealed no evidence that the facility developed or implemented specific interventions to address the resident’s history of trauma or to identify and minimize triggers to prevent re-traumatization. During interview, the DON confirmed that Resident 14 did not have an individualized person-centered care plan to render trauma-informed care.
Infection Control Lapses During Wound Care and Linen Handling
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to follow infection control policies during wound care and linen handling for two residents. Resident 107 had peripheral vascular disease, a left above-knee amputation, and end stage kidney disease, and had a right heel arterial ulcer with a physician order for cleansing, betadine, gauze, and Kling wrap. During observed wound care, the LPN did not perform hand hygiene after cleansing the wound and before opening a gauze package, did not perform hand hygiene after pouring betadine and before applying the gauze to the wound, and did not wear a gown during the dressing change. The facility policy required gown and gloves for high-contact resident care activities, including wound care, and required hand washing after opening products and between glove changes.
Failure to Document Offering Influenza Vaccines
Penalty
Summary
The facility failed to offer influenza vaccines in accordance with its policy for two of five residents whose records were reviewed. The facility policy stated that between October 1 and March 31 each year, the influenza vaccine should be offered to residents unless medically contraindicated or already received, and that residents or their legal representatives should receive information and education about the benefits and potential side effects, with documentation of education and whether the vaccine was received or declined. Clinical record review showed that Resident 18, admitted to the facility on [DATE], had no documented evidence that an influenza vaccine was offered between October 1, 2025, and March 31, 2026. Clinical record review also showed that Resident 20, admitted to the facility on [DATE], had no documented evidence that an influenza vaccine was offered during the same period. During an interview on May 20, 2026, at 2:20 p.m., the DON confirmed there was no documentation related to influenza vaccines for the identified residents according to the policy.
Failure to Offer Updated COVID-19 Vaccines to Residents
Penalty
Summary
The facility failed to offer the updated 2025-2026 COVID-19 vaccine in accordance with its policy to three residents whose records were reviewed. The facility policy required each resident to be offered the COVID-19 vaccine according to CDC recommendations, with education provided on the benefits, risks, and potential side effects before the vaccine was offered, and with documentation of the education and whether the resident received or declined the vaccine in the medical record. CDC guidance cited in the report stated that the updated 2025-2026 COVID-19 vaccine is recommended for people who live in LTC settings. Clinical record review showed that Resident 4, Resident 20, and Resident 40 were each admitted to the facility and had last been offered a COVID-19 vaccine in 2024. There was no documented evidence that any of these residents were offered the updated 2025-2026 COVID-19 vaccine. During interviews, RN 3 confirmed that COVID-19 vaccines were offered yearly, and the DON confirmed that there was no documentation that the 2025-2026 COVID-19 vaccines were offered to the identified residents.
Widespread Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of unclean and unsafe food storage, preparation, and serving areas. Surveyors noted a black substance on ceiling tiles above the dish machine and kitchen doorway, rusted shelves storing clean dishes, and condensation accumulating on ceiling bars above food preparation areas. The ventilation system was not adequately managing condensation, resulting in moisture accumulation for over a month without any remedial or temporary measures taken. Ceiling tiles above the steam table were chipped and discolored, and there were holes in ceiling tiles above the beverage station, where open carafes of beverages were stored underneath. Additional issues included a leaking pipe under the sink, wet coffee filters, liquid accumulation on the floor, peeling wall molding with black substance, and stains from dripping moisture. Further observations included a black substance on the floor around the ice machine, dried substances on the outside of a garbage can stored next to clean dish racks, and debris inside the hot top used for meal service. In dry storage, food items and packaging debris were found under shelves, along with open containers of food on storage shelves. The freezer had significant ice accumulation on various surfaces and food items. The food preparation area contained debris, an open bottle of vegetable oil, and an open box of parchment paper contaminated with debris. A black substance surrounded a wall fan, and the slicer cart was dirty and uncovered, with food debris present. Additional food and debris were found behind and under storage surfaces, and there was liquid on the floor in front of hot holding equipment. A piece of drainpipe and dirty floor were also noted under the food preparation counter sink.
