Scottdale Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottdale, Pennsylvania.
- Location
- 900 Porter Avenue, Scottdale, Pennsylvania 15683
- CMS Provider Number
- 396035
- Inspections on file
- 26
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Scottdale Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to report allegations of abuse involving three residents in a timely manner, as required by state law and facility policy. Incidents included a nurse aide's refusal to assist a resident, rude behavior, and aggressive handling of a resident. These were not reported to authorities until six days later, resulting in a deficiency finding.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers and reasons for hospitalization for seven residents. This deficiency was identified through clinical record reviews and staff interviews, revealing a lack of documented evidence of written notices for transfers due to various medical conditions, including osteomyelitis, chest pain, altered mental status, fractures, cellulitis, and gastrointestinal issues.
The facility failed to follow physician orders for two residents. A resident with heart failure received Midodrine despite blood pressure readings above the ordered threshold. Another resident with chronic kidney disease and congestive heart failure did not have weights obtained as ordered on multiple occasions. The DON confirmed these deficiencies.
The facility failed to document the administration of controlled medications for three residents, leading to a deficiency in pharmaceutical services. Doses of Lorazepam, Tramadol, Morphine, and Oxycodone were signed out without corresponding documentation in the residents' clinical records. This discrepancy was confirmed by the DON, indicating a failure in the facility's processes for documenting medication administration.
The facility failed to complete comprehensive admission MDS assessments within the required timeframe for four residents. The assessments were completed 15 to 16 days after admission, exceeding the 14-day requirement. This was confirmed by the RNAC through clinical records and staff interviews.
The facility failed to complete quarterly MDS assessments within the required time frame for four residents. Two residents had assessments conducted beyond the 92-day limit, while two others had assessments completed late beyond the 14-day completion period. These deficiencies were confirmed by the Regional RNAC.
The facility failed to accurately complete MDS assessments for three residents, leading to incorrect documentation of medication administration. One resident's assessment did not reflect the administration of hypoglycemic medication and incorrectly recorded an anticonvulsant. Another resident's assessment inaccurately documented an injection, and a third resident's assessment failed to record anticoagulant and opioid medications while incorrectly indicating an anticonvulsant. These errors were confirmed by the Regional RN Assessment Coordinator.
A facility failed to create a comprehensive care plan for a resident with frequent UTIs, despite multiple antibiotic treatments and concerns from the resident's daughter. The facility's policy requires individualized care plans, but none was documented for this resident, as confirmed by the DON.
A facility failed to update a resident's care plan to reflect the correct dialysis schedule. The resident, who was cognitively intact and required assistance with care needs, had a diagnosis of end-stage renal disease and attended dialysis on Mondays, Wednesdays, and Fridays. However, the care plan inaccurately stated the dialysis days as Tuesdays, Thursdays, and Saturdays. This discrepancy was confirmed by the DON during an interview.
A facility failed to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who had a diagnosis of urinary retention and neurogenic bladder, was observed with catheter tubing lying on the fall mat, contrary to facility policy. The Director of Nursing confirmed the tubing should not have been in contact with the mat.
A facility failed to have a physician's order for a resident requiring dialysis. The resident, diagnosed with end-stage renal disease, received dialysis thrice weekly, but their clinical record lacked an active physician's order for these services. This was confirmed by the DON.
A facility failed to attempt non-pharmacological interventions before administering Ativan to a resident on multiple occasions, despite policy requirements. The resident, who was cognitively intact and receiving hospice services, was given the medication without documented evidence of prior interventions. The DON confirmed the oversight.
A resident with atrial fibrillation did not receive the prescribed doses of warfarin on multiple occasions. The resident was supposed to receive 3 mg daily, but it was not administered on two separate days. Additionally, an incorrect dose of 9 mg was given instead of 6 mg on another day. The DON confirmed these medication errors.
