Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Seton Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that food storage and sanitation practices were not followed in the kitchen dry storage area and in nourishment rooms on LTC, Rehabilitation, and Memory Care units. Bulk containers of modified food starch, flour, and sugar had measuring cups stored inside, and one container had an unsealed, loose-fitting lid. In multiple nourishment rooms and refrigerators, surveyors observed dirty equipment, including a dusty ice and water machine filter and a microwave with debris and foul odor, as well as numerous open food and beverage items that were unlabeled, undated, or expired, contrary to facility policy requiring resident food items to be labeled with name and use-by date and discarded after five days.
The facility failed to follow physician orders for four residents, including incorrect programming of an enteral feeding pump water flush for a resident with a feeding tube, and missed or unrecorded daily weights for three residents with conditions such as CHF, emphysema, diabetes, and cellulitis. For two residents with orders for daily weights and PRN diuretics (torsemide or furosemide) to be given when specific weight gains occurred, weight records showed multiple qualifying gains without documented administration of the ordered PRN medications. The DON confirmed that ordered medications were not given and that ordered weights were not consistently obtained or recorded.
Two residents with cognitive impairment, stroke history, and dysphagia did not receive required assistance and supervision during meals, despite care plans and therapy assessments indicating the need for staff help. One resident, with dominant-side weakness and aphasia, was left in the dining room without needed utensils or proper setup and was observed licking gelatin from its cup and spilling food until staff removed the tray. Another resident, with Parkinson’s disease and dementia, was seated alone facing a wall and TV, with spilled milk on the tray, and was observed sucking gelatin through a straw without staff assistance until the tray was taken away. The Administrator later confirmed staff should have assisted both residents during meal service.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment on multiple nursing units, with a grey substance observed on exhaust vents in central bathing rooms, on filters of heating/air conditioning units in several resident rooms, and on filters of oxygen concentrators. Additional issues included damaged resident room doors and a broken floor tile in a resident room doorway, indicating broader environmental and maintenance deficiencies affecting several units.
A resident with a history of stroke and bladder dysfunction had an indwelling urinary catheter ordered for urine elimination, with a care plan and facility policy requiring the catheter bag and drainage tubing to remain below bladder level to ensure proper drainage. During observations, the resident was found in bed with the catheter tubing routed over a wedge pillow at the side, positioned above the bladder, and urine was seen backed up in the undrained tubing. In an interview, the DON confirmed that the tubing should have been kept below the bladder level, indicating noncompliance with the facility’s urinary catheter care policy.
Surveyors found that the facility did not follow its planned menus or honor resident meal preferences for several residents. On one occasion, a resident with moderate protein-calorie malnutrition and GI conditions was served a grilled cheese sandwich and gelatin without whipped topping instead of the posted menu of baked ham, sweet potatoes, Italian green beans, and gelatin with topping, and reported not receiving her preferred meal. On another occasion, three residents, including one with type 2 DM, CKD, peripheral arterial disease, anxiety, and depression, received pasta with sausage and cream but no tomatoes, despite the menu and meal tickets specifying pasta with sausage, tomatoes, and cream; this resident stated he would have preferred the full planned dish. The Administrator acknowledged that the menus were not followed for these meals.
A resident with a history of hip fracture and Parkinson's disease was found with the call bell out of reach on two occasions, despite being dependent on staff for daily activities and at risk for falls. The resident reported the call bell had been inaccessible for three weeks.
The facility failed to maintain adequate grooming and hygiene for two residents requiring assistance with ADLs. One resident with ambulatory dysfunction and another with Parkinson's disease were observed with long, unkempt fingernails despite expressing a desire for nail care. The Assistant Administrator confirmed that nail care should be done on shower days as needed.
The facility failed to properly dispose of trash and refuse, with a crooked dumpster lid and scattered debris including crushed plastic, paper, used gloves, smashed carrots, and a bag with a brown substance. A large piece of meat covered with a white substance was also found behind the dumpster.
A resident with cognitive impairment and behavioral disturbances ingested a skin cleanser on a locked dementia unit due to inadequate supervision and accessible personal hygiene items. Observations revealed that items like skin cleansers and lotions were left accessible in resident rooms, contrary to facility policy. The DON acknowledged the failure to keep these items out of reach.
The facility did not meet the required NA to resident ratios over a 21-day period. During the day shift, the ratio of one NA per ten residents was not maintained on multiple days. The evening shift failed to meet the ratio of one NA per eleven residents on several days, and the night shift did not uphold the ratio of one NA per fifteen residents on numerous occasions. These deficiencies were identified through a review of nursing time schedules.