Failure to Serve Meals at Scheduled Times on Two Nursing Units
Penalty
Summary
The facility failed to serve meals at regularly scheduled times in accordance with resident needs and preferences on two of four nursing units, specifically the Homestead and B-wing units. Review of the facility's meal schedule indicated that lunch was scheduled for 12:00 p.m. on both units. However, observations on December 11, 2025, revealed that residents were seated in the dining rooms at the scheduled time, but meals had not been served. On the B-wing unit, residents reported that meals were often late, and the lunch meal did not arrive until 12:52 p.m., with service beginning at 12:58 p.m. On the Homestead unit, an LPN confirmed that lunch typically arrived between 12:00 p.m. and 1:00 p.m., and on this occasion, the meal arrived at 12:57 p.m. with service starting at 1:05 p.m., over an hour after the scheduled time. These findings were based on facility documentation, staff and resident interviews, and direct observation.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition as required by facility policy. The resident in question had multiple diagnoses, including dysphagia, anxiety, respiratory failure, and required a feeding tube. A physician's order specified oxygen administration at two liters per minute via nasal cannula every shift. On one occasion, staff observed the resident with a dangerously low oxygen saturation of 49% while on supplemental oxygen, necessitating the use of a rebreather mask at ten liters per minute. Later, the resident experienced choking on saliva, required suctioning and a breathing treatment, and developed a fever of 101.1°F. The oxygen flow was increased to five liters per minute, exceeding the physician's order, to maintain oxygen saturation at 90%. Despite these significant changes in the resident's condition, there was no evidence that the physician or any practitioner was notified or assessed the resident until the following day. Staff interviews confirmed that the physician should have been notified at the time the change in condition was identified, but documentation and interviews revealed this did not occur. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) for nursing services.
Failure to Follow Physician Orders for Insulin Administration and Blood Glucose Notification
Penalty
Summary
The facility failed to implement physician orders for three residents with diabetes and related conditions. For one resident with diabetes, chronic kidney disease, and heart failure, staff administered a short-acting insulin injection (Admelog) at 12:15 p.m., but the resident did not receive her meal until 1:15 p.m., an hour after the insulin was given, contrary to manufacturer instructions and physician orders that specified insulin should be administered 15 minutes before or immediately after a meal. Another resident with diabetes, diabetic retinopathy, chronic kidney disease, and dementia was administered Humalog insulin at 11:15 a.m., but did not receive her meal until 1:24 p.m., over two hours later, also in violation of the prescribed timing for insulin administration. Staff interviews confirmed that insulin was not administered in accordance with physician orders and manufacturer guidelines. Additionally, for a third resident with hyperglycemia, dementia, diabetes, and chronic kidney disease, staff failed to notify the physician when blood glucose readings exceeded 400 mg/dL, as required by a physician's order. Blood sugar logs showed readings of 424 mg/dL and 416 mg/dL on two separate occasions, with no evidence of physician notification. The Director of Nursing confirmed that there was no documentation of physician notification for these elevated blood glucose levels.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to provide adequate supervision and follow established safety procedures during the use of a mechanical sit to stand lift for a resident with a history of COPD, stroke, and one-sided weakness. The resident was dependent on staff for toileting and hygiene and was identified as being at risk for falls, with care plans specifying the use of a sit to stand lift with two staff members for all transfers. On the date of the incident, staff were providing incontinent care and used the lift, but one staff member left the room, leaving the resident with only one staff member present. This deviation from protocol resulted in the resident sliding out of the lift and falling. The DON confirmed that staff did not adhere to facility safety procedures by both using the lift during cleaning and by leaving the resident unattended by the required number of staff.
Delayed Response to Call Bell for Resident Requiring Assistance
Penalty
Summary
A deficiency occurred when a resident with hemiparesis and unsteadiness, who required assistance from two staff members and a mechanical lift for transfers and toileting, did not receive timely assistance after activating the call bell for help to use the bathroom. The resident's care plan specified that staff were to provide assistance with toileting as needed and that the resident had been educated to call staff for help. On the day of the incident, the resident activated the call bell at 11:09 a.m. and informed staff of the need for assistance. A staff member acknowledged the request and stated they would return with another staff member, but no one returned promptly. The call bell remained activated for 39 minutes, and the resident continued to wait for assistance, reiterating that no staff had returned during this period. Staff did not return to the resident's room to provide the required assistance until 11:48 a.m. The Director of Nursing later confirmed that staff were expected to respond to call bells in a more timely manner. This delay in response resulted in the facility failing to provide a reasonable accommodation of the resident's needs as required.
Plan Of Correction
The facility will continue to provide a reasonable accommodation of needs. 1. R3, upon notification, was followed up with by the unit manager and has no further concerns. 2. Call bell response time was addressed at resident council on 8/5/2025. Concerns were addressed, and call bell response time audits will be initiated. 3. The Director of Nursing or designee will provide nursing staff education on call bell response times and addressing the needs of residents. 4. A call bell audit will be completed by the Director of Nursing or designee for 20 residents weekly for 4 weeks, with results communicated to the QAPI Committee. 5. Date of compliance is 08/20/2025. The facility will continue to provide a reasonable accommodation of needs. 1. R3, upon notification, was followed up with by the unit manager and has no further concerns. 2. Call bell response time was addressed at resident council on 8/5/2025. Concerns were addressed, and call bell response time audits will be initiated. 3. The Director of Nursing or designee will provide nursing staff education on call bell response times and addressing the needs of residents. 4. A call bell audit will be completed by the Director of Nursing or designee for 20 residents weekly for 4 weeks, with results communicated to the QAPI Committee. 5. Date of compliance is 08/20/2025.