The facility's QAPI committee failed to maintain compliance with nursing home regulations, resulting in repeated deficiencies. These included failures in developing comprehensive care plans, updating resident care plans, following physician's orders, accounting for controlled medications, and adhering to infection control practices. Despite previous plans of correction, the committee was ineffective in implementing these plans, leading to repeated citations.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with a history of ESBL infections. Observations revealed a lack of signage and PPE outside the residents' rooms, and interviews with the DON confirmed that EBP should have been in place. This deficiency highlights a lapse in following infection control guidelines from CMS and CDC.
The facility did not maintain an effective preventative maintenance program for the walk-in freezer, resulting in significant ice accumulation on the ceiling, walls, and floor. The Dietary Manager confirmed the issue, and the Director of Maintenance, who had been in the role for six months, did not recall any maintenance work on the freezer. A Maintenance Worker mentioned a past compressor replacement and lack of a manual, with a service technician suggesting possible causes for the ice buildup.
The facility did not provide effective communication training to its nursing and direct care staff, as required by its Facility Assessment. The review of four employee files showed no documented evidence of such training, which was confirmed by the DON. This deficiency violates specific sections of the Pennsylvania Code related to staff development and management.
A resident experienced multiple episodes of respiratory distress and hypoxia without documented assessments by an RN, as required by the Pennsylvania Nursing Practice Act. Despite symptoms such as shortness of breath and low oxygen levels, no RN assessment was recorded, leading to the resident's transfer to the ER with pneumonia and sepsis. The DON confirmed the lack of RN assessments during these critical times.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report timely allegations of abuse to the State Survey Agency and other state agencies as required by the Older Adults Protective Services Act. The facility's policy mandates immediate reporting of suspected abuse, neglect, exploitation, or misappropriation to the administrator and relevant authorities. However, the facility did not report the allegations involving three residents until several days after the incidents occurred. Resident 131, who required assistance due to a hip fracture, reported feeling scared of a nurse aide who refused to assist her and was argumentative. Resident 132, with a fractured tibia, experienced rude behavior from the same nurse aide, who knocked over a drink and did not clean it up. Resident 133's wife reported aggressive behavior by the nurse aide, who snatched a urinal from her hand and handled the resident roughly in bed. These incidents were not reported to the appropriate authorities until six days later. Interviews with staff confirmed the delay in reporting. The Director of Nursing acknowledged that the allegations were not reported in a timely manner, attributing the oversight to her absence on vacation. The lack of immediate reporting violated both state law and the facility's own policies, resulting in a deficiency finding by the surveyors.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives in writing about transfers to the hospital and the reasons for hospitalization for seven residents. This deficiency was identified through clinical record reviews and staff interviews. For Resident 1, there was no documented evidence of a written notice provided to the resident's representative and state ombudsman when the resident was transferred to the hospital for osteomyelitis. Similarly, Resident 5 experienced a change in mental status and was transferred to the hospital with chest pain, fever, abdominal pain, altered mental status, and leukocytosis. However, there was no documented evidence of a written notice provided to the resident's representative and state ombudsman. Resident 9 was transferred to the emergency room due to lethargy and low blood oxygen levels, but again, no written notice was documented for the resident's representative and state ombudsman. Additional cases included Resident 14, who was transferred due to chest pain, Resident 22, who was transferred after a fall resulting in fractures, Resident 23, who was transferred with cellulitis, and Resident 24, who was transferred with gastrointestinal pain and other symptoms. In all these cases, there was no documented evidence of written notices provided to the residents' representatives and state ombudsman regarding the transfers and reasons for hospitalization.