The facility did not meet the required LPN to resident ratios over a 21-day period. The day shift ratio of one LPN per 25 residents was not maintained on several days, while the evening shift ratio of one LPN per 30 residents and the night shift ratio of one LPN per 40 residents were also not met on specific days. These deficiencies were identified through a review of nursing schedules.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day over a 21-day period. Nursing schedules showed daily care hours ranging from 2.58 to 3.03, consistently falling short of the mandated standard.
A resident with heart failure, dementia, and atrial fibrillation fell and sustained a hematoma. Despite the fall occurring early in the morning, the physician was not notified until several hours later, delaying the resident's transfer to the hospital for testing.
The facility failed to ensure a dignified environment and adequate care for residents, including outdated information on white boards and lack of assistance during meals for residents with cognitive impairments. Additionally, a resident did not receive scheduled showers as documented in their care plan.
The facility failed to respond promptly to the call bell system, with response times ranging from 31 to 64 minutes. A resident with paraplegia and other conditions reported extended wait times for assistance, and multiple residents confirmed experiencing similar delays. The Nursing Home Administrator and DON acknowledged the expectation for timely responses.
The facility failed to notify a resident's representative of a change in condition. The resident, with multiple diagnoses and cognitive impairment, had a red and warm lower left leg, leading to new physician orders. However, there was no documented evidence that the resident's representative was informed, as confirmed by the Administrator.
The facility failed to develop a comprehensive care plan for a resident with anxiety, bipolar disorder, and Parkinson's disease. Despite identifying moderately severe depression in the MDS assessment, the care plan did not include interventions for this issue. The DON confirmed the omission.
The facility failed to assess and document the status of wounds for a resident with a sacral pressure sore and congestive heart failure. Clinical records showed no evidence of wound assessments during specified weeks, which was confirmed by the DON.
The facility failed to provide adequate supervision in the Cloister unit, leading to safety hazards for residents with cognitive impairments. One resident mixed non-food items with her food and handled dirty dishes without staff intervention, while another ate a sugar packet with the wrapper and took another resident's cake. A third resident was seen collecting soiled clothing protectors without redirection.
Improper Food Storage and Unsanitary Nourishment Rooms
Penalty
Summary
Surveyors identified a failure to properly store food and maintain sanitary conditions in the kitchen dry storage area and in nourishment rooms and refrigerators on multiple units. In the kitchen food preparation area, a measuring cup was stored inside a bulk container of modified food starch that had an unsealed, loose-fitting lid on two consecutive days. In the dry storage closet, bulk containers of flour and sugar also had measuring cups stored inside them. Review of the facility policy on foods brought by family/visitors showed that items left for residents to consume later were to be clearly labeled with the resident's name, item, and use-by date, and discarded after five days. During observations of the LTC, Rehabilitation, and Memory Care unit nourishment rooms and refrigerators, surveyors found multiple instances of unlabeled, undated, and expired food, as well as unclean equipment. In the LTC nourishment room, the ice and water machine filter was coated with dust and debris, and the microwave contained debris and had a foul odor. Open, unlabeled, and undated food items were found in cabinets, freezers, and refrigerators, including peanut butter, bread, chocolate bars, ice cream, pickles, grape jelly, relish, whipped topping, chocolate milk, yogurt (including one with an expired date), canned drinks, a packaged salad, and prepared food containers missing either a name or date. Similar issues were observed in the Rehabilitation and Memory Care unit nourishment rooms, where open packages of various foods and beverages, including pancakes, toaster pastries, ice cream, cheese slices, coffee creamer, strawberries with visible black and white substance, sour cream, yogurt drinks, hoagies, and bottled beverages, were not labeled with resident names or dates. The Administrator confirmed that the facility failed to properly store food and follow the resident food storage policy.