Failure to Follow Physician Orders for Blood Glucose and Blood Pressure Management
Penalty
Summary
The facility failed to implement physician orders for two residents. For one resident with diabetes mellitus, staff were required to obtain glucometer readings and notify the physician if blood glucose levels reached or exceeded 400 mg/dL, as per the physician's order. On one occasion, the resident's blood glucose was recorded at 438 mg/dL, but there was no evidence that the physician was notified of this elevated result, contrary to the order. For another resident with hypertension, physician orders directed staff to check blood pressure twice daily and administer clonidine as needed if the systolic blood pressure exceeded 160 mm Hg or the diastolic exceeded 100 mm Hg. On two separate occasions, the resident's blood pressure readings met or exceeded these thresholds, but there was no evidence that clonidine was administered as ordered. The Director of Nursing confirmed that in both cases, staff did not follow the physician's orders regarding medication administration and notification.
Plan Of Correction
NotSpecified The facility will continue to implement physicians' orders. 1. R1 no longer resides at the facility. R2's MD and RP were notified of elevated BP on 7/11/2025 and 7/26/2025, and PRN not administered. No negative outcome to R2 noted. 2. Facility audit completed for like residents with sliding scale and blood pressure orders with parameters. 3. The Director of Nursing or designee will provide licensed nurses education on ensuring orders with parameters are being followed and have proper prompts, and notifying MD and RP. 4. The Director of Nursing/designee will audit cardiac medications and sliding scale orders weekly for 4 weeks. Results of audits will be reported to the QAPI Committee. 5. Date of compliance is 08/20/2025.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
A review of nursing schedules for a 21-day period revealed that the facility did not meet the required minimum nurse aide (NA) to resident ratios on several occasions. Specifically, the facility failed to provide at least one NA for every ten residents during the day shift on two days, one NA for every eleven residents during the evening shift on six days, and one NA for every fifteen residents during the night shift on one day. These findings were based on direct examination of the facility's staffing schedules and reflect noncompliance with the mandated staffing levels for nurse aides during the specified shifts and dates. No information regarding the medical history or condition of individual residents was provided in the report.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility continues to attend job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. Facility continues with an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 08/20/2025. P 5520
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to comply with state regulations requiring minimum LPN-to-resident staffing ratios during specific shifts. A review of nursing schedules from July 14, 2025, through August 3, 2025, showed that the facility did not meet the required ratio of one LPN per 25 residents during the day shift on four separate days, and did not meet the ratio of one LPN per 30 residents during the evening shift on one day. Additionally, the facility failed to meet the minimum ratio of one LPN per 40 residents during the night shift on one day. These deficiencies were identified through a review of the facility's nursing time schedules for the specified period. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
P 5530 1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility has scheduled recruitment appearances at LPN schools to recruit new staff, and introduced employee referral program. Recruitment outreach via social media and messaging to area LPNs encourage joining our facility staff. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 08/20/2025.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules over a 21-day period revealed that on 12 separate days, the total direct care hours per resident fell below the mandated threshold. Specific days were identified where the care hours ranged from 2.72 to 3.16 per resident, indicating that the facility did not consistently staff enough nursing personnel to meet the required standard during the reviewed timeframe. No information regarding the medical history or condition of individual residents at the time of the deficiency was provided in the report.
Plan Of Correction
1. Nursing hours noted in the survey cannot be corrected as this is a past event. 2. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility recently completed nurse aide training classes to fill vacant nurse aide positions. LPN school recruitment efforts continue with presentation scheduled this fall to graduating LPNs. Continue with collaboration with local Penn State campus to introduce graduating nurses to long term care in our facility. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. 4. PPD hours will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. 5. Date of compliance is 08/20/2025.
Failure to Maintain Updated All-Hazards Risk Assessment
Penalty
Summary
Schuylkill Center was found to be noncompliant with federal emergency preparedness requirements following an Emergency Preparedness Survey. The facility failed to provide an updated all-hazards risk assessment, which is required to be reviewed and updated at least annually. During document review, surveyors were unable to obtain documentation of a current all-hazards risk assessment for the facility. At the time of the exit conference, both the Administrator and Maintenance Director confirmed that they could not provide an updated all-hazards risk assessment. This deficiency affected the entire facility component and was based solely on the lack of required documentation. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Plan Of Correction
The facility will continue to provide an updated all hazards risk assessment for the facility. 1. The facility utilizes the Kaiser Permanente Hazard Vulnerability Assessment Tool, which was last updated at the time of annual manual approvals on 1/17/2025. This tool will be updated at least quarterly, or as needed, and used to identify and update the facility's Emergency Preparedness plan. The Hazards Risk Assessment will be filed in all copies of the Emergency Preparedness plan. 2. The Maintenance Director or designee will audit the Hazard Vulnerability Assessment tool at least semi-annually to confirm that updates are filed in all copies of the Emergency Preparedness plan. Results of the audits will be reviewed at least semi-annually with the QAPI Committee, including any revisions required to the Facility Emergency Preparedness plan as a result of the assessment. Date of Correction is 7/30/2025.