Failure to Administer Medications and Obtain Weights as Ordered
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents. Resident 5, who was moderately cognitively intact and diagnosed with heart failure, had a physician's order to receive 5 mg of Midodrine three times a day for hypotension, with instructions to hold the medication if the systolic blood pressure exceeded 130 mmHg. However, the Medication Administration Record (MAR) showed that staff administered the medication on multiple occasions when the resident's systolic blood pressure was above the specified threshold, including readings of 138/76 mmHg, 135/76 mmHg, and 140/90 mmHg, among others. The Director of Nursing confirmed that the medication was improperly administered on these dates. Additionally, the facility did not obtain weights as ordered for Resident 17, who was cognitively impaired and had diagnoses including chronic kidney disease Stage 3 and congestive heart failure. The physician's orders required weekly weights on Thursdays, but the MAR revealed that weights were not obtained on several specified dates across multiple months, with no documentation indicating attempts or refusals by the resident. The Director of Nursing confirmed the failure to obtain the required weights on the mentioned dates.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents, leading to a deficiency in pharmaceutical services. For Resident 12, there were multiple instances where doses of Lorazepam and Tramadol were signed out but not documented as administered in the resident's clinical records, including the Medication Administration Record (MAR) and nursing notes. This lack of documentation occurred despite the resident having physician's orders for these medications and being on hospice care with a diagnosis of congestive heart failure. Resident 22, who was cognitively intact and required assistance with daily care, had physician's orders for Morphine Sulfate to be administered as needed for pain. However, several doses of Morphine were signed out without corresponding documentation in the resident's clinical records to confirm administration. This discrepancy was confirmed by the Director of Nursing during an interview. Similarly, Resident 26, who was also cognitively intact and receiving routine and as-needed pain medications, had doses of Oxycodone signed out without evidence of administration in the clinical records. The Director of Nursing confirmed the absence of documentation for these signed-out doses. These findings indicate a failure in the facility's processes for documenting the administration of controlled medications, as required by their policy and state regulations.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required timeframe for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 181, 182, 183, and 184 were completed 15 to 16 days after their respective admissions, exceeding the mandated timeframe. The deficiency was confirmed through a review of clinical records and staff interviews, specifically with the Regional Registered Nurse Assessment Coordinator (RNAC). The RNAC acknowledged that the assessments for the four residents were not completed within the required timeframes, as outlined in the RAI User's Manual. This oversight indicates a failure to adhere to the regulatory guidelines for timely resident assessments.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 days after the ARD. However, the quarterly MDS assessments for Residents 10 and 29 were conducted 93 days after their previous assessments, exceeding the 92-day requirement. Additionally, the quarterly MDS assessments for Residents 11 and 18 were not completed within the required 14-day period following the ARD. Resident 11's assessment was completed two days late, and Resident 18's assessment was completed three days late. These deficiencies were confirmed during an interview with the Regional Registered Nurse Assessment Coordinator, who acknowledged that the assessments were not completed within the required time frames.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in the documentation of their medication administration. For one resident, the MDS assessment incorrectly indicated that the resident did not receive hypoglycemic medication, despite physician's orders and the Medication Administration Record (MAR) confirming the administration of Metformin. Additionally, the assessment inaccurately recorded the administration of an anticonvulsant medication, which the resident did not receive. This error was confirmed by the Regional Registered Nurse Assessment Coordinator. Another resident's admission MDS assessment inaccurately documented the receipt of an injection, which was not supported by the MAR. Similarly, a third resident's significant change MDS assessment failed to record the administration of anticoagulant and opioid medications, while incorrectly indicating the receipt of an anticonvulsant medication. These inaccuracies were also confirmed by the Regional Registered Nurse Assessment Coordinator, highlighting a pattern of errors in the facility's MDS assessments.
Failure to Develop Individualized Care Plan for Frequent UTIs
Penalty
Summary
The facility failed to develop comprehensive care plans with specific and individualized interventions for a resident's care needs. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident. However, for one resident, who was moderately cognitively impaired and frequently experienced urinary tract infections (UTIs), there was no documented evidence of a care plan addressing these specific needs. The resident had multiple physician's orders for antibiotics to treat UTIs over several months, and a nursing note indicated that the resident's daughter was concerned about the frequent UTIs. Despite these ongoing issues, the facility did not create an individualized care plan to address the resident's frequent UTIs. This deficiency was confirmed by the Director of Nursing during an interview.