Failure to Follow Physician Orders for Tube Feeding, Weights, and PRN Diuretics
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for treatments and monitoring for four residents. For one resident with a history of stroke, aphasia, dysphagia, and an enteral feeding tube, a physician ordered 100 ml water flushes every six hours. Observation of the enteral feeding pump showed it was programmed to deliver 175 ml water flushes every six hours, and the DON confirmed the pump was not set to the correct volume. Another resident with encephalopathy, type 2 diabetes, and cellulitis of the lower left leg had an order for daily weights and PRN torsemide to be given if weight increased by 2 lbs in 24 hours or 5 lbs in a week. The MARs showed multiple days where no weights were recorded, and documented weights reflected several qualifying weight gains without any documented administration of torsemide as ordered. A third resident with emphysema and chronic congestive heart disease had a physician’s order for daily weights to monitor the resident’s condition, but the MARs showed multiple dates where no weights were recorded. A fourth resident with congestive heart failure, intestinal obstruction, and diabetes had orders for daily weights and PRN furosemide 40 mg for weight gains of 2 lbs in one day or 5 lbs in one week, along with a care plan noting a nutritional problem related to fluid shifts and interventions including fluid restriction and medication administration as ordered. The weight records showed repeated instances of 2 lb or greater gains in one day without any documented evidence that furosemide was administered. The DON confirmed that the PRN furosemide was not given for the documented weight gains and that weights and medications were not administered or recorded as ordered for the affected residents.
Failure to Maintain Resident Dignity and Provide Required Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide meal assistance and maintain dignity for two residents with significant cognitive and physical impairments. One resident had a history of stroke with upper and lower extremity weakness on the dominant side, aphasia, and dysphagia. An MDS assessment indicated cognitive impairment, functional impairment of the dominant side limbs, and a need for supervision or assistance with eating, including intermittent cueing or steadying. The resident’s care plan specified setup and supervision at all meals, use of a plate guard, and placement of all supplies within reach. During a lunch observation, the resident was seen seated in the dining room licking gelatin from the manufacturer’s cup without utensils within reach. Staff briefly pushed the tray to the center of the table, served cereal in a bowl with a spoon, and then left the resident with the spoon and gelatin cup. The resident struggled to eat, spilling some on the floor, until staff returned and removed the tray, spoon, and unfinished gelatin. The second resident had diagnoses including Parkinson’s disease, dementia, and a history of stroke with upper and lower extremity weakness on the non-dominant side. An MDS assessment showed cognitive impairment and a need for substantial assistance from staff, and a speech therapy dysphagia assessment indicated the resident should have assistance for all meals. During a lunch observation, this resident was seated alone in a wheelchair facing the television and wall at the far end of the room from the nurses’ station, with a meal tray in front of her. Spilled milk was observed on the tray, and the resident was eating packaged gelatin by sucking it through a straw. She declined to eat the remainder of her meal, and staff did not provide assistance until they removed her tray. In an interview, the Administrator confirmed that staff should have provided assistance to both residents during meal service.
Environmental Cleanliness and Maintenance Deficiencies Across Multiple Nursing Units
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment on four of six nursing units (B, C, D, and H). During observations conducted over two days, surveyors noted a grey substance covering the exhaust vents in the central bathing rooms on nursing units C and H. In multiple resident rooms (503, 505, 603, and 705), the cover was off the heating/air conditioning units and a grey substance was observed covering the filters. Additional environmental deficiencies included damaged doors to certain resident rooms and a broken floor tile in the doorway of another resident room. A grey substance was also observed on the filters of oxygen concentrators in several resident rooms. These conditions were cited under 28 Pa. Code 201.14(a) regarding responsibility of the licensee and 28 Pa. Code 201.18(b)(1)(3)(e)(2.1) regarding management. No specific resident medical histories or clinical conditions were described in the report; the findings were limited to environmental observations in resident rooms, central bathing areas, and on equipment such as heating/air conditioning units and oxygen concentrators.
Improper Positioning of Indwelling Catheter Tubing Leading to Undrained Urine
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate catheter care for a resident with an indwelling urinary catheter. Facility policy on urinary catheter care, last reviewed December 17, 2025, required that urinary drainage tubing be checked to ensure proper drainage. The resident had diagnoses including a history of stroke and bladder dysfunction, and a physician ordered an indwelling urinary catheter for urine elimination. The resident’s care plan specified that the catheter bag and tubing were to be positioned below the level of the bladder. However, observations on February 11, 2026, at 12:20 p.m. and 2:20 p.m. showed the resident in bed with the catheter tubing positioned over a wedge pillow at the resident’s side, above the bladder, with urine visibly backed up in the undrained tubing. In an interview at 2:20 p.m. the same day, the DON confirmed that the catheter tubing should have been positioned below the bladder.