Failure to Maintain and Document Fire Alarm System Testing
Penalty
Summary
The facility failed to provide required testing and maintenance for its fire alarm system on a semi-annual basis. Documentation review revealed that there was no evidence of semi-annual visual inspections or testing of the fire alarm system within the previous twelve months. Additionally, the facility lacked documentation for the semi-annual inspection and testing of both wet and dry system valve supervisory switches and pressure switch waterflow alarms. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director. Further review of service call reports indicated that certain supervisory and tamper flow switches on the wet system failed to register as a priority fire alarm. There was no documentation provided to show that this issue had been resolved. The absence of records verifying the correction of these alarm deficiencies was also confirmed by facility leadership during the exit conference.
Plan Of Correction
The facility will provide testing and maintenance to the fire alarm system on a semi-annual basis as required. A copy of the January 2025 inspection report was acquired and placed in the facility life safety book. Documentation of repairs will also be placed in the life safety book. At least semi-annually, the Maintenance Director or NHA will audit the life safety book to confirm that all reports have been filed in the book. Results of the audits will be reported to the QAPI Committee. Date of correction is 7/30/2025.
Failure to Maintain and Document Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to provide documentation verifying that quarterly inspections of both wet and dry automatic sprinkler systems were conducted for the second and third quarters of 2024. During document review, it was found that records confirming these inspections were missing, and this was confirmed by the Administrator and Maintenance Director. Additionally, two sprinkler heads located behind the dryers in the laundry area were found to be incorrectly oriented above the ceiling tile, an issue previously identified in a quarterly report but not corrected. The facility also lacked documentation showing that deficiencies related to the wet system's Supervisory Flow Switches and Tamper Flow Switches, which failed to register as a priority on the fire alarm panel, had been resolved. Further observations revealed that multiple sprinkler heads in the laundry room were covered with debris, specifically four in the clean area, two in the soiled area, and two in the personal area. These findings were confirmed by the Administrator and Maintenance Director during the exit conference. The report does not mention any residents or specific patient involvement, nor does it provide information about their medical history or condition at the time of the deficiency.
Plan Of Correction
1. The facility will ensure the wet/dry sprinkler systems are subject to inspection and/or testing at least quarterly. The two sprinkler heads noted during the survey behind the dryers in Laundry will be modified for correct orientation. The 1 and 2 Wet System Supervisory Flow Switches will be repaired to resolve the issue. The sprinkler head identified as covered with debris will be cleaned. The sprinkler inspection reports will be maintained in the facility Life Safety book, including repair reports. 2. The Maintenance Director or designee will perform at least quarterly audits of the facility Life Safety book to confirm that the sprinkler system has been inspected and tested, and that deficiencies have been repaired. Audit results will be reported to the QAPI Committee. Date of compliance is 7/30/2025.
Failure of Hazardous Area Door to Self-Close and Latch
Penalty
Summary
Surveyors observed that the door to the Service Hall Food Storage Room did not self-close and latch within the door frame as required for hazardous area enclosures. The door was found dragging on the floor, which prevented it from closing and latching properly. This deficiency was confirmed during an interview with the Administrator and Maintenance Director, who acknowledged that the door failed to self-close and positively latch, thereby compromising the smoke resistance of the hazardous area enclosure in one of seven smoke compartments.
Plan Of Correction
1. The door to the Service Hall food storage room will be modified and/or replaced to allow self-closure and latching within the door frame, and repair the drag on the floor. A time-limited waiver will be requested if door replacement is required. 2. A time-limited waiver will be requested until 1/5/2026 for the door replacement in the Service Hall food storage room. Maintenance will complete monthly door checks to verify ongoing compliance with regulatory requirements, and report any negative findings to the QAPI Committee monthly. Date of compliance is 7/30/2025.
Deficiencies in Life Safety Documentation and Carbon Monoxide Alarm Compliance
Penalty
Summary
Surveyors identified several deficiencies related to the facility's compliance with Life Safety Code (LSC) and state regulations. During document review and interviews, it was found that the facility's life safety drawings were incomplete, lacking critical information such as resident room capacities, door swings, fire wall and smoke wall boundaries, hazardous areas, and compartment designations. This was confirmed by the Administrator and Maintenance Director during the exit conference. Additionally, the facility did not have documentation of annual testing and inspection of installed carbon monoxide alarms as required by the manufacturer's instructions and the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. There was also no documentation confirming that the carbon monoxide alarms could be heard by on-duty staff or verifying evacuation and alarm protocols related to these alarms. These deficiencies were acknowledged by facility leadership during interviews.