Failure to Update Resident's Care Plan for Dialysis Schedule
Penalty
Summary
The facility failed to update and revise a resident's care plan to accurately reflect the resident's specific care needs. The facility's policy requires that a comprehensive, person-centered care plan be developed and implemented for each resident, with revisions made as the resident's condition changes. However, for one resident, the care plan was not updated to reflect the correct days the resident attended dialysis, which were Mondays, Wednesdays, and Fridays. Instead, the care plan inaccurately stated that the resident attended dialysis on Tuesdays, Thursdays, and Saturdays. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have been revised to reflect the correct dialysis schedule. The resident in question was cognitively intact, required assistance with care needs, and had a diagnosis of end-stage renal disease, necessitating regular dialysis treatments. The failure to update the care plan was identified during a review of the resident's clinical record and dialysis communication records.
Failure to Prevent Urinary Tract Infections in Resident with Catheter
Penalty
Summary
The facility failed to ensure proper interventions were in place to prevent urinary tract infections for a resident with an indwelling urinary catheter. The facility's policy, dated December 7, 2023, stated that indwelling urinary catheters should be used sparingly and monitored for complications such as symptomatic infections. However, during an observation on November 12, 2024, it was noted that the resident's catheter tubing was lying on the fall mat, which is not in accordance with the facility's policy. This observation was confirmed by the Director of Nursing, who acknowledged that the catheter tubing should not have been in contact with the fall mat. The resident in question was cognitively intact and had a diagnosis of urinary retention, necessitating the use of an indwelling urinary catheter due to neurogenic bladder. Physician's orders required the catheter to be changed every 30 days or as needed for dislodgement or blockage, and the care plan specified that the catheter should be secured with a securement device. Despite these directives, staff failed to reposition the catheter tubing after entering the resident's room to administer a flu shot, leaving it improperly placed and potentially increasing the risk of infection.
Lack of Physician's Order for Dialysis Services
Penalty
Summary
The facility failed to ensure there was a physician's order for a resident who required dialysis services. Resident 16, who was cognitively intact and diagnosed with end-stage renal disease, received dialysis treatment every Monday, Wednesday, and Friday. Despite the care plan indicating that the resident received dialysis services, there was no documented evidence of an active physician's order for the resident to attend dialysis in the clinical record. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Implement Non-Pharmacological Interventions Before Antianxiety Medication
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications by not attempting non-pharmacological behavioral interventions before administering as-needed antianxiety medications. Specifically, for one resident, non-pharmacological approaches were not documented as being attempted prior to the administration of Ativan, an antianxiety medication, on multiple occasions. The facility's policy, dated December 7, 2023, mandates the use of non-pharmacological approaches to minimize medication use unless contraindicated. The resident in question was cognitively intact, required assistance with care needs, and was receiving antianxiety and opioid medications, along with oxygen therapy and hospice services. Despite these conditions, the Medication Administration Record showed repeated administration of Ativan without documented evidence of prior non-pharmacological interventions. The Director of Nursing confirmed that such interventions should have been attempted before administering the medication.
Failure to Administer Warfarin as Prescribed
Penalty
Summary
The facility failed to ensure that physician's orders were followed, resulting in significant medication errors for a resident. The resident, who was cognitively intact and had a diagnosis of atrial fibrillation, was prescribed warfarin, a blood-thinning medication. On October 25, 2024, the resident was supposed to receive 3 mg of warfarin daily, but the medication was not administered as ordered. Additionally, on October 28, 2024, the resident was given 9 mg of warfarin instead of the prescribed 6 mg. Further discrepancies were noted on October 29, 2024, when a PT/INR test was ordered to monitor the resident's clotting time, and the results indicated a therapeutic INR level of 2.3. Despite this, there was no documented physician's order to administer 3 mg of warfarin on October 30, 2024, and the medication was not given. The Director of Nursing confirmed these errors during an interview, acknowledging that the staff failed to administer the correct doses of warfarin on the specified dates.