Failure to Follow Planned Menus and Honor Resident Meal Preferences
Penalty
Summary
The facility failed to follow planned menus and honor resident preferences for multiple residents during observed meals. The written menu for one lunch specified baked ham, sweet potatoes, Italian green beans, and gelatin with whipped topping. Instead, one resident with diagnoses including moderate protein calorie malnutrition, epigastric pain, and gastro-esophageal reflux disease was served a grilled cheese sandwich, sweet potatoes, green beans, and a sealed gelatin cup without whipped topping. This resident, who had no cognitive impairment per a recent MDS assessment, stated she did not receive what was on the menu or what she preferred, and her responsible party confirmed her statement. On another date, the planned lunch menu called for bow tie pasta with Italian sausage, tomatoes and cream, tossed salad with dressing, diced peaches, juice of choice, and coffee or hot tea. Review of meal tickets for three residents showed that their meals should have included bow tie pasta with Italian sausage, tomatoes and cream, but they were served pasta with sausage and cream without tomatoes. One of these residents had diagnoses including type 2 DM, chronic kidney disease, peripheral arterial disease, anxiety, and depression, and a social service assessment documented moderate cognitive impairment. This resident stated he would have preferred the pasta with sausage, tomatoes, and cream as planned. The Administrator confirmed that the facility menus were not followed for the lunches in question.
Inaccessible Call Bell for Resident
Penalty
Summary
The facility failed to ensure that a call bell was accessible for a resident, leading to a deficiency. The resident, who had a history of a left hip fracture, Parkinson's disease, and anxiety, was alert and oriented but dependent on staff for activities of daily living, including toileting, dressing, and personal hygiene. The care plan indicated that the resident was at risk for falls and required staff to ensure the call bell was within reach before leaving the room. However, on two separate occasions, the resident was observed in bed with the call bell on the floor, out of reach. The resident reported that the call bell had been inaccessible for the past three weeks.
Failure to Provide Adequate Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for two residents who required assistance with activities of daily living (ADLs). Resident 42, diagnosed with ambulatory dysfunction, muscle weakness, and osteoarthritis, was observed on two occasions with long, pointy, and sharp fingernails while eating lunch in bed. The resident expressed a desire to have his nails cut, but staff had not offered to do so, and there were no documented refusals. Similarly, Resident 96, who has Parkinson's disease, was observed with long, pointy, jagged fingernails with dirt underneath on two separate occasions. This resident also expressed a willingness to have his nails cut, with no documented refusals. The Assistant Administrator confirmed that nail care is supposed to be performed on shower days as needed.
Improper Disposal of Trash and Refuse
Penalty
Summary
The facility failed to properly dispose of trash and refuse, as observed in the dumpster area. One of the dumpster lids was crooked and not fully covering the top, leading to multiple pieces of crushed plastic, paper debris, and used gloves scattered around the outside. In front of the dumpster, there was an area with smashed carrots, and a bag covered with a brown substance was wedged below the dumpster, with gauze debris surrounding it. Additionally, behind the dumpster, a large piece of meat was found covered with a white substance.
Resident Ingests Non-Consumable Item Due to Inadequate Supervision
Penalty
Summary
Seton Manor Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding accident hazards and supervision. The deficiency was identified on the Cloister nursing unit, a locked dementia unit, where a resident with cognitive impairment and behavioral disturbances was able to access and ingest a non-consumable item. The resident, who had a history of dementia with anxiety and depression, was independently ambulatory and known to enter other residents' rooms. On January 23, 2025, the resident ingested Derma/Vera, a skin and hair cleanser, after being found with the bottle in the activity room. Observations on January 28, 2025, revealed that personal hygiene items, including skin cleansers and lotions, were left accessible in various resident rooms on the Cloister unit. These items were found on bathroom counters and in open closets, with bathroom doors left open, allowing the resident to ambulate near these areas. The Director of Nursing and Assistant Director of Nursing acknowledged that personal hygiene items should have been kept out of reach of confused residents, indicating a failure to maintain a safe environment free of accident hazards.
Plan Of Correction
1) R1 has not had any further incidents involving attempting to ingest non-edible objects/non-consumable items. 2) Room audits will be conducted on the cloister (locked) unit for assessable non-edible/non-consumable items. 3) All staff will be educated on securing non-edible/non-consumable items out of reach of confused residents. 4) NHA/designee will complete random audits daily for 7 days, weekly for 3 weeks. Results will be tracked and trended and reported to QAPI committee.
Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios over a 21-day period from December 15, 2024, to January 4, 2025. During the day shift, the facility did not maintain the minimum ratio of one NA per ten residents on multiple days, specifically from December 16 through 31, 2024, and January 1 and 4, 2025. Similarly, the evening shift did not meet the required ratio of one NA per eleven residents on several days, including December 17, 19 through 28, 30 and 31, 2024, and January 2, 2025. Additionally, the night shift failed to uphold the minimum ratio of one NA per fifteen residents on numerous occasions, including December 15, 17 through 23, 25 through 31, 2024, and January 1 through 4, 2025. These deficiencies were identified through a review of the nursing time schedules, indicating a consistent shortfall in staffing levels across all shifts during the specified period.
Plan Of Correction
1) Findings of nursing aide nursing staff care ratios cannot be retroactively corrected. 2) Facility will provide a minimum of 1 nurse aide per 10 residents on the day, one nurse aide per 11 residents during evening and one nurse aide per 15 residents overnight. 3) Scheduler will be educated on the requirements of 1 nurse aide of per 10 residents on the day, one nurse aide per 11 residents during evening and one nurse aide per 15 residents overnight. 4) NHA/designee will conduct random audits to verify that nurse aide dayshift, evening and overnight ratios meet the requirements weekly for 4 weeks. Audit results will be presented to the QAPI meeting for review and recommendations.
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. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on several days, including December 19, 22, 25, and 27 through 30, 2024. Additionally, the evening shift ratio of one LPN per 30 residents was not met on December 24, 2024, and January 2, 2025. Furthermore, the night shift ratio of one LPN per 40 residents was not adhered to on December 15, 21, and 25, 2024. These deficiencies were identified through a review of the nursing schedules for the specified period.
Plan Of Correction
1) Findings of LPN staff care ratios cannot be retroactively corrected. 2) Facility will provide a minimum of one LPN per 25 residents during dayshift, a minimum of one LPN per 30 residents during the evening shift, and a minimum of one LPN per 40 residents during the overnight. 3) Scheduler will be educated on the requirements of one LPN per 25 residents during the day shift, a minimum of one LPN per 30 residents during evening shift, and a minimum of one LPN per 40 residents during the overnight shift. 4) NHA/designee will conduct random audits to verify that LPN dayshift, evening shift, and overnight shift ratios meet the requirements weekly for 4 weeks. Audit results will be presented at the QAPI meeting for review and recommendations.
Failure to Meet 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 24-hour period. This deficiency was identified through a review of nursing schedules over a 21-day period from December 15, 2024, to January 4, 2025. During this time, the facility consistently provided less than the required hours of care, with daily averages ranging from 2.58 to 3.03 hours per resident. The shortfall in nursing care hours was observed on all 21 days reviewed, indicating a systemic issue in meeting the mandated care standards.
Plan Of Correction
1) Findings of PPDs cannot be retroactively corrected. 2) The facility will provide a minimum of 3.20 hours of direct care for residents. 3) The scheduler will be educated on maintaining the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident. 4) NHA/designee will conduct random audits to verify that the minimum of 3.20 hours of direct care for residents is provided daily weekly for 4 weeks. Audit results will be presented at the QAPI meeting for review and recommendations.
Failure to Promptly Notify Physician of Resident's Fall and Pain
Penalty
Summary
The facility failed to promptly notify a resident's physician of a change in condition for one of the sampled residents. The resident, who had diagnoses including heart failure, dementia, and atrial fibrillation, was on a physician's order to receive Eliquis twice daily to prevent blood clots. On November 5, 2024, at 3:10 a.m., the resident fell and sustained a large hematoma on the right side of her forehead. A nurse documented the fall at 4:05 a.m. and noted the resident's complaint of pain, for which Tylenol was administered at 4:10 a.m. However, there was no evidence that the physician was notified of the fall and the resident's pain until 11:01 a.m. that day. The physician then instructed the staff to send the resident to the hospital for testing, and the transfer occurred at approximately 12:00 p.m.