Plan Of Correction
1. The facility Life Safety drawings will be revised to include the items noted lacking in the survey process. Documentation of annual testing and inspection of installed Carbon Monoxide alarms, per manufacturer's instructions, will also be maintained. The Carbon Monoxide alarms will be modified to ensure they can be heard by on-duty staff as required. Evacuation and alarm protocols will be updated and reviewed at least annually, with annual in-service education for facility staff. 2. The Life Safety drawings will be reviewed for compliance with the required components by the Maintenance Director and NHA. The documentation of annual testing and inspection of Carbon Monoxide alarms will also be reviewed monthly by the Maintenance Director, and documentation of the Carbon Monoxide alarms being able to be heard by on-duty staff will occur monthly. Evacuation and alarm protocols will be reviewed and updated as required, and staff in-services will be held with facility staff to educate on same. Each of these items will be reported monthly to the QAPI Committee for three months, and at least quarterly thereafter until compliance is achieved. Date of correction is 7/30/2025.
Failure to Document Fire Suppression System Checks and Hood Cleaning
Penalty
Summary
The facility failed to provide documentation of the required owner's quick checks for the fixed chemical fire suppression system installed in the kitchen. During a review of facility records, surveyors were unable to locate evidence that these quick checks had been performed as required. This was confirmed in an interview with the Administrator and Maintenance Director, who acknowledged the absence of documentation for the quick checks on the kitchen's fire suppression system. Additionally, the facility could not provide documentation verifying that the kitchen exhaust ductwork had been cleaned on a semi-annual basis. The last available documentation showed that the most recent cleaning cycle was completed several months prior, with no records of subsequent cleanings. This lack of documentation was also confirmed by the Administrator and Maintenance Director during the exit conference.
Plan Of Correction
1. Kitchen suppression system inspections and hood cleaning certificates will be placed in the facility's life safety book. The owner's quick checks of the fixed chemical fire suppression system will continue to be displayed in the kitchen. The semi-annual hood cleaning has been scheduled for July 2025, and documentation will be maintained when completed. 2. The Maintenance Director will audit, at least semi-annually, the facility's life safety book to verify the existence of the required kitchen suppression inspections and hood cleaning certificates, and report to the QAPI Committee with results of these audits. Date of correction is 7/30/2025.
Food Storage and Sanitation Deficiencies in Dietary Department
Penalty
Summary
The facility failed to store and serve food in a sanitary manner in both the dietary department and on one nursing unit. During a kitchen tour, surveyors observed multiple violations of facility policy and food safety standards. In several coolers, opened food items such as tea, sliced turkey lunch meat, ham, and shredded cheese were either undated or stored past their use-by dates. Juices from an opened bag of turkey lunch meat were dripping onto a box of pork below, forming a puddle on the cooler floor, and opened bags of ham and cheese were stored inappropriately. Milk crates were stored directly on the floor, and a juice lid was found on the floor near the milk. The trayline refrigerator had visible dried food substances on the door and shelves, and utensil drawers had dried food debris. Flying insects were present in both the food preparation and dish room areas, and dry storage had a fly, an open window, and bug and dust debris on the windowsill. During meal service on one unit, a dietary employee with uncovered facial hair was observed serving food. The employee wore gloves but failed to change them or perform hand hygiene after touching the phone and then handling resident plates and utensils. The same gloved hands were used to serve food, and the employee did not change gloves or perform hand hygiene between tasks, contrary to facility policy. The administrator confirmed that utensils, not gloved hands, should have been used to serve meat. These findings demonstrate multiple failures to follow food safety and sanitation protocols as required by facility policy and federal regulations.
Failure to Monitor Hot Beverage Temperatures and Supervise Leads to Resident Burn
Penalty
Summary
The facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units, resulting in residents being placed at risk for burn injuries. Observations and interviews revealed that staff did not routinely test the temperature of hot beverages before serving them to residents, and coffee was served at temperatures as high as 181 degrees Fahrenheit. The facility's policy allowed hot beverages to be served at temperatures above 155 degrees Fahrenheit, which is contrary to safety recommendations from the American Burn Association, and there was no evidence that beverages were retested at the point of service before being given to residents. A resident with significant medical conditions, including Parkinson's disease, Lewy body dementia, apraxia, and cognitive impairment, required assistance with meals and supervision during self-feeding. Despite these needs, the resident was observed unsupervised in the dining room on multiple occasions, drinking coffee without a lid. The resident sustained a burn injury to the abdomen after spilling hot coffee, which was measured at 15 cm by 2 cm. The incident was discovered when the resident was heard screaming, and staff noted the spill and resulting burn. Further interviews with dietary and nursing staff confirmed that they did not typically test the temperature of coffee before serving it to residents. Residents also reported that the coffee was too hot to drink and needed to sit before it could be consumed. The lack of temperature monitoring, failure to provide required supervision, and absence of adaptive equipment contributed to the incident, resulting in actual harm to a resident and the identification of an Immediate Jeopardy situation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during observed medication administration on two of four nursing units. Over the course of two observation periods, there were 26 medication administration opportunities, with four errors identified, resulting in a medication error rate of 15.38%. These errors were confirmed by the Director of Nursing. Specific deficiencies included a nurse not instructing a resident with chronic obstructive pulmonary disease and diabetes to rinse their mouth after using a tiotropium bromide inhaler, and failing to clean the tops of two insulin pens with alcohol before attaching needles, contrary to physician orders and manufacturer instructions. Additionally, another nurse crushed an extended-release acetaminophen tablet before administering it to a resident with chronic pain and dementia, despite drug information stating that these tablets should not be crushed.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs and preferences on three of four nursing units. Multiple residents reported that meal delivery was frequently late, with one resident stating she had to wait a long time for a meal and another indicating that late meals interfered with participation in scheduled activities. Additional residents confirmed that the delivery of meal trucks and steam tables was often delayed. Review of the facility's meal schedule showed specific delivery times for each unit, with a 15-minute grace period allowed. However, observations revealed that meal deliveries were significantly late on several units, with delays ranging from 33 to 49 minutes past the scheduled times. One resident was observed without a meal tray during the delay and confirmed that late meals were a typical occurrence. The DON acknowledged that meal service should have adhered to the scheduled delivery times.