Repeated Deficiencies in Care Plan Development and Compliance
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 the failure to develop comprehensive care plans, update resident care plans, follow physician's orders, account for controlled medications, and adhere to proper infection control practices. Despite having developed plans of correction in response to a previous survey, the facility's QAPI committee was ineffective in implementing these plans to ensure ongoing compliance. The deficiencies were initially identified in a survey ending December 20, 2023, and the facility had developed plans of correction that involved completing audits and reporting the results to the QAPI committee. However, the current survey, ending November 14, 2024, revealed that the QAPI committee did not successfully implement these plans, resulting in repeated citations under F656, F657, F684, F755, and F880. The facility's inability to address these recurring issues indicates a failure in the QAPI committee's role in maintaining regulatory compliance.
Failure to Implement Enhanced Barrier Precautions for Residents with ESBL
Penalty
Summary
The facility failed to adhere to infection control guidelines from CMS and CDC, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for two residents with a history of Extended Spectrum Beta Lactamase (ESBL) infections. Resident 9, who was cognitively intact and required assistance with care needs, had a documented history of ESBL as indicated by a physician's progress note. However, during a facility tour, it was observed that there was no signage or personal protective equipment (PPE) available outside the resident's room, indicating a lack of EBP implementation. Similarly, Resident 14, who was also cognitively intact and required staff assistance for daily care, had a confirmed diagnosis of ESBL. Despite this, observations revealed that there was no signage or PPE present at the resident's room to indicate EBP precautions. Interviews with the Director of Nursing confirmed that both residents should have had EBP in place due to their ESBL history, but these precautions were not implemented, leading to a deficiency in infection control practices.
Failure to Maintain Walk-In Freezer
Penalty
Summary
The facility failed to maintain an effective preventative maintenance program for the walk-in freezer, as observed on two separate occasions. There was a significant accumulation of ice on the ceiling, extending from the condenser to the opposite side of the freezer, as well as on the four side walls and multiple areas on the floor. The Dietary Manager confirmed the presence of ice accumulation during an interview. The Director of Maintenance, who had been in the position for six months, did not recall any maintenance work being performed on the walk-in freezer. Additionally, a Maintenance Worker reported not having a manual for the freezer and mentioned that a compressor had been replaced last summer by a contracted vendor. The worker also noted that the service technician suggested the ice buildup could be due to a bad door seal or improper door closure by staff.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on effective communication to its nursing and other direct care staff, as evidenced by the review of four employee files. The facility's Facility Assessment, dated July 17, 2024, indicated that the training program should include effective communication as part of the orientation and ongoing training for all staff. However, there was no documented evidence that Nurse Aide 5, Nurse Aide 6, Licensed Practical Nurse 7, and Registered Nurse 8 received this training within their respective employment periods. The Director of Nursing confirmed during an interview that there was no documentation to support that these staff members had received the required education on effective communication. This lack of training was identified as a deficiency under the Pennsylvania Code, specifically sections 201.14(a), 201.18(b)(1), and 201.20(a)(c), which pertain to the responsibility of the licensee, management, and staff development, respectively.
Failure to Conduct RN Assessment for Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse conducted an assessment for a change in condition for a resident, as required by the Pennsylvania Nursing Practice Act. The resident, who was cognitively intact and required assistance for daily care needs, experienced respiratory distress on multiple occasions. On April 26, 2024, the resident was noted to be short of breath, breathing heavily, with a dusky skin color and blue nail beds and lips. Despite these symptoms, there was no documented evidence of an assessment by a registered nurse during or after this episode. Further incidents occurred on April 29, 2024, when the resident's oxygen level dropped to 72 percent, and again, there was no documented assessment by a registered nurse. On May 1, 2024, the resident experienced shortness of breath and low oxygen levels, leading to a transfer to the emergency room where they were admitted with pneumonia and sepsis. An interview with the Director of Nursing confirmed the lack of documented assessments by a registered nurse during these critical episodes, which was a violation of the required nursing services standards.
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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