Failure to Ensure Dignified Environment and Adequate Care
Penalty
Summary
The facility failed to ensure a dignified environment, care, and services to promote quality of life for residents on three nursing units and in one dining room. Observations on the Cloister and Sub-Acute nursing units revealed outdated information on white boards, which displayed the date of April 20, 2024, instead of the current date. This outdated information was present in both the dining room and residents' rooms, indicating a lack of attention to detail and resident engagement. Additionally, multiple residents with cognitive impairments and specific care plans requiring supervision and assistance during meals were observed eating with their fingers without any staff intervention or assistance. This included Resident 1, Resident 9, and Resident 64, all of whom have diagnoses such as dementia, depression, and Alzheimer's disease, and were on restorative nursing programs for dining that necessitated staff supervision and assistance. The staff's failure to provide the necessary support during meals compromised the residents' dignity and quality of life. Furthermore, Resident 95, who had diagnoses including cerebral infarction, Alzheimer's disease, and depression, did not receive scheduled showers on multiple occasions as documented in the task flowsheet. The Director of Nursing confirmed the lack of documented evidence for the showers, indicating a failure to adhere to the resident's care plan and maintain proper hygiene standards.
Failure to Respond to Call Bells in a Timely Manner
Penalty
Summary
The facility failed to accommodate resident needs in a timely manner by not responding promptly to the call bell system on one of the three nursing units. Resident 76, who had diagnoses including paraplegia, dysphagia, anxiety, and depression, was observed with the call bell activated and reported waiting for an extended period for assistance. The resident's care plan indicated a need for prompt response to all requests for assistance due to a fall risk. During a group interview, multiple residents reported experiencing long wait times when activating their call bells for assistance. Review of call bell audits for the weeks of April 1 and April 15, 2024, revealed that response times ranged from 31 to 64 minutes, indicating a consistent issue with delayed responses. The Nursing Home Administrator and Director of Nursing acknowledged that call bells were expected to be answered in a timely manner. This deficiency was identified as a failure to meet the regulatory requirement for nursing services under 28 Pa. Code 211.12(d)(5).
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative of a change in condition for one of the sampled residents. Resident 34, who had diagnoses including diabetes, soft tissue disorders, and adjustment disorder with mixed anxiety and depressed mood, was found to have cognitive impairment. On April 20, 2024, a nurse's note indicated that Resident 34's lower left leg was red and warm, leading to new physician orders for doxycycline and a venous doppler. However, there was no documented evidence that the resident's representative was informed of this change in condition. The Administrator confirmed this lapse during an interview on April 26, 2024.
Failure to Address Identified Mood State in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed the individual needs of a resident as identified in the comprehensive assessment. Clinical record review revealed that the resident had diagnoses including anxiety, bipolar disorder, and Parkinson's disease, and the Minimum Data Set (MDS) assessment indicated moderately severe depression. Despite identifying mood state as a problem area in the Care Area Assessment summary, the facility did not include interventions for this issue in the resident's care plan. The Director of Nursing confirmed that the care plan did not address the identified concern.
Failure to Document Weekly Wound Assessments
Penalty
Summary
The facility failed to assess and document the status of wounds for Resident 28, who was admitted with a sacral pressure sore and congestive heart failure. According to the facility's Skin Management Guidelines, staff were required to evaluate and document wound status weekly. However, clinical record reviews revealed that there was no documented evidence of wound assessments for Resident 28 during the weeks of January 28, 2024, February 11, 2024, February 25, 2024, and March 17, 2024. This deficiency was confirmed by the Director of Nursing during an interview on April 26, 2024. The failure to adhere to the facility's policy resulted in a lack of proper wound care documentation for Resident 28, who had a Stage 3 pressure sore since admission.
Inadequate Supervision Leading to Safety Hazards
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents and hazards in the Cloister unit. Resident 9, who has dementia and Alzheimer's disease, was observed mixing non-food items with her food and drinking from a contaminated cup without staff intervention. Additionally, Resident 9 was seen handling dirty dishes and taking condiments off the counter without redirection from staff. On another occasion, Resident 9 was observed eating lunch with a packet of pepper in her spoon, and staff only intervened after being alerted by the surveyor. Resident 64, diagnosed with dementia and depression, was observed eating a sugar packet with the wrapper and taking another resident's cake without staff assistance. Resident 117, who has severe cognitive impairment and anxiety, was seen collecting soiled clothing protectors from other residents without any staff redirection. These observations indicate a lack of adequate supervision and assistance for residents with cognitive impairments, leading to potential safety hazards and accidents.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Orwigsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orwigsburg Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 7 | 0 |
| Rosewood Rehabilitation And Nursing Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Edenbrook Of Greenwood Hill | 4.3 mi | ★★★★★ | 4 | 0 |
| Schuylkill Center | 4.5 mi | ★★★★★ | 16 | 0 |
| Gardens At York Terrace, The | 6 mi | ★★★★★ | 0 | 0 |
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