Improper Disposal of Trash and Refuse
Penalty
Summary
During an observation of the dumpster area, various items were found improperly disposed of on the ground next to the garbage dumpsters. These items included multiple used gloves, plastic debris, condiment packets, a waffle, and a pile of animal droppings behind the dumpster. Additionally, one of the dumpsters had four soiled briefs and cloths sticking out from underneath it. These findings indicate that the facility failed to dispose of trash and refuse properly as required.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information as required. During facility tours on June 8 and June 9, 2025, it was observed that the staffing information displayed in the lobby was outdated, showing the date of June 6, 2025. In a subsequent interview, the Nursing Home Administrator confirmed that the posted staffing information was incorrect. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Inadequate Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to comply with the required nurse aide (NA) to resident ratios over a 21-day period from March 14 to April 3, 2025. Specifically, the facility did not meet the minimum staffing requirements on multiple occasions across different shifts. During the day shift, the facility was short of the required one NA per ten residents on seven days. The evening shift was understaffed on eleven days, failing to maintain the required one NA per eleven residents. Additionally, the night shift did not meet the minimum requirement of one NA per fifteen residents on two days. These deficiencies were identified through a review of the nursing schedules, indicating a consistent pattern of inadequate staffing levels.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility continues to attend job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. Nurse Aide classes will resume at the facility on 4/28/25. Facility continues with an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 06/11/2025.
Non-Compliance with LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by the regulation effective July 1, 2023. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on March 15, 16, 29, and 30, 2025. Additionally, the facility did not meet the required ratio of one LPN per 30 residents during the evening shift on March 16, 29, and 30, 2025. These deficiencies were identified based on a review of nursing time schedules over a 21-day period from March 14 through April 3, 2025, indicating non-compliance on four of those days.
Plan Of Correction
1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility has attended LPN schools to recruit new staff and introduced an employee referral program, as well as calling area LPNs to consider joining facility staff. Presentation to local LPN school graduates scheduled for 4/28/25, and they graduate in May. Entered collaboration with local Penn State campus to introduce graduating nurses to our facility onsite. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 06/11/2025.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of nursing schedules from March 14 through April 3, 2025, revealed that on 16 out of 21 days, the facility did not meet this minimum standard. Specific days with deficiencies included March 14, 15, 16, 17, 18, 22, 23, 24, 26, 28, 29, 30, 31, and April 1, 2, and 3, 2025. On these days, the care hours per resident ranged from 2.52 to 3.16, falling short of the required 3.2 hours.
Plan Of Correction
Nursing hours noted in the survey cannot be corrected as this is a past event. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. The facility has developed internal incentives to retain and attract new staff. Two nurse aide classes have been already scheduled and are being recruited with the first class starting 4/28/25. LPN school recruitment efforts continue with a presentation scheduled on 4/24/25 for nurses that graduate in May. Developed collaboration with local Penn State campus to introduce graduating nurses to long term care in our facility. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. PPD hours will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. Date of compliance is 06/11/2025.
Failure to Prevent Neglect Resulting in Pressure Sore
Penalty
Summary
A facility failed to protect a resident from neglect when staff did not provide timely assistance with toileting. The resident, who was cognitively impaired, had difficulty communicating needs, was dependent on staff for mobility, and was unable to use a toilet independently, was identified as being at risk for pressure sores and required turning and repositioning every two hours per care plan. On one occasion, the resident was placed on a bedpan at approximately 2:30 p.m. and was not assisted off until about 7:00 p.m. Subsequently, a nurse assessed the resident and found a ring-shaped stage 1 pressure sore, matching the size and shape of the bedpan, on the resident's buttocks. The evening shift aide acknowledged being aware of the resident's care needs but failed to provide timely assistance, a fact confirmed by the Director of Nursing.
Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios for 19 out of 21 days reviewed, as evidenced by a review of nursing schedules from December 9 through 29, 2024. Specifically, the facility did not maintain the minimum NA to resident ratio of one NA for ten residents during the day shift on 15 days, one NA for 11 residents during the evening shift on 18 days, and one NA for 15 residents during the night shift on 11 days. This deficiency was confirmed by the Director of Nursing during an interview on December 30, 2024.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility has attended job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. We are using recruitment lists to call area CNAs to consider joining our facility. We have reached out to Nurse Aide training institutions to determine their ability to staff ongoing Nurse Aide Training classes. The facility has introduced an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee. 5. Date of correction is 03/05/2025.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on multiple occasions over a 21-day period in December 2024. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on six days, one LPN per 30 residents during the evening shift on three days, and one LPN per 40 residents during the night shift on eight days. This deficiency was confirmed by the Director of Nursing during an interview, acknowledging the facility's inability to meet the staffing requirements on the identified days.
Plan Of Correction
1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility has attended LPN schools to recruit new staff, and introduced an employee referral program, as well as calling area LPNs to consider joining facility staff. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee. 5. Date of correction is 03/05/2025.
Deficiency in Meeting Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for 20 out of 21 days reviewed. The review of nursing schedules from December 9 through December 29, 2024, revealed that the facility consistently fell short of the required care hours, with the lowest being 2.08 hours per resident on December 25, 2024. The Director of Nursing confirmed during an interview that the facility did not meet the minimum required nursing care hours on the identified days.
Plan Of Correction
1. Nursing hours noted in the survey cannot be corrected as this is a past event. 2. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Re-introduction of a Nurse Aide Training program is scheduled with classes to train new nurse aides. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. 4. PPD hours will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. 5. Date of compliance is 03/05/2025.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for five residents who required assistance with activities of daily living (ADLs). These residents were scheduled for showers on specific days, but there was a lack of documentation indicating that showers were provided on several occasions. Interviews with the residents confirmed that they had not refused showers on the dates in question. Resident 1, admitted with diagnoses including diabetes mellitus with diabetic neuropathy and an acquired absence of the right leg above the knee, was not documented as having received showers on three scheduled dates. Resident 4, with a history of ischemic attack and diabetes mellitus, missed showers on two scheduled dates. Resident 5, diagnosed with acute chronic diastolic heart failure and difficulty walking, was not documented as having received showers on three scheduled dates. Resident 6, with hemiplegia following cerebral infarction, missed showers on five scheduled dates. Resident 8, with hypertensive heart disease and mobility issues, was not documented as having received a shower on one scheduled date. The facility's Administrator and Director of Nursing acknowledged that the residents should have been offered showers on their scheduled dates.
Plan Of Correction
1. Resident 1 has been discharged. Resident 4 received a shower on 12/3/24. Resident 5 received a bed bath and care planned as a preference. Resident 6 received a shower on 12/4/2024. Resident 8 received a bed bath and care planned as a preference. Resident 5 and 8 interviewed again for shower preference. 2. Facility will complete a 7 day look back audit of resident showers. Any resident documented as not receiving a shower on their designated day will be offered a shower. 3. The Director of Nursing/Designee will re-educate nursing staff on providing resident showers on designated shower days and/or PRN. Current residents to be interviewed to determine bathing preference. The education will include providing shower per bathing preference. If shower unable to be given, shower to be offered on the next day/shift and documented. 4. The Director of Nursing/designee will complete bathing audits weekly x 4. The results of the audits will be presented at the monthly QA meeting. 5. Date of compliance will be 1/15/2025.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination by not providing scheduled showers to two residents. Resident 3, diagnosed with anxiety and insomnia, was oriented and required staff assistance for bathing. Despite preferring and being scheduled for showers twice a week, the resident was not offered a shower on two out of eight scheduled occasions in the past 30 days. Similarly, Resident 4, who had hemiplegia and diabetes mellitus, was also oriented and required staff assistance for bathing. This resident preferred and was scheduled for showers twice a week but was not offered a shower on five out of nine scheduled occasions in the past 30 days. These failures were identified through clinical record reviews and resident interviews.
Failure to Implement Physician's Orders for Blood Pressure Medications
Penalty
Summary
The facility failed to implement physician's orders for two residents with diagnoses of hypertension and atrial fibrillation. For Resident 2, a physician ordered metoprolol to be administered twice daily, with instructions to withhold the medication if the systolic blood pressure was less than 100 mm/Hg. However, the medication was administered 15 times when the resident's systolic blood pressure was below this parameter. Similarly, for Resident 4, a physician ordered carvedilol to be administered once daily, with instructions to withhold the medication if the systolic blood pressure was less than 110 mm/Hg or the heart rate was less than 60 bpm. The medication was administered eight times when the resident's vital signs were below these parameters. During an interview, the Director of Nursing confirmed the absence of documented evidence that the medications were withheld when the residents' systolic blood pressure or heart rate were below the established parameters.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
The facility failed to store food under sanitary conditions in the kitchen, as observed during a survey. The Director of Dietary Services stated that refrigerated foods should be labeled, dated when opened, and used within three days. However, during a kitchen tour, several items in the walk-in refrigerator were found to be improperly labeled or stored. These included a container of pumpkin puree, raspberry glaze, pureed peaches, cottage cheese, salad, and spaghetti with sauce, all of which were either undated or past the three-day usage guideline. Additionally, in the reach-in refrigerators, there were items such as chopped lettuce, ham luncheon meat, turkey luncheon meat, and chicken that were either undated or past the recommended usage period. The walk-in freezer had a large accumulation of ice buildup on food items, including a container of ground beef with ice directly on it. In the food preparation area, there were undated opened containers of cereal, and in the dry storage area, an opened, undated bag of noodles was found. Furthermore, there were chunks of tile missing on the floor in several areas of the kitchen.
Failure to Follow Pre-Approved Menus on C Unit
Penalty
Summary
The facility failed to adhere to the pre-approved menus on one of its nursing units, specifically the C Unit. This deficiency was identified through a combination of observations, facility documentation, a test tray audit, and staff interviews. A review of the monthly Resident Council and Food Committee meeting minutes from December 2023 to April 2024 revealed consistent complaints from residents regarding the portion sizes of food served at mealtimes. On May 8, 2024, during a confidential group meeting, residents reiterated that the portion sizes were often too small. The facility's menu for lunch on May 8, 2024, specified that residents should receive three ounces of glazed pork medallions and four ounces of California blend vegetables. However, a test tray audit conducted on the same day showed that staff served only two ounces of glazed pork and three ounces of vegetables. The Dietary Manager confirmed in an interview that the incorrect portion sizes were provided for the lunch cart delivered to the C Unit, thus failing to meet the nutritional needs as outlined in the pre-approved menu.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide dining assistance in a manner that promoted and maintained dignity for two residents on two different nursing units. Resident 42, who has Alzheimer's disease and cognitive impairment, was observed eating spaghetti with her fingers in the dining room without any staff intervention or assistance, despite her care plan indicating she required supervision with eating and was on a restorative nursing program for dining. Similarly, Resident 74, who has arthritis and vision problems, was observed eating cake with her hands, resulting in her hands being covered in cake and icing. Despite her care plan indicating she required meal set-up and as-needed assistance due to her compromised functional ability and impaired vision, no staff offered assistance or redirection during the meal. These observations indicate a failure to uphold the residents' rights to dignity and appropriate nursing services as outlined in the relevant state codes.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as identified during a clinical record review and staff interview. Resident 141, who has cognitive impairment, hearing loss, and dementia, was noted to have communication issues that were supposed to be addressed in the care plan according to the Care Area Assessment (CAA) summary. However, there was no evidence of interventions for communication problems in the current care plan. Similarly, Resident 168, diagnosed with dementia and chronic kidney disease, was occasionally incontinent of urine. The CAA summary indicated that urinary incontinence should be addressed in the care plan, but no interventions were included. The Director of Nursing confirmed that the care plans for these residents did not address the identified care areas, which is a violation of 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food that was palatable and at appetizing temperatures on one of its nursing units, specifically the C Unit. On May 7, 2024, residents reported that their lunch was cold, and a review of meeting minutes from December 2023 through April 2024 revealed a pattern of complaints about food temperatures. During a confidential group interview on May 8, 2024, residents reiterated that food was often not served at the right temperature and that the pork was too tough. A test tray audit conducted on the same day showed that the glazed pork was served at 120.7 degrees Fahrenheit, scalloped potatoes at 111 degrees Fahrenheit, and California blend vegetables at 116 degrees Fahrenheit, all of which were cool to taste. Observations of residents eating lunch in the C unit dining room confirmed that the pork was tough and not hot, with residents expressing difficulty in cutting and chewing it.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment to two residents, both of whom had specific medical conditions necessitating such equipment. Resident 29, diagnosed with Parkinson's disease, dementia, arthritis, and a lack of coordination, required assistance for all meals and was supposed to use Kennedy cups as per their care plan. However, observations on May 8 and 9, 2024, revealed that Resident 29 was served drinks in regular cups without lids or straws, contrary to the care plan and dietitian's recommendations. Similarly, Resident 76, who had paralysis on one side and vision problems, was also supposed to use a Kennedy cup with a straw for all meals due to their cognitive impairment and nutritional needs related to diabetes and impaired skin integrity. Despite this, observations on May 7 and 8, 2024, showed that Resident 76 was using regular cups without lids or straws. The Director of Nursing confirmed that both residents were supposed to have their drinks served in Kennedy cups, indicating a failure in adhering to the prescribed care plans.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 207 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pottsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Of Greenwood Hill | 0.8 mi | ★★★★★ | 4 | 0 |
| Gardens At York Terrace, The | 2.8 mi | ★★★★★ | 0 | 0 |
| Green Valley Skilled Nursing And Rehabilitation Ce | 2.9 mi | ★★★★★ | 11 | 0 |
| Rosewood Rehabilitation And Nursing Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Seton Manor Nursing And Rehabilitation Center | 4.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.